This is an interactive course led by key thought leaders in venous disease with a multi-specialty approach to the diagnosis and treatment of venous disease. The audience will learn about disease process, diagnosis and treatment of post-thrombotic disease. This will all be achieved by didactic presentations, case reviews and Q&A.
Good evening and welcome to the treating the post robotic patient webinar. My name is Nicole Delmer and I'm the medical education specialist for phillips. I would like to first introduce dr Kathleen Gibson. She's a vascular surgeon at lake Washington. Vascular surgeons in Bellevue Washington. She serves on multiple boards and has written articles and book chapters and it's a global speaker for the venus disease. Next is dr erin Murphy. She's a vascular surgeon at Sang. Her heart and vascular institute in charlotte north Carolina. She serves as the director of the venus and lymphatic disorders at Sanger. She has authored many articles, book chapters and our editorials and is active and ongoing trials. Next up is doctor E. Brook Spencer. She's an interventional radiologist at minimally invasive procedure specialist in South Denver colorado. She is the director and ceo of that practice and she has been involved in several research studies M. P. I. For several trials. I'm erin Murphy, I'm the director of the venus and lymphatic institute at saying her heart and vascular in charlotte north Carolina. First night with my colleagues Brooke spencer and Kathy Gibson. And I'm going to start off by discussing a little bit about post traumatic disorder and um we're gonna then eventually evolve into cases and talk about our treatment options. These are my disclosures, more disclosures. So as we know, DVT can affect up to a million people almost in the U. S. Each year. Um We're all aware of what this looks like and what this patient is the risk of propagation, the risks of P. E. It causes up to 300,000 deaths annually. Um It's one of the leading causes of preventable hospital deaths and we have made great progress, but it's still a major issue that we see, particularly in hospitalized patients. Um What we don't talk as much about, but we are starting to finally the past couple years is post traumatic syndrome. So this is the syndrome that results from the persistent or recurrent symptoms of venous hypertension. So symptoms that are present recurrent or still present at least six months from the inciting DVT symptoms are lim, heaviness, oedema pain, various is new skin thickening, hyperpigmentation, LDS, ulcers and the disease can progressively worsen over time. This is seen most often in patients with alia ephemeral DVT in this group, up to 50% and we know in the attract trial that we? Re infirmed again, about 50% of patients here will get evidence of post traumatic syndrome. When you're looking at that group specifically, up to 90% have chronic venus symptoms and complaints. Up to almost half the venus clarification and 15% will have venus ulceration. This equates to a very huge number, especially as our population continues to grow. And when we're looking at the numbers before, equated to about 15 million people living in the United States with PTS induced ulceration. From a patient perspective, this is a really big deal. Um It's associated with significantly worse quality of life, both from a physical standpoint, but also from a mental health standpoint. The quality of life that patients reported for um when they had PTS matched what patients reported with severe medical conditions including CHF COPD and advanced diabetes. And what's very interesting about this, a lot of the patients with P. T. S, you have to remember are much younger. So we have quality of life issues that match really advanced medical conditions in our fairly young, otherwise healthy patient population. From a societal perspective, also because it's involving these groups, we have high work absenteeism, we have high disability claims, we have high medical costs. Um and when looking at these DVT and PE patients, you can see there's not just short term claims with them, these long term claims or where these patients are getting post robotic syndrome and and prolonged recovery, if any recovery, um $15 billion each year are spent on the worst case scenario of advanced venus disease venous leg ulcers. With a good majority of these being shouldn't say always majority, but a good percentage of these being our patients with post traumatic syndrome, but in order to understand how to prevent it, but also how to treat it. Once it already occurs, we have to understand the underlying mechanisms of it. So these roughly the mechanisms are complex but can be roughly broken down into persistent venous outflow obstruction, fiber optic valve damage and calf pump dysfunction and persistent outflow obstruction is felt to be one of the most important contributors to the disease process and it further potentially Eights both more fiber optic valve damage, as well as inflammatory mediated calf pump dysfunction at the end of the day. All of this results in the shared mechanism of PTS, which is ambulatory venus hypertension. In fact, as the pressures go up, you can see the symptoms that you would expect and the severity of the PTS also gets worse. So when you see these patients in clinic, these CP three to seep six post robotic patients with a history of DVT, a leg that looks pretty bad or pretty uncomfortable, um you have to know what, what steps to take in what order. So the first thing I do with all of these patients is to get a proper imaging work up to know exactly what, what are we looking at. And so you want to look at their functional status and their use of the limb, their calf pump. You want to look at any underlying obstruction and you want to look at their valves So to do that this is my typical um imaging pathway. So iliac and lower extremity duplex ultrasound. I'm looking for external compression points. I'm looking for um post robotic changes. So do you have discrete narrowing and webbing or do you have diffuse the thickened walls? You have a sclerotic vein? Do you have in flow? Because a lot of times these patients with these um prior histories of big D. V. T. S. Have disease. Federals disease Profundis. Um That affects whether you can offer them an operation and it affects what kind of planning for your surgery you're going to do. So I also get lower extremity DVT reflects testing to assess again that that candidacy what does the ephemeral vein look like? What does uh papa to look like? Um Also what what valves are working and what aren't in both their deep and superficial system. Um At my institution I currently use C. T. V. S. And I'll show I'm gonna kill one of those. Um But I I do like those for imaging of the pelvic anatomy am and for operative planning I think they work well in conjunction with the duplex. Um My last institution we use more MRV. It's a little bit of your preference, your ability to read them and your institution's ability to do them. So this is just an example of a you know iliac ultrasound. This is the right side in this patient with fairly normal veins versus the left side. You can see these areas of sclerotic vein and build up in scoring within the vein um and narrow um problem and iliac or just some of the findings you'll see um on cTv it's kind of an important thing to get used to looking at and Brooke can comment on this. You know she's I would trust her to read my cts in her sleep. But unfortunately I think um venus disease overall has not been a part of education and a lot of areas and I think a lot of radiologists still aren't used to reading the the venus uh findings on the C. T. S. So I have a lot of cts that are just read as normal. Um Even in patients with completely occluded iliac veins. So it's um kind of behoove you to be able to interpret you know your own images to a sense. And I'm just going to show you one C. T. This this patient for example was read as having you know normal normal venus anatomy. And so what this patient has is who you follow the I. V. C. Down. Yeah and you can see the left iliac coming under the artery much smaller than the right side. This is the internal coming up here as you're watching. And then you can barely kind of trace like as you're coming down. You have to go up and down to kind of trace where the external is. Yeah but you kind of see it appear again here. But in comparison to the other side you can tell there's a vast difference now at my institution I may have one out of 100 that has um contrast in the veins on A. C. T. V. Um So but honestly I thought that was a big deal when I first started looking at these and I've realized that for post robotic patients and patients with a lot of venus disease, you really don't need the contrast to see that this caliber vessel is considerably different and it's a considerably diseased vessel. So just kind of get used to looking at these and comparing to the other side and knowing what a normal vein looks like versus these patriotic or almost disappeared vessels. And this would be what your normal may Thorner looks like going under an artery on your ct. So we'll go on to once you diagnose these patients. Your goal is to take them from, you know, their whatever their level of