All right, up next we have Dr. Nathan Fagan, he's at Akron Children's, he's an interventional radiology doctor. He's been at multiple Ohio Children's hospitals too, so many of you probably know him. And this is our favorite topic of putting lines in. Well, thanks everybody for having me here. So, you know, we are going to talk about some updates, but really the main point in my talk is, please don't forget about your friends interventional radiology. So we're really happy to help you with these problems. You know, these can be very complex patients. And also, we love troubleshooting very simple things that can also be very powerful. So at that point, we're just going to kind of talk about a couple easy ways that I can kind of help you. And then where the updates come in, I'm going to show some new technologies that, you know, if you guys have complicated issues and access, you can come talk to me. But really, again, if you take anything away from this talk today, it's the power of friendship. So I think of us in IR and with my surgical colleagues, the kind of two halves, the same coin, right? And really, with these patients, there's a lot that we can benefit from one another just helping out. So, but, you know, I have a whole thing here. I was going to compare you guys, you know, you guys are Superman and I'm kind of Batman. And we're mixing a guy or two. And that might be why you guys forget to call us sometimes, right? Because like Batman's a Lou, he likes to hide in the shadows and he has to put the backside up and hope that he shows up. But I will say if you can get a hold of us and talk to us, we will, we love to help you with these cases. And so let's just move on and get talking through a case. And so, and this is, this case kind of spurred what I want to talk about today. So the clinical scenario is just a real simple thing. It's a teenager with a left-sumclavian dual-lumen port that the history of some clavian thrombus around that line. They were successfully treated with Hepron. But, you know, the surgical team was consulted because love behold, the media aluminum won't flush. Lateral aluminum looks like, looks like a dream, but the media won't do anything. So I don't have any poles. But I kind of wanted to, you know, I just kind of want to pick everybody's brain in the room. So, so here's the chest X-ray. Any thoughts on what you would do next? And keep in mind, this is not a, oh, only the radiologist is going to figure this problem out in the room. This chest X-rays are otherwise normal. But in that clinical scenario, what would you guys do in the room? What would you guys do next? If you had one aluminum, it didn't work. Yes, you. Thorsten. Would that be the die? Yep, die study. That's good. That's good. Any other thoughts? Ultimately. Altemplase. Altemplase is another good one. So they couldn't flush the port at all. They couldn't get anything forward. So that's why they didn't try altemplase. So initially, what they, you know, what they came, they initially consult with surgical teams, surgical team got a hold of me and like, hey, let's do a die study. But they wanted to done the same day and I couldn't do it because I was busy. We only had one room and they would took up, I pretty much took up the whole day with cases. So they then contacted the APPs on surgery and they, and the APPs are okay, well, you need it. We'll just take it out and replace it. So any thoughts on that? Would you just take the port out? Would you just do it the APP? No, I, yeah, I agree with you. So don't, don't do that. And the reason why is, you know, sure it could be a whole bunch of complicated things that could be due to an air ring, like I have, like I have up here. But really, it's Occam's razor, right? It's almost always a simple problem. And I'm glad they called me. So here's some intra-procedural pictures. And the first one to laugh is I haven't done anything yet. But you can see they've accessed both of the loom, both the loom ends, both loom ends look fine. And then the picture on the right, it might not be projecting well, but I was pushing very hard to get contrast through. And there's just a little bit of contrast kind of welling up into the around the port and in the pocket itself, and not actually going to the reservoir, right? So this was a, so this was a really simple problem. It just wasn't accessed, right? So and then all I did was I go, well, I reaccessed it, you know, and it worked in a flush like a dream. Yeah, so, so it was a beautiful port, no problem at all. But this kind of demonstrates my point, right? Right? Yeah. Don't forget about, don't forget about us in IR. I know sometimes we can be busy, and like I said, we're a loophain hard to find. But we can help you with really, really simple problems, right? Because if you think about it, why is this so powerful, right? You know, like, okay, Nate, this is stupid. Why are you showing me this, right? Well, think about it, right? You know, they were going to put, you know, the surgical team in a bad situation. They just, you know, the hematology oncology team wanted the port now, and so they set them up for every move or replace, right? And so the patient may have gone through a whole procedure or a whole thing that they didn't need and the requirement of recovery and all of that stuff for just a poorly accessed port, right? The other thing is, is there was an ultrasound read