Chapters Transcript Video Case-Based Learning- Acute Scenarios Back to Symposium Gonna move on to slightly different cases and then I'll get to Doctor Lesni so we can get over to the PAD side, um, so here just talking about a Nevil case, right? And, and I find it's fascinating to have these conversations and see where we all land with it, but 41 year old debilitating pelvic pain, left lower extremity swelling. And so as mentioned before, you know, I will usually have a diagnostic, uh, venogram because, you know, I think no matter which, you know, place we're at if we have a discussion are we gonna stent these cases or not, there isn't a consistent answer. uh I think many of us would say that despite how wonderful our outcomes are, we're gonna try not to stent at a young age if we can. And so from that standpoint I find it very helpful to have a very thoughtful venogram and IVIS, you know, with also a thoughtful postoperative visit with the patient to really determine, you know, are they compliant, are they committed to antiplatelets, does this impact their life in such a way that they're, they're willing to come and see me for surveillance. Um, and then they're not surprised, right? What did I have when I wake up? Um, so we tend to do those from jugular, obviously there's discussions of whether you like femoral or jugular access for these cases, but from a diagnostic standpoint, obviously it's, it's very easy to go jugular access and, and identify everything from a single point and have them discharged in a pretty rapid way. Uh, and for all of those ladies, many of them are comfortable being in New York that they can wear a turtleneck for a couple of days and not feel embarrassed about their dressing and not be limited, um. It is a point though, right, that some people again think that this is beneath them, right, and they rush these cases and if you just kind of jam glide wires down from jugular, which it can be a lot more traumatic than going femoral if you're careless, um, I've had, you know, patients come back in with these reported, you know, stenosis of 98% and 90%, and they really don't have a compression, it's just that. You know, you throw these wires down really fast, um, they will have some, some spasm, so something to consider along the way but in in this situation again, um, she really couldn't function and so we did go ahead and placed a 14 by 120. The Novo and you can see the difference of kind of the the classic Mather lesion both phonography and on Ibis and um again used that technique of just as you're deploying you start to deploy right you can pull back on your stent and you can use both tactile sensations so some people would say really you know half of what we do is by feel try to um. Have people not become so dependent on everything's on the monitor, but at the same time you also can use that redundancy of injecting some contrast and proving that you're in the right place while you deploy and you do have that ability while you're not gonna resheet this, you know, adjusting a little bit. So always allows us to be perfect and then you know as we talk about kind of the design of the stent and optimizing it. Um, sometimes we think, well, you know, it, it has radial strength, so just kind of drop it and run away, but really you want it to be the size that it was designed to be, so same size, so 14 to a 14, a 16 to a 16, and, um, you know, you may be a little bit different in terms of your, your graduated, uh, plasty as you, uh, angioplasty a little bit less as you go more peripheral, um, so that you're maintaining that laminar flow. So here is a 44 year old male and uh left lower extremity swelling, erythema pigmentation change um and this is is just kind of more of a thought provoking discussion it's not necessarily that this is the right way to go, but he um had a stent placed at an outside hospital and these are the images they had um and. I think they had had thought about whether they should do thrombectomy but they didn't, right? They didn't, uh, do any pre-plasty, they didn't do any thrombectomy they, and again the, the thought was let's do as little as you need and, and it was with good intention and so but you can see that on the image to the right right after number one when the stent is dropped. It, it's pretty unhappy, right? We, we didn't do as good of a job as we could to optimize that and you can get yourself into a little bit of trouble if you have nowhere to go, um, obviously they maintained their wire access which is good, and you can see on the image on the right there's still outflow varices, right? So there, there isn't wonderful flow at that point and so, uh, the patient then was, was sent to our clinic and would have been happy if they were clinically doing well, but. Really didn't notice any improvement after the stent, um, and continued actually to have a functional disability that continued to worsen and again it's a 44 year old guy that's trying to continue to work and and things were getting worse so so we brought him back and again started you know with phonography II, uh, thrombectomy and then. You know, given the, the challenge of providing optimal inflow and outflow, basically treated it like he hadn't been, uh, stented in the first place. So again, identify GSV and profunda and stented, uh, below across the bre that existed and then, you know, again go up to measure what your second stent should be. Obviously we, we have an idea of what the 1st and 2nd stent should be. But really like to optimize before having them pull the 2nd 1. Uh, by doing a true measurement with IVs. And again, you know, a lot better but not perfect, do some, some post stent, uh, plasty and then you know at that point really you can see nice flow, uh, both inflow outflow, and, and he did come back to clinic and, and is doing wonderfully. With that. We'll move on again. Published Created by
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