obstruction is. Clearly these patients fairly dramatic to a, you know, recapitalize well functioning. Uh being a system. Uh huh. Somebody's not muted jodi Mahanta, you're not muted. Oh thanks Brooke, I can't tell you how you knew that. Um So the I'm gonna give just kind of some key points for these cases once you diagnosed them with obstruction. Um What you're some of the key points of the procedures when you really think about it, the procedure itself comes across as um fairly simple. It's accesses re can it's imaging, it's dilation and stenting it's post imaging. Um But with these cases the attention to detail is really what determines the patient's outcome. Uh There's a common error in thinking among people who do these kind of who do vascular type cases in general that veins are more forgiving than arteries. That's both true and completely wrong. Um It's true in the sense that um you know, you're not gonna frequently have disastrous bleeding from veins because of the low pressure of the system but at the same time what protects us from disastrous complications like that also predisposes us to having more thrown biotic episodes and sent inclusions. If we don't do things perfectly, if you don't do things perfectly with slow flow or in a low pressure system and things tend to occlude. So you really can't leave any errors, any disease below your stent, any outflow problems your stent will include. Um so you really need to approach all steps very thoughtfully and skillfully. Um, and I think almost more thoughtfully sometimes and you had to do in the arterial cases. Um, or at least as thoughtfully, the some of the major points um in access, you always want to have enough room to see your lowest point of disease. So particularly in post traumatic patients who have big, big thrombosis in the past, you want to make sure you're well below the pre fund a because often you have to stand directly into the propaganda and you at least need to image all of that to make sure you're leaving no disease behind. Um My typical accesses in the femoral vein in the upper third of the thigh. Um This gives you good running room after you put your sheath in but never have your sheath above the level of the lesser truck inter. You're not gonna completely image the common femoral vein. Um Other sites. Um I think you know, some of my colleagues will talk about pop little some people do tibial. Um You can do I j but I find that difficult for most most probiotics because they typically have a lot of disease. It's hard to access from the top. I use it as a secondary access to help with front with difficult conclusions. Um This is just a case of consequences of high access. So this is the patient before treatment. This is the post result looks great wide open, Certainly better than this seclusion. Um But when you're looking at the office you can see just, I just caught the tail end when I reviewed this isn't one of my cases. When I was reviewing the I was from the time of the case. You see it was pretty wide open but just below the stent. You see that looks pretty disease still for a common femoral vein. Um And when you looked back at his original ultrasound you could see he actually had a landing zone right at the federal performed a confluence. But as I told you before that's at the lesser trow cancer. So his stent should have been landed probably a couple you know an inch or two lower. Um And then he probably would have stayed open. But unfortunately the scent closed um and was unable to be open. And this guy had pretty severe debilitation from um ulcer disease. And we we have not been able to successfully keep descent open since. Um so just make sure you're paying attention to your access initial venogram I use for kind of case planning. Just give me an idea of what's going on. Most my imaging decisions are going to be with avis, but this does give you a really good road roadmap for what you're up against. And it does help give you a roadmap for recapitalizing any included vein um during recapitalization. I'm just going to mention a couple of things. Um you you're trying to trans verse uh these Tribeca dilated veins are rarely a solid core lesion, even though they look like it. So, um you know, I don't use a lot of loop techniques. You're not going sub internal, you're kind of trying to go through these channels. Um I don't worry a lot about perforations are self limiting. That's where the low pressure system does help you. I don't often check um what's really important to check and if any slide I show you is um important. It's these next couple in recapitalizations. Your wire passes smoothly transition from the right to the left across the lower spine. Any recapitalisation should get a lateral image and you should see it softly go across the sacral area and then anterior to the vertebral column. Um What you don't want to see. Um And these are a couple of things that really can kill a patient on the table is this where you see an abrupt crossing. Um And when you look here, you see that the on your lateral that this went straight, you know, into the into the vertebral column and probably through the spinal plexus. Um So this you know, rupturing a big collateral or something like this can can be disastrous consequences. Um This is so I I did this image, we recognize this, but I did this image during the case just to show you how how wrong that is. Um When you get proper imaging, this is another instance where it enters the spinal plexus, unfortunately. So here this again was not my case, but um here's a VC stent already placed and this wire from the right side is trans mersing midline on the spinal, on the spinal column. And you can see this even without the stent there, you should know this is wrong midline on the on the vertebral bodies. Um and in fact it was not recognized and this patient was stent ID into his vertebral column. So that's being a step. Um you never want this to happen so always get your lateral image, make sure it's in the right place. Um Other things to confirm you're in the right place. You should have very free wire movement. Once you're in the I. V. C. Your wire should kind of beat with the with the heartbeat when you're getting closer to the atrium, you should have your good imaging. And then of course I this um I've as guides the remainder of procedure after crossing. So this allows to detect the severity of disease how bad the disease is the extent of it from top to bottom. Where is your cranial landing zone? Where is your just the landing zone? Um There's you know I think pretty pretty much consensus from us who who spent a lot that you really need. I've is to um accurately determine this. The gold standard. Um Is I've this in my mind. We'll see if you know Cathy or Brooke feel any different on that. Um Other tips always pre dilate the size of your intended stent. Um You don't want to skimp here. The balloons are much stronger than the stents. If you don't pre dilates the size you want, your stent will not necessarily expand to the size that you want. Um So the you want to use correct sense sizing which is a little bit different with nightingale stents. Make sure using the correct length. Um You want to make sure you're covering the full disease, Good inflow, good outflow, no disease above or below. You want to make sure you use sense that at least go into the external iliac vein. Never use short little stents in the common iliac. There's all sorts of complications we can talk about with that. Um Don't jail the contra lateral vein when it can be avoided. Um And make sure you post dilate. And that is especially true with the newer nightingale stents. So night and all by nature all night and all sense will not hit their um the intended strength until they are post dilated. Post dilation of nightingale sense to proper size, even if it looks like they're fully expanded that extra pressure loading when you post dilate, it actually changes the crystal structure of the metal so that that is now a stronger stent. So post dilated, whether you think you need it or not, don't take shortcuts in the veins. Um And then I'm just gonna show you quick case or two and we'll move on to I think Kathy Kathy is a couple of cases and Brooke does too as well as some um some more uh kind of important patients that we haven't yet talked about. Um So this first patient just to show how how extensive and disabling this disease can be 39 year old male with a 10 year history of lymphedema, just kind of ruining his life. He was near disability. Um He had bilateral relations of the Gsp for oedema, which of course made no difference. He had massive like swelling. Um He presented to me, he lived in Tennessee and he had a two week history of worse right leg swelling compared to his baseline. Um And he was kind of blown off by multiple facilities because his legs were so swollen at base line. They were like okay you have a fem pop dvt, here's your blood thinner. Um And so he actually looked us up online, drove to another state, showed up in the wrong clinic asking for me. Um and this poor guy. Um Anyways he uh kind of gave his story and he had bilateral iliac and ibc inclusions, right renal vein occlusion as well um as well as a acute right fem pop below that. So his 10 years of lymphedema