at some point that said, hey, there might be some, a loo, some narrowing around the port catheter itself, right? And so, you know, what happens in that scenario? If you just pull the port catheter out, right? You've not lost my, you've not lost any potential access for us to kind of work together to kind of maintain it. And really, I think that the most important point, and I have no data to back this up, but I think that things like this kind of start, this cascade of what I call, I'm sure you guys have heard this before, the vasculopath, right? The patients who have like no upper and lower central access, no normal access to the ones that have to go through the weird ways. And I think that simple things like this are kind of what start that cascade, right? Like odds are, if they would have pulled the left subclaiming port, they may have put a one on the right side totally fine. But now, maybe the left side would have went down and now we've lost a potential point for future access, which is a huge problem. So, okay, so what if I'm, so what if I'm wrong? So, what if it doesn't matter if you get IR involved at all, and you're still going to end up with these vasculopath patients no matter what? And so, we can still help in those situations. And so, and these updates we're going to talk about are not really, there is some new technology, but they're very, they're well hashed techniques. I just think we use them more in the adult world a lot. And that's the reason being is a lot of these, there's more of these vasculopath patients in that population because they end up having more a hemodialysis lines to the chronic renal disease, and therefore everything goes away. And because of that, I think that we don't know, a lot of people forget that in the pediatric world, you know, we can actually, we can do these techniques as well. So, but before I go on, how many, how many people in the room have a dedicated PDIR team? Okay, all right, how many, how many people in the room have like adult center covering for you? Okay, is it, how hard is it pretty hard to get a hold of them or they're pretty easy? Good, that's what I like to hear. So, so, so, that tends to be my experience is sometimes they can be hard to get a hold of. But again, still keep us in mind, throw up the bat signal, page us. Sometimes we could be, you know, pretty, you know, difficult to deal with, but we're always wanting, usually always wanting to help. All right, so, so what if we're dealing with one of these vasculopath patients? So again, this is not a new technique, but how can, but how can we help, how can we help this? So, a lot of times some patients might go to like the more, the more complicated forms of access, which I'll touch on later, but something that we can do in interventional radiology is we can do a sharp recanalyzation of the SVC, okay? And the most, the most basic way of doing this is is we use ultrasound to look at the jugular vein and then some combination of floro and ultrasound to guide a really tiny needle through the area of stenosis and through the SVC beyond this stenosis and into the right atrium. So, full disclosure, these are not my pictures. I tried to get some pictures from my prior institution, but my, my colleague is a little slow with replying a text messaging. But so, but the technique is relatively the same. So, I'm showing two different techniques here. So, the one on screen left is what you're seeing is you're seeing a contrast injection from above. There's a little circle there. I don't know if it projects very well, but there's a little circle here which is a target that the interventionalist is then gonna come from below from the femoral vein to use to try to drive a needle through that target to connect the two. It balloon-plastic the stench and then go ahead and place the line. And so, in the, in the, have the patient leaves the room with a perfectly functioning line at that point. The screen right is another technique. It's just basic, the same, basically same thing just showing two ways to do it. Instead of using like a circle as a guide, they're just using a, they come from below, blow up a balloon with contrast and then try to jab that balloon with a needle. And that sort of acts as like a, kind of a safety net. No, I hit the balloon, we're safe, we're not outside here. And then they go through the same steps and place the line and go from there. Questions or comments about that? No? All right, Justin. All right, this is actually, this is my partner Nate Heinz, a links patient. This is a patient with intestinal failure. It lost all traditional access and this predated you or we would have just told you to do it, I guess, using that last technique. But has anybody done this? Thorick is Gampic? One, two. Where are we going to do there? Like Thorick is Gampic approach for... The cervical approach. You're going to start with the guiding. Yeah, like to get below the equation in the SVC. You got the video of the solid that you're going to see in one. We forgot to hit record, but there are videos. So, are you going to... I think it's worth taking 30 seconds to explain it. Have you seen it or done it? Or do you want... This is our patient. We've done it. You were there with Nate. Yeah, I didn't know if you were... Okay, he did it. This patient survived. Because it's worth explaining, because I had a hundred percent of survival