Chapters Transcript Video Dr. Carr Immertec Maven Dr. Carr Immertec Maven Case 1 Um I'm Jeff Carr. I'm an individual cardiologist here in Tyler, Texas. We welcome you uh around the country. So you'll have to do uh to pull that full screen up. So when we're referring to an ultrasound uh feature, an image on the ultrasound, please click on the ultrasound so you can get a much bigger view of that. Uh because this is a lot of what we do. Of course, a lot revolves around excellent uh and good ultrasound scanning uh to make this successful and she's had previous uh great sis uh vein ablation in another institution years ago. Uh But she has uh C four C disease or so, I don't know if you can zoom in down on her uh physical findings down here just going to let off. So she's, you can see the hyperpigmentation. She's got uh Carole statica and, but she continues to have focal pain really uh right over these sites of these two perforators that we're gonna demonstrate to you. And after several years of conservative management and compression therapy and all that, she's not happy. Are you happy with the pain? I'm not happy with the very unhappy So again, we're talking here about a quality of life issue. As far as the indication to do this, we know the first thing to really do is to demonstrate uh the perforator in a sag or longitudinal view the best you can. And uh A is trying to lay out this distal c perfer the right uh distal cap perforator uh on our original ultrasound was 5.2 millimeters. So it's greater than equal to 3.5. And it had 742 milliseconds of reflux back on the original diagnostic study that we had some time ago and you can see it's really horizontal. Um And you get the pointer there, the key things to look at when you're lining up and, and evaluating these perforators is to look for that the drainage pattern and find the deep system. So as if down there to the right is showing you the post your tibial vein uh that it drapes into and we want to identify our fascia planes. You can see the deep fascia, which he's gonna show you at the line. You go ahead and pop open your ultrasound uh panel if you will and you can see right there with the plus mark, the deep fashion, you could see that perforator, by definition, it pierces through the deep fascia to drain to the deep system right there. So this is one of our main focus or foi or targets. If you will of where we want to deliver our thermal energy. Now, having said that we have to be very careful, uh, most careful about safety and we wanna make sure we don't cause a thermal injury and a deep vein thrombosis. So we wanna avoid the de the deep vein system. We wanna avoid arteries, bones and nerves. So those are what I call hazards. Um, we wanna keep a safety distance from delivering the 130 °C, uh thermal injury to those hazards. So we put a safety distance because we know the temperature drops off at five millimeters. Why don't you put color on there? So you can see, um, I'm gonna do a little cast, squeeze there or a foot squeeze to show that reflex. You'll see, you'll see the blue is the reflux. So there's quite a bit of reflux there in that uh distal cap perforator here. It's almost an ankle perforator. It's right on that border, but we're looking for arteries. We don't see any pulsation here yet and we're gonna really confirm there's the artery. And remember these are paired with the vein, we have paired tibial veins. So the tibial vein is large right there as it drains in right above that, right. Do you agree? But we want to talk about angles of getting into this perforator. Um And so if you see to the lower left, it's really kind of, you go ahead and point to that I can't see the point. There you go. You know. So we're coming in from the top here. And how would you approach this, I guess is the question would you would be to try to treat as a longer uh a length of a segment, the longest segment that you can? And that's the really distinct and unique advantage of the um maven device. Is it a five millimeter millimeter coil? So you can do Pullbacks along the length of the treatment se section. So if you get intraluminal early, you have a much a greater opportunity to treat a longer segment. So I like in and you'll hear me this with this other cases, I liken an analogy to a air uh airport runway. Uh We find the runway, we wanna land our plane, meaning get into the lumen as quickly as we can on the runway, right when the runway starts, if you can. So you have a lot of run room to go. And also if you don't hit the vein, if you miss it, you can move up, right. If you start further down at the end of the runway, then if you miss it, you're done, you know, you don't have any room for air. We have two options on access. One is a 12 gauge Angio cap which has a very rigid Pro card. Uh We'll talk about that in a little bit and we have a, just a standard uh needle introducer over the wire technique where you put in a sheath. And for this case, I think I would adopt the over the wire, the standard wire case, so we can get the wire to be to come down. And the one thing you wanna do, if you're gonna use the wires, you need to make sure the wire can go down far down the vessel into the deep vein system. So you have what we call purchase, you can deliver a sheath into it. If the wire doesn't go very far, it's gonna be really hard to deliver a sheath to where you were to go inside the room, it falls. So we wanna be really careful about this one again because the deep fascia is really close to that poster tibial vein, right? So often show us where you believe the poster tibial vein is just that large round one, right? Ok. Now, how can you prove that? Because it looks like, well, why wouldn't it be the one above that? Right? Well, you can go flip it 90 degrees and go sile, you can see it run up the leg. So I do that. This is really a good technique. This is really important to show and you can put color on it. You see that drainage there, beautiful. You see that drain going, right? And that's all reflux. So you just are you flipped it? I guess it would be nice. I think I'm gonna try to get my needle in the fattest part of that vein right in the middle here. Try to open that up right there and see if my wire will slip and make that