management was really ibc an iliac conclusions that were now only brought to attention because of his acute dvt and his persistence. So we did leis the fem pop overnight just to get his inflow back. And this is his after license pictures um or venogram. Um His stent reconstruction again when all the way I think he believed he was to the hepatic vein. Um And that's his post reconstruction. This guy finally took him off his blood thinners to treat his varicose veins which were his only remaining complaint last year. Um After you know again 10 years of disability. Um The guys married, he now has a child, His whole life has kind of turned around with proper treatment so you can make a huge difference for these patients. Um this is another 1 um recently seen. So this guy had uh a cute extensive I. V. C. And L. E. A. D. V. T. In 2017. Um They had placed a adoptees filter and he was now presenting with left more than right, debilitating swelling skin changes. He had small ulcers appearing now on the left leg, handsome reflux, but not enough to explain his conditions of deep reflux. Again not enough to explain this. Um And what he had an ultrasound was it included left common iliac vein. Um And C. T. He also had a obstructed filter of 60 to 70% but not completely occluded. Um And I apologize but I think I put some placeholder images in here and meant to come back and put some more but his adoptees filters about this level um and what you're actually seeing here, which was super interesting. I don't know Brooke Cathy if you want to comment on this later, but um he actually had a piece of calcified thrombosis extending from the filter all the way down into the mid common iliac vein which you know, I've seen a handful of times these calcified thrombosis but it was it was fairly interesting to me. Um This is his initial venogram. Um And again the filter was just up here but it was patent just released diagnosed um on the inside and then here's his end result um with the filter um you know, crushed and the and the iliac vein stenting, his collaterals aren't filling. Um He had great flow. Um This is actually a ana bray um stent and a wall stent in the in the cava. So he did. Well I think I agree with I agree with you completely. You know there's lots of data on these options filters they're very very dangerous to remove. But the data for reconstruction through the filter with a large stent is really equivalent to removing these filters. I've been sent a lot of patients where I've been asked to remove the filter and I think it's better if you can filter but if it's been in for 10 years you're probably not going to get that filter out without destroying a large portion of the I. V. C. It's very dangerous. And the long term potency of doing it the way you did it is great. So I mean I'm in full agreement with that. Yeah that's great to hear hear. I I I've had pretty good luck with this this way and I agree. I um I wouldn't put in optimize filter in. I'm surprised that they're still being used agreed. So I think we're going to hand it over Kathy Gibson um from uh lake Washington vascular surgery and she has a couple of cases um that are that I think are are similar, but I think it's important to see, you know, how we're, how we're all, what is similar about how we're approaching it and where the subtle differences are. So thank you. Great. Can anyone hear me? My a muted yes, we can hear you. Okay. So I think do I have got control of the screen it looks like. So these are my disclosures and another set of disclosures and I can't remember what order I put these two cases in, but they have some similarities and some differences That my female 1 1st. So what you'll see in both of these patients are these two people are are folks that formed robust collaterals and I think where this makes a difference um is neither one of them have ulcers, but both of them have leg symptoms. And I found that patients with these robust collaterals oftentimes Maybe years before they come to see you because they don't have wounds and whatnot. So um this is a young woman 38 years old and she had a DVD 10 years ago. She came from another state. She has leg aching, heaviness, painful, cross pubic, very costs and pelvic pain. She has other medical conditions and where this becomes interesting is her anti coagulation management. So she's got Crohn's disease and gastro paris is and what's interesting about the Crohn's disease of course, as we know that that has a link to DVT and she has a hyper co available state that is a bit undefined but that is um uh she's having problems eating oops sorry about that. Um And she may have an impossible lipid syndrome. She's chronically and a coagulated currently with Lovenox. Okay and I'm having trouble controlling this. Uh Let's see here that's the wrong way. Okay. Sorry. Okay so her imaging from out of state showed that she has patent capital tibial veins with no reflux. The cephalopod portion of her ephemeral vein is included. She has a patent pro fonda with some mild webbing and the G. S. V. And ssv were um patent with no reflux. She has large cross pelvic and pubic collaterals and included external and common iliac veins on the left and the right side appeared normal. So this is her physical exam. So she's got these large cross pubic varicose veins. She has some media five eric costs are left legs a little bit bigger than the right that no skin changes or ulceration. So she had an attempt by a vascular surgeon out of state to revascularization. This goes to erin's point that um you don't want to access to low. So there were a couple of things they access the Gsd um probably uh sorry access to high. So this wasn't a good access for um what they plan to do and they were able to get the wire and their catheter up into the common iliac vein but they could not cross into the Vienna Kaveh. And so they aborted an attempt and referred the patient to me. Sorry, I'm just not doing a good job. I don't have the arrows visible to me too. Go forward. Can you still hear me? Yeah, we got your happy. Okay. Yeah, sorry, I'm just having a little control problem here. Okay. So what did I do? So once somebody else is not um succeeded, you know, and I've had cases before where I haven't succeeded and luckily I have another vascular surgeon across the lake, Mark Meisner that sometimes we send cases to each other if one of us has tried not been successful. So the plan that I had was either to access the pre fund A or the I. J. And when I looked at the patient on the table, the profound to look like it would have been a difficult access. So what I ended up doing and I'll show you some pictures as I access the right I. J. And then I did access the GSP to get some puffs and road mapping from the bottom. And I attempted to get across the top with a tri force and I'll show you some slides in a minute. That's a try actual crossing system that I like for tough cases. And I was not able to access from the top despite multiple attempts, but I was able to cross from my access in the G. S. V. And what I did then was I snared my wire from below and was able to exchange for a stiff wire and able to redirect the wire down so that I had a good landing zone just above the propaganda. I then pre dilated didn't either stinted and post dilated, the same technique which Aaron discussed. And so here showing the access and I don't know if you can you guys see my cursor at all when I move it around. Okay, so here's the GSP access and I know that I want to land down here. So obviously this would have been too high of an access if I because I got across from here that I wouldn't be able to come down far enough and you can see my tri force up here. And I had attempted to get across this and had been unsuccessful. So directed from below and was able to cross and snare from right there. And then once I was across and had this kind of body floss wire I pre dilated. This was only a seven millimeter millimeter mustang because my IV's catheter would not go through my area. So this is like a teeny balloon that I used in order to be able to try this. And then I'm going to dilate again with a bigger balloon to the size of the stent. And this is after I've done the seven millimeter balloon, I've got my eye this in. These are some still I vous imaging I. V. C. Um kind of area of occlusion. And then this I believe was my landing zone here with some webbing there. But not bad. And then this should be a movie that shows the avis run going from groin, Davina Kaveh. After I've done the seven millim angioplasty. Or it might have been actually after I used my atlas balloons. But it shows, you know, after an angioplasty. Things are still pretty diseased. So you see a looming but it's not great and there's Kaveh. So that's from growing to cuBA. So then I ballooned to 12 millimeter at the groin and 14 above. I suppose I could have done 14 the whole way. Um, but that's that's what I did. So this is like pre dilating. Before I placed a stent. You can kind of see a little waste there. And then this is a wiki. And one thing to notice here is this area is pinched still and I landed a little high and I ended up extending here. And this goes to what Aaron said of going from good to good. And also that my ballooning ahead of time wasn't enough. Um