mark. Well, Tom learned it from Keith Jorgison. And I had to have him really explain it to me. Yeah, it's actually pretty easy. It kind of feels like doing the laparoscopic inglorerino repair. You stay inside the plura. You can use ultrasound and see where the crotted is. You obviously won't see an IJ. It's completely occluded. But you stay interior and a little lateral to the crotted. And then you see it. You want port to insulate and see inside the chest. And you basically get the access. And then it's just a regular central one. Yeah, that's the needle. Yeah. Yeah, so this is a great technique to show. But, you know, I've been convinced that this is maxly invasive compared to our radiology colleagues these days. But definitely something to have in the armatee arm. The end of the system. I was just curious about making the angle around the clavicle. Like when you put the, when you put the dilator down and then you put the, the sheet or put the catheter through it, does the catheter still function? Because it looks to me like it's a really sharp angle around the clavicle. Yeah, it's, I mean, it's just an IJ. I mean, it's, you just make the same curve in the neck and tunnel it down. This is for a broviac, but tunnel down to the toe. Okay, so you're going above the clavicleer. Yeah, you're going. Yeah, I guess just above the crotted in the neck. Just like you went in the whole life. Yeah, and you'll see when you die. You die, you die. It's kind of the same. It's very, you see the whole thing because it's seafir, but you'll see the wire and then you'll see the dilator. You get like a little bit of echinmosis in the, that floral space just to ignore that. It'll stop. And it works really well. So for the, you know, this sort of predated him. No, doing on spot. No, during. No, no, just. No, but still, though, I can imagine it's like, you know, if I show these pictures, it looks real, you know, it looks real easy, right? You know, no big, no sweat. But I can imagine a scenario that maybe, you know, I get in there or something that might not go quite as well as I wanted to, right? Or it's just not working, or I don't think it's safe. And this is a, you know, this is not a bad option in that scenario, too. Yeah. And usually the, you know, the clot and the scar are kind of more up in the neck. So you've got good SVC. You can access there. Any other questions? Comments? Yeah, I'm going to make a little plug. So on the new version of Stay Current, there's now a way to direct message anybody. So I'm going to offer out these guys to direct message them because whether you have telementoring in your hospital or you can honestly carry a rig it, it was really helpful for me to have somebody mentoring me virtually as I was doing my first one. So I really think we need to do better as a community by messaging each other and reaching out and saying, hey, can you show me how to do it? I'm going to do this for my first few. So I'm offering up your help. In of one thing. That should be good. More than most. I've seen one done one and I'm ready to see someone. All right. So we're going to go on kind of the more, we're going to talk about new toys essentially. Kind of the way that I think that the technique might evolve in the future or ways that it is evolving now. So there's this newer thing called it's the surface earths made by Merit Medical. It's basically image guided SVC recannulation using a special piece of equipment. And it's not going to work in all these patients. I think it's probably going to work the best when there is at least a remnant of something there that you can get through. But if there is something, I think this might be safer than me trying to jab a needle down there and get through into the right atrium. So the way this works is the patient has to have a patent femoral vein. We come up from the femoral vein and get into the SVC right in the area where the clot is. And this is what I mean. If you don't have a remnant of something, you can imagine this not working, right? But you have to bury this special catheter where you want your exit site to be. And then we can use a special, on our machines, we can essentially draw a target that we can kind of use, you know, 90 degrees where we think we're going to come out of. I think it's like, yep, I submit them out of order. But so this is the next step. So what you do is you kind of define where you want your target to be and then you move our big X-ray machine around. So that way you can see that little marker on the catheter come out of where you want your planned exit site to be. And then what you do is you drive a special needle through the catheter that you pulled up there, pulled through the skin surface and now you've got through and through, you've got body floss, through and through access. And then over that, you can go ahead and drop your sheath and then drop your catheter like you normally would. But again, you can see how this would, this is probably good in a lot of cases because we tend to deal with more acute clot in the pediatric realm as opposed to the chronic like, you know, start up. There's just nothing there. So this might be really good for our patient population. But so where I'm kind of interested in something that I've kind of, you know, toyed around with is this in our, in the ones that are harder to get, harder to deal with, the ones that might require sharp recalculation. So