so I had to kind of re dilate that and let's see here and then there's my final configuration and then post stent. Avis can groin to cuba. This one's going a little faster mercifully for you. Okay. And then this is her during the case I maintained her anti coagulation. I had not stopped her anoxia Perrin used I this at every step. This is her follow up duplex in the office and her leg symptoms were gone. Oops, her pelvic symptoms went away and her cross pubic collaterals are diminished and I probably she's going to have her varicose veins treated back in our home state okay? And she had some low back pain for a week. And I maintained her on an ox a parent. So usually on these patients, I don't know what brook and Aaron do, but I typically will treat them minimum. She's going to stay on it because she's not able to eat very well. Uh And one thing Crohn's disease, particularly with the eloquence can be an issue because of eloquence gets absorbed in the uh terminal ilium and the colon. So that can be a problem if patients are having diarrhea, that eloquent doesn't get absorbed very well. And with her Gaston paris is you worry about Xarelto. Um And so she's staying on an ox a parent but say she didn't have these digestive disorders. Typically what I will do is three weeks of an oxy Perrin and then usually I switch them to Warfarin for six months. Um and then sometimes switch them over to a doe ac what do you what do you do? Aaron And and Brooke I do I do the well I don't use Warfarin much because I worry about them going up and down and becoming subunit. But I basically do the same thing. I just switched them to eloquence after three weeks and then if they're ultrasound doesn't look great or they're still symptomatic, I'll leave them on it for another month or two and then recheck them and then switch. Yeah. And the other thing that's complicated about this lady is that this kind of nebulous of, does she have Antofagasta lipid syndrome or not? And there's a hematologist working with her on that. But that's the one. You know I feel very comfortable dealing with a lot of the hyper collectible states. But if they have anti foster lipid syndrome I usually have a hematologist helping and those patients typically are on a knocks a pear and depending on what their antibodies are. So with her you know it's kind of like I was really happy that I didn't have to convince her she needed to be on an occipital because most patients, a lot of patients don't like that idea. She was already bought into that given her this poor girl has these horrible digestive issues. So um you know for her none of the other agents make sense for a lot of different reasons. And the point that Brick brought up to um with her say uh say she she another reason Warfarin wouldn't be good is somebody that that's diet is really erratic. Like this gals there I and r. Can be all over the place. They can be really hard to manage. I did have one question. It looks like that popped up. Additional insight on placing the stent. Coddled cranial. So the reason that this stent was placed from the neck is there was not enough room from below. Remember I got into the GsD and then when I redirected my wire I did not have access out that I could have placed it from so I didn't have enough room at the bottom. Yeah. And I would say that I um I like the codel to cranial approach. Um when you, depending on the stench you're using if you're using a beachy that you know until they come up with their reverse deployment which is coming soon. But with the current beachy or with the wall stands it's easier to land that that front the top part of the stent. So if you're coming from the neck landing that right on the beach fonda is sometimes easier than landing the back end of it. Um That's a nice way to do it now again. Beachy. That's going to go away because they're going to have a reverse deployment system where I think we'll kind of solve that issue for them. But erin, I do, I do probably, I don't know, 150 ivy celiac reconstructions a year and for 20 years I've never had a fracture at the groin and since I put five beaches across the groin and four of them fractured with recurrent thrombosis in 20 years, I've never had a fracture. I will not put Avicii across the groin anymore ever. Yeah, and I'm really, really, I preach it and I'm adamant about it. I've put tons of bonobos across the ground. I've never had a problem. I put tons of walls, tents across groin, never had a problem. Tons of proteges never had a problem. I've had five PCI fractures in three months and I'm a huge VG fan. I used tons of beaches for my kissing steps in the iliac six. They're really strong. They're fantastic. The reversed appointment from the jugular is going to be fantastic for being able to put my turner stents in from the jugular without having to puncture the groin. But I personally wouldn't, wouldn't encourage using beaches across the groin, having put many of them in myself in the past. Yeah, I think that's a good point. This got this one I did a little earlier this year. I think that I would agree. I would not pick that at this point. We did a reverse deployment stent this week, um, and, uh, I'd say it was okay. Uh, you know, I'd have to put in a few more, you know, if you cheat uh to, to to say for sure, I love it. Uh they're difficult, it's a little stiff. Um, you know, it didn't move a little bit. So uh anyway, it was okay. I'll have to try more to to see there's a question about says iliac stent hugs the contra lateral wall. So it kind of looked like that on on the venogram. But if you remember when I showed the I this, which I'm not going to torture you and go through again, it actually wasn't touching the contra lateral wall. So, um, you know, I try to avoid touching the contra lateral wall if I can, occasionally it happens. Um So let's go to case presentation too. So this is female. That's actually a man. Obviously I didn't change my slides well enough. So the lesson with this one, um I think the lesson with the last one I could say was uh sometimes you have to go from the neck to be able to land it where you want. And even though somebody else has failed, it's worth another try. That would be I guess my lessons or three lessons. The third one is uh figuring out what you want to do for anti coagulation is important. So this one, I think the lesson and it's one that many people that do veins already know is that it doesn't really matter how old, is, you can still treat them right. I mean it's different than somebody that says Okay may or has been occluded for 20 years. Although we don't see that many patients like that because usually they deceased from other issues, But that even after many years you can help these people. So this is a man, not a female that had a motorcycle accident 40 years ago and had a leg injury. And um has these huge pelvic collaterals, left ankle oedema and large ropey varicose veins. He's not anti coagulated for years. People told him there was nothing that he could have done and he is one interestingly uh that he had a ct that also said that was not abnormal. Which is crazy. Uh To think when you see when you see his picture of his abdomen that they called it not abnormal. Uh So the difference with him from the last one is his femoral veins open. Um It does have some webbing and its large he's large femoral vein, large pro fonda. Gsp. And SBR patent. They're huge, they're re flexing. And he, other than a patient I saw in Nicaragua on a mission trip, he has the largest cross pubic collaterals I've ever seen. Uh maybe uh Brooke and Aaron have seen bigger ones. But he's you know it's like a picture of the biggest fish you ever caught. So I'll show you here in a minute. So he has an included extra iliac vein. It's calcified. So that's one thing on the ct that you could see is I think what they were calling normal was a collateral that you could see a strip of calcium on his C. T. He has a Peyton common iliac, it's not normal but its patent and his right side looked normal on imaging. So this is his cross pubic collaterals. So his whole pubic area is one giant ropey varicose vein. Um It's been you know this is a dude. What's that? You win. Those are the biggest cross public fam fam spontaneous bypass I have ever seen. They're huge. They're huge is gigantic and he's a skinny guy. Yeah, it's it's huge. Um So uh anyway um the left again the same physical exam I just said so I was able to, he was really actually a blessing to access because he's a skinny guy and he had a big femoral vein. So um this actually crossed uh my initial, I usually try to get across with the company and just glide wire, but with him there was the glide wire. Didn't want to go in a command wire went through. I just said I'll try command wire, went through pre dilate i this instead and this was done what I did him last week. So I don't have good after pictures and he was our first Aubrey case since we since it was FDA approved. Aaron did the and this was I think the second one done in the US and um post dilated so this is him once we've got across and you can see um kind of all this webby junk here. And is this the have a movie? This was supposed to be a movie. I thought is that not a movie? Oops, sorry, I'm sorry, I'm terrible at this driving thing. Um I thought that this was a movie. So you'll have to imagine, I'll pretend it's a movie, it comes here and then it goes through those collaterals and you can kind of see it starting to do that and here but no flow up. And then I did a pre delimitation with the smaller balloon because the office just like the last case got kind of stuck and didn't want to go. And then this was my common femoral vein and I was really happy with how big it was even though there are these fronds down here. So this is a big vein. Um and it measures that it should be with an Aubrey about 16. If you look at just like a slight over sizing when you look at the area there and then this is I think a very excruciatingly slow movie. So bear with me maybe we'll talk as we're going. So unlike the other one which went from bottom to top. This is I. V. C. To groin. And so here's our common iliac. So it's open but it doesn't look completely normal and you'll see a little further down it it looks worse. So here that's common iliac still. And then the internal it was narrow there and then there's the hippo I believe was in there and then our X. We're going to get to the occlusion in here. This is after I've already done an angioplasty. So here looks pretty bad and then here's my common femoral so I was pleased with how big it was. Kind of a gift. And then we're in the ephemeral. Okay, so then I pre dilate to chosen stent diameter, just like dr Murphy said And for him I actually chose to 16. Now one thing that's really important here you look at this, the stem has been deployed and this goes to what Aaron said is, look how funky it looks in here. This is before I post dilated it. So there's an open cell stent and sometimes they look funky as your before you post dilate. But if you look at this view and then look at this one, how much better the stent looks And it also looked much better with avis. So these are 2 16 millimeter hombres. I went right down to the trio cantor and then this should be a movie final venogram. It looks pretty good and you don't see the big warm doesn't feel anymore. Um that's the same thing. And then our post stand by this. Unfortunately I don't have any after pictures of his leg for you because I just did this last week. But I'm very excited to see whether those big wormy things get smaller. And then I have another question for the panel. Um my thought with those things across his growing, they're not going to go completely away and they drive him crazy. How long would you wait before you would consider doing flood flow back to me there? How long would you wait for those to shrink? I think I would at least do a venogram from way down low and make 100% sure that he's not still collateralize ng at all. Yeah. You know, and then if he hasn't, after 3-6 months I think you could take you could form um for victimising, whatever. That's what I was thinking was 3 to 6. I would I would study him, make sure everything was good, make sure he stayed open and then my thought was exactly what you said 3 to 6 months and then I think I'm probably going to be doing it to mess and assisted fly back to me because unless they dramatically shrink, I think that there's so bulky that and he's got also a huge GSB. We'll see what that one does as well. I'd be curious, Kathy I'd love to hear follow up because I had I had a patient that I can think of that had unfortunately we have a picture but he was included for 28 years and his his main symptom was pelvic pain from all these various you can see go across the abdominal wall and I can't find a single one now wow that's impressive. You know every they weren't quite that big but they were pretty impressive and they're gone. Yes so the gal that I showed you the first picture of with the kind of the very first one. So when I saw her back because she lives in another state I saw her two weeks after. They were I could still see them but they were substantially I would guess that they were going to go away and I don't I don't think I'm gonna have to do anything on that gal on him. I just have never had the person that I saw Nicaragua. We couldn't treat. You know he came in for varicose veins and he said that these aren't varicose manger included and we looked with an ultrasound and he was and I'm like we can't treat this here. Um So I don't know. And I've I've never had a patient with veins this big to see what happens. But I think brooks idea, you know, I agree with that. I hadn't thought of doing the ascending geography, but I think that that's probably pretty prudent to do. I was thinking of just imaging with ultrasound, but ascending geography is probably a good idea. Um And then I think just waiting to see how much they were model. Yeah. All right. Thank you. Dr Gibson yep dr spectra. Can you take control now? Let's see. So, okay, so same disclosures, yep. Okay, so so I as a crazy person and maybe as an interventional radiologist, you know, do a lot of chronic from a pop, it'll dvt recapitalisation which there aren't that many people in the country doing it yet. And it is, you have to be a glutton for punishment. It's very, very challenging, but it can be incredibly rewarding. Um, so I thought I'd speak to this a little bit. Um, I know we talk about the fact and the attract trial showed that PTS tends to be less severe with fem pop disease. However, if someone has a severe inclusion, which usually includes significant disease in the pop little vein, they can have significant symptoms and you can open the pelvis all day long as much as you want to and it's either not going to stay open because you don't have enough inflow or it's not going to help because the distal disease is, the pressure has not been relieved because there's too high level and inclusion in the femoral and pop itself. So, um, I found this shocking to me. This is a patient who is a dentist who is a fairly educated person who had been seeing. And this is by no means a dig but a vascular surgeon for a year and a half who said there's nothing that can be done lived in a rural area. There are lots of interventional cardiologist, faster surgeons who do this work. I'm not prejudiced on any level about that. I've heard. I've seen lots of interventionists who say things too. But this one happened to be seeing a vascular surgeon. And this is what the patient's leg ended up as, which is moderately horrifying to me. So, um a really talented um podiatrist did do some debridement, right, but was very worried about the healing of the wound. So we were able to go through the posterior tibial wreak analyzes fem pop. You can see a significant reduction in adama complete change in the guy's coloration and now he has a pink vascular, you know, granulomas, bed of tissue that can heal. In fact, they've been talking about doing a skin graft on him. But because the edges of the wound have been healing so rapidly there thinking that he's just going to hell without even needing a skin graft. So I think that there are a lot of people who kind of pooh pooh the significance of chronic them pop disease. But I think in certain patients, it's really critically important to to understand that it exists. And if it's not something that you or even anyone in your area can take on people who are this bad, are willing to travel to people have a lot of experience doing it. So what do you do if you have an ultrasound, you can't really tell do they have too much distal fem pop disease? You know, their funerals open above the knee, We think it's probably fine, but they have a wound. What happens if I'm going to take out the staff and spain? Are they going to get better worse or stay the same? So you can always do a venogram from a poster to Melvin approach. The problem is the access is very challenging when people are really diseased. But if you can get a good venogram, for example, in this patient, you can see this patient had a knee replacement, horrible dVt. Every vein in the calf is severely scarred. The vessels are tiny. The papa till vein is essentially included with a tiny string in the femoral vein. And the only way that this calf is surviving is through collaterals through the great staff. In this vein. If you take out the great staff, it is vain in this patient. This patient is in big trouble because there is not adequate deep venous flow. So if you're not sure, then do a venogram and it'll help you understand to what level you're using the great staff in this vein for collateral ization. So, you know obviously it's abated question. But you know what happened to this patient, right whose skin was originally intact and had lower extremity swelling and venus insufficiency and bilateral fem pop tv T. S. You know, do they have nothing done? Did someone stent their pelvis and think they had adequate flow and then oblate their softness veins or fail recapitalization. The magic answer is they had their pelvic veins which were about 50% narrowed stent id. That led to a sense of comfort that the deep venous system had been fixed, lead to treatment of the saxophonist veins and the patient had nearly exclusive disease in bilateral. These wounds have taken me five years to heal. Um Three interventions on the right leg to get the papa Children to stay open, cutting balloons, terra tola echoes, repeated angioplasty. And