there's this thing called 4B ice or intracardiach echo cardiography. So it's used more in cardiology. They use it for their procedures, you know, their ablations or left atrial appendage occlusions. But you know, could I use it to drive a cat, to basically do that sharp dissection safer as opposed to guessing with fluoroscopy? So this is what the thing looks like. It's basically a special, special kind of ultrasound probe. It's got a whole bunch of doodads on there. All the companies make them, GE, Siemens, Philips. But the cool thing about it is it does this. So what I'm showing you here is this is from the Siemens website, but it's a cathode basically projects a ultrasound wave in all 360 and 360 degrees. So then you can reconstruct that image in any way, any plane you want. You know, whether it be anterior post, your inferior and then you could use the, you could use all the pieces and parts on here to kind of twist it any way you want. But the idea being is that I know this image is confusing, but just pay attention to the bottom right. So what that showing is is that these are pictures of the heart of them doing a right atrial appendage occlusion, but they're, they're essentially projecting all three different planes during the process with just one catheter. So my thought is if we can do, if we can do that with that special catheter, can I, instead of just driving a regular catheter up to where the occlusion is, can we take one of these special catheters up there up to where the occlusion is, get access, get access from above with a normal ultrasound, then use this special catheter, reconstruct and just guide the needle across the occlusion. So nobody's doing this yet. We're using these more for tips, but the premise is still the same, right? Can you guide the needle intravascularly using these special kind of probes? So any questions about that? Comments. Any, any excise restrictions? Like in terms of size of the patient or size of the vessel you can do? The thumb are 10 French, the new, some of the newer ones are coming down to 8 French. So there's the traditional ice catheters, those get, I think, 7.5, and you can usually get away with 8 French catheters. Some people using special, like the radial sheets and pediatrics, they tend to be smaller with a bigger loom and you can get away with, you can get away with less, but 10 French is difficult. If you go with 10 French or save. Sorry if I missed this, Nate. Do you dilate at all or no? For this? No. Well, yes, yes we do. We're going to get the catheter across, right? And so you can imagine if it's that tight, nothing's going to, nothing's going to go across there. So usually what we'll do is we'll get in from above, right? And then we'll put a really tiny wire down there, over that tiny wire we'll put a really tiny catheter, use that to drop a more robust wire and then dilate up and then allow us to get the catheter across it. Can you see this ever being automated? You get an MRV or a CTV or whatever and then you put a clamp thing around the neck and then computer just guides the catheter based on fiduciaries? Yes and no. There's a lot of work being done in sort of the image guided automation. You know, I have an interest interventional oncology and there's a lot of newer ablation techniques with ultrasound and stuff like that where they use the CT guidance and stuff like that to go where you need to. And to be honest, MRI overlays actually really good too. So there's no work being done in that. I don't see why that couldn't. They're actually so Dan Van<|de|> Ulman, he works with Ben Green University and they made a robotic IV insertor. So yeah, so it lays on it, sees it and it inserts it in and then another company also, so they're like competing companies. So the good news is hopefully one of them will get to be an actual mainstream product. I know. I'm going to put you out of business. Come on. No, but if that already, I mean, I could imagine it being great because a lot of MRI guided biopsies, they're starting to come out with some of those, probably based off the same principles like some of those robot arms to guide it to targets. I could imagine with fiduciaries and all that. It would, yeah, it would probably work just fine. A quick question. When you dilate across that gap there, are you using like, do you have better dilators than I have? Yes, so we're using balloons. So we're not, so don't, when I, I should have, it's not like a regular dilator, which are push and real hard. Please go, please go, don't bet. It looks like it's like flanging. Yeah, no, it's like flopping around. It's going to take a core biopsie. Yeah, no, no, no, no. So what we do is is by diet, we'll usually use a balloon. So there's a whole variety of them in different sizes. If they're real, if this, the noces is real tight, we usually start with cardiac balloons, like just five millimeters, just to create enough space. That way we can kind of keep going up and up and up. But yeah, trying to dilate with a regular traditional dilators, yeah, then it's hard, it never, never feels great. Any else? I think we have four minutes. All right, so just briefly got to touch on the big gun. So let's say, none of that, you know, you don't want to try that. If you like the patient, there's not a good candidate for that. And all the potential options are exhausted. So I just want to briefly kind of touch on