we finally, after hyperbaric therapy graphs and everything else are getting this guy healed but his skin was intact before that intervention. So I just make the argument that fam pop diseases in something that should be ignored and it should definitely be evaluated for um in patients with a history of significant DVT prior to treating superficial veins. So how do you do that? We talked about ultrasound and I know there's another breakout session going on right now for stenographers, which is fantastic. The the key thing is to look for the signs of chronic DVt, which include wall thickening, a reduced Luminal diameter, compensatory enlargement of the refund to say Nicaea webs and stranding in the veins and collateral ization. So it's all well and good to say that on a slide. But what does that look like? Okay, so this is an ultrasound where you know the patient's native femoral vein which is usually below the artery. On the ultrasound imaging is almost completely occluded with a tiny channel. So this small vessel anti really is either a duplication or a collateral vessel. The other thing is this is a vein that was called normal by a radiologist. I can say this because I am a radiologist. I'm in complete agreement with Doctor Murphy and DR. Gibson that the majority of these imaging studies are read incorrectly. Both ultrasound MRI and cat scans. So you've got to learn how to look at this yourself. But if this is the artery and this is the vein, the vein should always be almost twice the size of the artery. So if the vein is significantly smaller than the artery, The wall is thickened and the Luminal diameter is only three. This is a pretty severe chronic DVD and often will be read as a normal or recapital,ized, deep main um Which to a primary care doc or another physician who doesn't have the knowledge or understanding of the nuances is going to think that everything is fine. So this is a venogram in that same patient where we can see a big web up through the middle of the vein. The femoral vein approximately is very narrowed. There is um there is always a collateral at that adductor hiatus that goes into the profundity memories. If you see filling of the profundity memories, the patient has elevated venous pressures based on obstructive pathology, in the femoral vein or more approximately. So there is no such thing as a well collateralized vein in the legs. These are symptomatic. And if you can get through this and do high pressure, prolonged balloon angioplasty, these people do really well. This is a nice example of kind of before where the vein is kind of a mess. There's collaterals all over the place, there's filling of the staff in spain and after a prolonged balloon angioplasty, you can achieve a smooth channel with a single vascular channel of flow. So how do you do this? It's really challenging. But when you can see a tiny little string in the sea of abnormal veins, you're going to engage that. I don't use regular diagnostic catheters for any of my venus work. I only use tapered tip catheters. There are lots of them on the market. The quick cross is a great catheter. And then there's lots of others. These guys talked about tri force which seeks. I buy cook. The only thing that I'll warn you about that catheter is that where the catheter is soldered together? The C. X. I. About 15 centimeters back from the hub. If you're truly in a tight obstruction and you spin the catheter it'll fracture off. And I've had to take about six of them out using a snare and pull the catheter off my wire where you slide a micro snare over the wire, grab the catheter and pull it so I don't use it as much anymore. But Rubicon catheters work knave across. It doesn't matter. But a regular diagnostic catheter will not work to get through an obstruction this severe um And the technique is to put a small amount of wire out and then spin the catheter. You have to have both hands on top of the catheter. You can go forward, you can go back, you can go forward, you can go back and the pushing is kind of gentle, so it's a balance between finesse of spinning and force. If you push too hard to just buckle the catheter and we'll make it through the obstruction. So I call it kind of the sneak approach. It's a little bit of wire, a little bit of catheter, a little bit of wire, a little bit of catheter until you can get all the way up through. If you extravagant or puncture. If it's truly included like this patient, it's not the end of the world, there's no flow, they're they're going to be fine, but you may have to pull back significantly to find a separate channel of flow to be able to get back through. Because there is no such thing like the arteries where you get in a dissection wall and then you can get back into the true loom. And I've never been able to do it in a successful or a meaningful way in the veins. So if you're able to get through, like in this patient you can do a venogram of the pelvis and then I use an advantage wire but I find amplats wires to be really sticky. The glide wires are really sensitive to come in and out and then you start doing balloon angioplasty. Sometimes you need a four millimeter balloon to be able to actually get larger balloons through because it's so severely scarred. Sometimes even when you're you have to stop and balloon behind yourself with a small balloon to allow the catheter to be freed up from a long segment of included vein to be able to advance through more so these cases can be really painful. I used to angioplasty with a six millimeter balloon first. Now I go straight to a 10 millimeter balloon in the femoral vein. Uh So if you angioplasty with a 10 millimeter balloon, I leave it up for two minutes to stretch its like a rubber band. If you stretch quickly and let go it snaps back shut, you have to stretch in a prolonged fashion. So these patients have to be treated asleep with general anesthesia. They don't tolerate this with conscious sedation and they never will. Um I have three or four patients who say they have severe ptsD and have been in counseling because of physicians who tried to coax them through a procedure like this um without putting them to sleep. And it's been a big problem for them over their life. So I wouldn't recommend trying that with sedation. And then when you end up with their regularity that's persistent inside the vein like this. And some of the smooth segments, I go back and use an eight millimeter long balloon that goes up to 20 atmospheres And blow that up at very high pressures again and find a lot of times you can smooth that out and track that down. So in 90% of the patients, I do not use echoes or overnight thrombosis. I don't think there's a huge role for thrombin lyrics and chronic DVD when you biopsy it or take it out, it's type three collagen. It's not dissolvable. But I do think there may be a role with the echoes catheter in the ultrasound activity. In some of the patients who have persistent irregularity in the vein, it's about 5% of people that I can't re establish flow. And I do find that for whatever reason, if I drop them in a very low dose, I use a quarter of a milligram an hour or less of connected place overnight with an echoes catheter and I can bring them back the next day and they're either open or I can re plaster them um and they'll stay open. I've also used cutting balloons and tear it OLA and other devices. But I don't recommend doing any of that unless you plan on doing a lot of these and having experience with it because they're all fraught with their own potential issues or problems. So this you know you don't get a beautiful result. This vein doesn't look wide open. But if you put these people on Lovenox and you follow them carefully, you make sure they're anti tenure is therapeutic and not super therapeutic. There are very few complications associated with this and it's really hard to make these people worse. They're usually very symptomatic and most of them have ulcer disease. So you know that's my little spiel on fem pop disease. So I think it's super important if you're in an area where yourself or your or your referring docs don't do this to look around natural because there are people who can do this and achieve this and it can be really life changing for these people. Look, there is a question on here that how do you maintain maintain potency in the chronic fem pop? Um and is there ever any time you consider stenting that? So I would never consider stenting it, remove it from your vocabulary. The answer is never, Never. Never and never. So the problem is you have to think about this like it's not you know, stenting is for trees that are upside down. So when the iliac vein is a giant trunk at the trop and all the veins come in at the groin. You can stent the trunk, you can never stent the branches all you do by stenting the branches is include all of the side walls, all of everything else. So the answer is never stent below the confluence of the profound and the femoral vein. It doesn't work. I will tell you that. I don't know if Aaron and Kathy do this. I'm a little jealous of them that they have the opportunity to potentially do or learn this if they wanted to. But I do think that um I have some vascular surgeon friends who will if absolutely necessary, which is very rare to a cut down on the groin, take the junk out of the common federal vein and provide a confluence patch the vein and then stent into it so that there is adequate flow there. And I think that that's not a totally unreasonable thing to do. I'm a little jealous that I can't do it. But what I would say is that I would not spend into the proximal femoral vein. Yeah, I concur with that. I would never sent the femoral vein. And um, I just did one of those cases a few weeks ago, um That but it was two operations to get it right, but it now looks really good. Yeah, and I wouldn't be too jealous because it's the ones I've done are excruciatingly long. Um you know, but I've had a couple of work. I'm glad that I don't have to do it very often because it's salvaged the hardest patients. It's very hard. And the other thing is, they tend to get lymph vessels. I mean, I think that in uh c c suite case Witten's um in the Netherlands, says a lot of these and he puts backs on him right away because he's had so many lymph vessels. So, lymph vessels are pretty common when you do this procedure. So, that's kind of a last ditch kind of thing. But I think at this point, what we're hoping is that we're going to come up with devices. A lot of the companies are working at this is that can help to remove some of this stuff in a per cutaneous way that will allow us to do a better job at the groin. So, for me, one of things I'll say is that I know the vascular surgeons do it. And so maybe it's something I could learn from them. But I haven't really been able to do it. and yet I can't I can't swallow it yet. I never access on someone with a central and iliac conclusion. I would never access the sadness or the common federal or the proximal femoral vein. I would always access the pop little vein. I do it with them supine and I try to go in the small staff and it's paying just before the pop little so that if the sheets scar the pop little, it's not a problem. And if they have disease in the pop until I go in the post, you're a tibial, I go through I angioplasty the whole inflow disease and then I get access in the pop little to get through the whole thing. It's a pain in the butt. But if you don't have adequate inflow and you sent someone bobby Mendez who is a friend of mine in Raleigh north Carolina is a vascular surgeon, was a resident when I was uh an intern in general surgery at U. N. C. A long time ago um was telling me he used to work in construction and I think this is a really great analogy. He used to mix cement you know in a bucket and if you drop a cement ball it will shatter into a million pieces. But if you put chicken wire inside the cement and you pour the cement in it solidifies it, it makes it solid like a rock, you can drop that cement and it will stay stuck together. So I think the analogy is that if you stent incorrectly and the patient seclude the obstruction is worse than it was without a stent in the first place. So you have to understand that you have adequate inflow into that system before you place a stent and you will not do harm to the patient, even if you've gotten through and you do an angioplasty, even if it goes back down, if you don't place a stent, if you don't know what you're doing and you don't know you had adequate inflow or outflow. So I don't recommend trying to put a stent in or learning on these patients. You really need to know what you're doing, Have a mentor, go somewhere and train with people who know what they're doing. If you're starting to see a lot of it or send the patients out and I've had a lot of people tell me for the big reconstructions that the patients can't afford to fly out. The problem is when they try to reconstruct them, they end up worse and they end up having to fly out no matter what. And now they've had double expense, double cost and double problem and it won't work. So this isn't stuff to dabble in, I do think people can do, make her understand silly accidents and they can learn those fine, right? But when you're talking about extensive ivy celiac disease with chronic them pop disease, really, really, you don't even want to do them because like Kathy said, I mean I've done nine our cases fairly regularly, they're really painful. So anyway, the last thing I wanted to go over real quick was kind of my version because I think the world is putting a lot of more may thinner Stenson, the more we learn about this being a problem for pelvic pain, um and other ideologies other than just DvT and lower extremity swelling, the more it's going to be happening. So I think a couple of things I wanted to talk about that erin was making fun of me for being a super nerd because I kind of am a super nerd, was to talk about Murray's law, told papa Murphy's law actually, I really wanted to hear. Okay, so I'm going to tell her about Murphy's Law. We'll call it Murphy's Law for tonight, although Murphy's Law, you know, that can be scary, but you know, we'll call it erin's law. So anyway, we're going to talk about that briefly and then I'm just gonna and then we're going to wrap up and let you guys ask some more questions. So okay, this this so this equation makes people's head spin, right? It's basically says that the cube root of the radius of the parent vessel should equal the sum of the cube root of the radi eye of the daughter vessels, which means absolutely nothing to most people. But what i it's an analogy that, like gravity has an equation, and it's a fixed law of nature. So Murray's law is the law of efficient flow and the sizes of vessels in a branching system. It's been proved in arteries, in bronchi and silom of plants. So when people are talking about stents sizing, you really can't choose appropriate stent sizing unless you know Murray's law, and you must know the size of your inflow vessel, and you must know the size of your outflow vessel in order to size extent correctly. So it should never be based on what you think the size of the vessel was supposed to be. So when you do the calculation, this is what it means. If someone's average diameter of the inferior vena cava is 17.6 millimeters, which is very common in small women. Their common iliac vein should be 14 millimeters to optimize flow. So you do not have to put a 16 millimeter stent in a person who has a small inferior vena cava. And in fact, you will not optimize flow by massively over sizing that stent to the same accord. If you have a large person with a 27 millimeter inferior vena cava, and you put a 16 millimeters dent and you will also not optimized flow in that patient based on their size of their vessels and how they're branching system should be. So if you don't learn anything from me in this talk other than this, I think you want to think about this or keep this in the back of your mind when you're trying. He used the intravascular ultrasound and non traumatic patient to their own size of this tent. But the size of the inferior vena cava is also important to take into consideration. I think. So how do you avoid stenting too short, too long or putting in the wrong size tent? Well for people who don't do a lot of this, you really have to have the area you're gonna stent in the center of the field. There's a principle in radiology of parallax where if something is on the edge of the field it's not actually a true position within your field. So if you're trying to land a stand accurately you need that part of the image In the middle of your screen and it's really going to help the other. The other trick is that Aaron showed a really cool picture earlier of a wire going way up the left side of the abdomen and then crossing over at about L. two. The the iliac vein comes into the inferior vena cava just to the patients right side of the L. Force finest process on 95% of patients. So if you're looking at your wire and that's not where it is. You should be checking anyway. But double check again because you may have moved the wire or you're not in the right place. So what does go through one quick case of a 38 year old person? Severe pelvic pain for years. It's direct me who freaked me? Endometriosis diagnosis worse after surgery. Left groin pain, leg pain pilo nephritis. You tease bowel symptoms. They all go along with dilated sacral venous plexus and epidural veins from cross pelvic collateral ization and pressures. Um And the C. T. V. Show to may 8th earner. So here's a you know a venogram that shows that with injection of the patient's iliac vein we have retrograde filling of the internal iliac and cross sacral collaterals with a lucid defect from the iliac artery. And then we're gonna do the intravascular ultrasound that's gonna pull down from the I. V. C. It's going to show you a reasonable size but fairly small I. V. C. Then we have a crossing vessel where the iliac vein becomes severely narrowed in this patient Almost completely pancaked. And then we can see the vessel returned to a more normal caliber. And that's where we're going to measure the side of the patients the size of the patient's native vessel. I always match 1-1 or slightly larger. So if it's 15 I put in a 16. I don't put it in 18. I think people are over sizing the new stents that are very very stiff and very strong. It's very different from the old wall stents. Okay then I know this may sound hokey