these, the transipatic and translumbar access. There's kind of a debate in which, what's beyond, there's a big debate in which one to do, right? In my mind, I think transipatic access probably makes the most sense because if there's bleeding or if it gets this large, particularly in pediatric patients, I feel like it's easier, it's easier to get to or control. The problem with transipatic access is there's some really weak evidence that shows that they might have more thrombosis, but it's kind of a top up. But, you know, otherwise, now caveat, I haven't done, I haven't done any of these translumbar access. And I think that sort of my other selling point is, I think if you get us involved earlier, we can kind of do what we talked about previously or kind of help to manage the patients up front more. You might not end up in this, up in this scenario. But if you do, it's real straight, you know, it's real straight forward. Again, even though I haven't done it, I use all the same, you know, principles of what I've done, everything else with the beef or biops or whatnot. I think the easiest way to do this is CT, some of the old school guys will just do it under a floor over there, start jabbing with a needle because there's an old principle that you can jab anything with a 21 gauge needle and get away with it. And boy, do they take that to an extreme. But usually what I would do is I would locate the IVC at the lumbar level using CT and then got a chief of needle down to that, get access and then go ahead and place the line. And this is just an example for a poor placement here. Yes. Hi, I'm Gloria Gonzalez. Before I work in Chile, now I'm clearly in clinic. I had two patients with transphatic catharsis done by radiation, intermission radiology, of course. But they get this ludge to the peritoneal cavity because of the, you know, of the breath movement and everything. So both of the patients had all the TPM plays into the abdomen and they started really bad, you know. And when they, I mean, you cannot realize the catheter tip is in the peritoneal cavity. That's why I change and I prefer translober. Okay. No, I mean, that, I mean, that does make sense, right? That is definitely one of the, yep, and there are no, it's like one of those vague, like you don't know until the patients, you know, days of pass, they've gotten so much, they've gotten how many bags of TPA dumped in their peritoneal cavity and they're all blown up, right? And usually the people go and try to do their reanimations through the cancer because that's the only axis. Yep. So they finish with a patient then. Yep. And it's, yeah. So that, so in that scenario, that makes sense. To me, I think the trans, the translumbar axis, I think of, it's more, it makes me nervous because if it gets dislodged, it's just going to bleed and there's no way. It's hard for me to get back to try to plug the hole just because now a lot of, a lot of the adult patients are a lot bigger than our patients, right? So you can hold pressure and you might get lucky, but I just get real nervous about that. Like, oh, you know, the patient rolled the catheter flipped out and then I got no way to get back in to try to plug the hole essentially. Yeah. It's true, but it's retroperitoneum and the muscles are in there. It's like a contain hematoma in the old one. It's an hemopiritoneum and the patient goes all the way. Definitely true. I mean, that's my experience. And I think the caveat is, is neither of them are great, right? So if we can avoid, you know, they both, I think they both have their caveat. They both work well. And if you look at the literature, there's a bunch of really tiny studies and they love, they like, oh, they work well, they're safe and they do, but like from your experience, there are problems, right? And so I think if we can, you know, again, don't forget about us where I intervention or radiology is around, right? And we're best friends. So, you know, get us involved, get us involved earlier, you might hopefully be able to avoid, you know, any potential issues like that. All right. So that's all I got. Questions? Have you had any experience with Assygos vein catheterization? I have no personal experience, but, you know, there's been a couple close like, ooh, are we going to have to do that sort of scenarios? But just like actually getting access into the Assygos vein and putting the catheter there. No, I haven't, I haven't personally had to do that, but, you know, I'm up to date on techniques on how to do that. And they can be interesting. Is that an interventional radio? Is that something you need to do for us cupidly? I think you know, I think it, well, we can't do an interventional radiology, but I'm assuming that same principles would apply, right? Like, you know, usually it's a little, I always say for interventional radiology, if I, you know, it's more, you know, even though what Justin was doing is minimally invasive, you know, with a venous, mind just a venous stick, right? And like at worst, you know, a 5, 6, 7, a French catheter. And if it doesn't work, you know, you know, generally there's very minimal complications from it, right? And if that's the case, then we can go to more of a surgical approach. All right. Thank you so much. It's so funny. I always get so much interest whenever we talk about it. So thank you so much.
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