but I literally draw on the screen where my vessels are on the venogram. I draw where I see the crossing vessel. And then I use intravascular ultrasound to identify the top. Now I know Aaron said you always extend into the external iliac. I don't do that but you better be pretty experienced if you don't do that and know how to size these stents correctly. But when you have a big mismatch like this person between the common iliac and the external iliac. If you put a stent all the way down into this, you're going to get what I call the snake that swallowed the human and you're gonna break Murray's law. You're going to get altered flow dynamics and a lot of time you get chronic organizing from us inside the stent because of that. So in this patient I would want to put a six centimeter stent in and land at the bifurcation here. But if you do that you have to know how to interpret your I. V. S in your venogram very carefully. Yeah. And I would add book the reason. One of the reasons I really advocate that is we we do see a lot of mis sized tents that are short they are getting displaced. Um And also I'm starting to see with the nightingale sense in particular. You see how your I don't have to tell the street but the angle of how that left coming off I'm starting to see a lot of short night. I shouldn't say a lot. I've seen three of them now. Short night no stents landed that start to eat through the vein on that right side because they're so like you said they're so strong and they tend to straighten that they basically straighten that curve and eat right through the wall. So I've seen so I I agree with you that when the angle is very horizontal, I've seen that. And with the vinovo stents, I've seen the flare stick out and make people feel like they're poked. So after you've placed the stent, if you see that, then you use a wall stent so that it can match the size of the top and you pull it around the corner to make sure that you do not angioplasty. The lower part where the vein is significantly smaller than the stent at the bottom. So I totally agree with you. And so this is where I don't think people should be going to a weekend course and picking this stuff up, it's very sophisticated, that much more difficult than people think to do accurately process. And in addition, when you do the ibis, you need to you need to drive us there. Now I will say that with a nightingale stents. If you're going to have the wire bias on the margin of the I. V. C. Like this. You want to start your stent right at the edge of the artery. You do not want to stand into the I. V. C. Because the stent itself will extend fairly far into the inferior vena cava. So with a nightingale stents, you want to start it here and then pull it back so it's right there and it's sticking out like this and then before you do that, you better come back and measure with IV's where it is. Whether it's problem is you really don't ever want to land eight or nine millimeters because that is right in the curve of the iliac and you never want to land on ivy's where the bifurcation of the internal and external iliac are. Because you will end up with a stent up against the wall of the vein instead of in line with the wall, it's going to be up against the wall and you're going to have to fix that also. So I'm encouraging all of the stent companies to make 70 centimeter stents because right now there's only 60 or 80 or 90 and those are the wrong size is so if anything, they should make 70 75 eighties, but it's not what's available right now. So the other alternative is to put a larger stenting come down here. The problem is that I'm starting to see a lot of stenosis at the bottom of the stent where the bottom of the stent is too large for the vein at the bottom. So I think it does require a significant level of sophistication to be able to put these stents in sized appropriately and accurately. And if you undersized these tents they will move and go to the lungs. If you oversized these stents, the patient will have unrelenting painter thrombosis of the other side. So it's not something to dabble in that being said when you do your intravascular ultrasound, if there's a tiny bit of incomplete wall opposition at the top, you're fine. But you have got to make sure that you have at least two full centimetres of complete circumferential wall opposition on that center. It can move. And if you don't you better put a second stent across it. Or maybe you did a long stint in the first place. But I agree with Aaron very much now. Um I've been putting in I put in probably four or 5 500 beaches in four or 500 vinovo. So I'm excited. The Aubrey stent is coming out. I think it will fix. The problem with the vinovo is where the flares are actually undesirable some of the time, some of the time they are desirable. I think the beaches are fantastic stent and we can now deploy them from the other direction coming soon. That's trickier than we think, but I think that's going to be a benefit. I think each one of these stents has its own benefit for different reasons and we'll learn more over time. But the key is you never want to do this, you never want to place that stent a full two cm too short because you're placing it like an arterial stents just at the bifurcation, which is what happened in this 20 year old girl. So this last one I'll show you here is just this is a venogram where people say that's normal. There's no collateral filling, there's no way sending lumbar filling. A retrograde filling. This is the after, after the stent. This is the this is the before of the iliac vein. This is the after the non healing wound that wouldn't heal healed for five or six weeks, healed within five days after stenting that patient. So you really need to use intravascular ultrasound. I'm in full agreement with Aaron and Kathy that you can't do these cases without ibis and I wouldn't even start trying. Um So uh in the end I think in the interest of time and for questions, I'm not going to go over these slides, but if people want to see them, they're available. It's just three quick slides that list the major studies that have been done in acute DVT. And then the conclusions from those studies that show that there are high rates of Pts. And the bottom line is that every single study showed a benefit for thrombosis in ilia ephemeral DVT and the bleeding rates have been significantly reducing overtime. So unfortunately the attract trials, end point was basically a normal patient. You could not prove that you can't treat them pop DVt from the portal vein. So they had no chance to prove that that would be an improvement. And in the iliac femoral population they did show a significant reduction in moderately severe Pts to mild Pts. So to prevent all these nightmares that we've been showing you on all these cases, if you have a young patient low risk for bleeding with L. E. Ephemeral DVt, there's no question that patients should have thrown his removal and I would second that and Kathy you give that a third. Yes, absolutely. You know. So I think that the attract trial for people that were doing this before, there was nothing surprising or different than what we do now, meaning that patients with federal Pop little DVT that's not involving the iliac segment, probably don't need license in most cases and watch out in the very elderly patients and treat the patients with severe symptoms. So I think that that's what most people were doing before. So if you do, you know, kind of a deep dive into the attract. You see that all of the conclusions aren't that much different than what we normally do. If you look at it. And I think the future will show that young patients who are hyper questionable with extensive fem pop tv t should be LISZT from a posterior tibial approach. The bleeding complication is almost nothing. And if you're 25 getting a DVT, you have a severe kogel apathy. In your lifetime outcomes are very, very different from someone who had a knee surgery at age 50 or 60. Yeah, we have a lot to learn. I agree with that. I see quite a bit of fem pop inclusive DVT Pts and patients who aren't supposed to get pts. Um so I I concur with that and I don't think we should just necessarily discard our friend pop. And one of the things that bring in a question off to the side about regarding I this evaluation in the black veins, how much influence is to be expected by an obese panis in prone position. I'll tell you, I don't do this in the prone position ever. I don't do any DVT work or any venus work in the prone position. There's tons of data from spinal research and spinal surgery striker who did a lot of work with their tables for the patients with elevated pressures and Batson's plexus during spine surgery and bleeding. There's lots and lots of data to show that they're significantly elevated inter abdominal pressures and venus pressures that occur with especially with obese patients in the prone position. So I do everything I do pop Little access to real access jugular and ephemeral all with the patient's supine. Mhm. Yeah I don't I don't do anybody prone either. Thank you. Dr spencer dr Murphy and dr Gibson. We're back in the main main group with everyone but that was outstanding. Thank you once again. Yeah you're welcome. Thank you for having us, mm.