curve. Ok. Do you think it's gonna go? All right. And I've had a couple of cases where I kicked myself because as soon as I put the n the lidocaine in it spasmed down the vein and we, you know, we had to wait it out. So I come back a little further uh from where I am and remember the edge of the probe is your marker from the edge of the screen. So I'm wanting to come in at this angle at a 45. And so I'm gonna start a little further back here. Sorry, pitch, dear, dear. And I, I like to watch on an ultrasound to make sure I'm not overdo. It just create a little wheel. You're sort of just that skin skin neck there. I think it's already starting to affect that day. So, all right. And um for this one, I don't usually make an 11 blade. Yeah, you know, creative wood for the occa, I will and I'll talk to you about that if you do an occa case, but of course, double up, usually pretty good here. OK? Everybody could see that remotely pretty well. So bubble up and I'm gonna uh see if you can open it up a little bit more before I do that. I'm sorry, before I'm ready to go, I'm gonna shake my wire right in line with your ultrasound. Ok. So I line everything up. These are the external markers because it's all a 3D deal here as you know. Yeah, the hospital did I already go. Sorry, there. Ok. I think I'm a little off for you here. So one more stick here. Sorry about that. So I'm gonna try to come in flat and now I can start seeing my needle come in and I just, I don't, I like to not get too aggressive. I mean, it's the tendency to be really anxious and just like, oh, there it is. Go for it. I like to really know as I move my hands back and forth that I'm in playing. Uh and I'm gonna come in a little bit deeper and do I have float return? It was like it, it's not, I'm not in play. It looked good, but I'm not in the vessel. How about there? Yes. Yes. So I have visual. I like assistance to tell me I can feel it, but it's much better and you can see on the overhead camera that we've got some blood return. I may not be fully in. Why? Sometimes I will grab the tissue, you grab that wall, they're so thin and flexible and friable that, that um I'm gonna need some help these uh they change these wires out sometimes and this was really a little too flexible, but we'll see if we can really gentle coming in. So I'm not sure I'm fully in the loom and, but I am, you can see the wire there and we gonna turn it down. I shaped it and let's see where it's going. Is it going? It's going very smoothly and you can see my wire is following that post, your tibial out. This is also a good way to know for sure where the post your tibial is right. If you're not sure it's a seven centimeter sheet and you see the dilator with the sheet there, you zoomed in pretty well. Ok. Good. And just anchoring that back and watching as we go here, I'm sorry, dear. It's gonna hurt a little bit. So the challenge is to know how deep it goes. Uh because you have a dilator in there, right? So it's hard to say. I see a double room in here. I don't think I'm pierced through the spoon yet. I'm through the vein. Yes. Do you agree? Ok. So a little harder hurt. A little hurt. Oh, I'm sorry, dear. Ok. Now it looks like I see it double lumen. Now, I see you here, but I can't point but you could see the lumen of the catheter is really right close to that bend where it bends out and I got leverage in. So I'm gonna very careful. I believe the wire down might take a dialer out just in case I'm wrong and no, I think I'm good. Right. I agree. We got, we're in the lumen. So I'm gonna take everything out and this asset is gonna try to demonstrate the sheet. You can get feedback, you know that I'm anchoring it here. Um I just don't want anything that and we've seen blood return so we have really good confirmation. We're in the lo I look that up. OK? Now time for the ma and you can see the coil is five millimeters, that's the business end and you have a point. And then I want you to see the dead space at the tip and it's 3.5 millimeters. It's a different color here. So you see the silver coil and you see the plastic um part of the, you know, the, the tip that basically just secures the catheter uh from an engineering standpoint, you have to have it, it's 3.5 but it's important because that's inert, that's not delivering energy. So you can't assume you can't say, oh there's the tip. I think that's what you're treating in. You have to come back 3.5 million. Uh this may not be erogenic, but we'll do that on the ultrasound screen to show you. But I really wanted to demonstrate this before we put it in. We've got these uh markers here, the two double XS which is the do not cross zone, the danger zone here. And then these markers that is the warning track. I call it for a centimeter when you combine these two. So we wanna stay five millimeters from every hazard. So five millimeters is that point. So if I start seeing the XS, when I'm bringing it out of the skin, I know I'm in danger for burning the skin. OK? This is a 40 centimeter shaft length and I'm just gonna simply insert it in here and we're gonna watch it come out and we're gonna try to locate that first here comes, can you help me with that? Ok. Just give me a sec. That's good. OK. And so we're coming out and we're coming right to the corner of the perforator. It looks like to me you show that also and I'm at the warning track, which means the coil is just outside of the seven centimeter sheet. OK? Like if I'm here, it's in the sheep. So, um, I've got five millimeters distal to the sheep at this point. So I'm gonna pull the sheet back a little bit because I think I uh just show that tip if we can. Again, you're on the other side. So OK, I'm gonna go deep and now I'm under the perforator, I'm under the deep fashion. You see that to the lower, right? And so I'm gonna come back and I wanna be just on top of that facial. So I'm kind of right on the edge of it. The, it, I call it two methods. But it's not to me it's just lidocaine. So we'll numb it up. You don't need two messages like you would with a small or great Sfax. But let's look at the overhead uh, here. Ok. So if you look on the overhead, um, you're gonna fill another pinch. This is to numb it up. Now, I'm way down deep. So I come, you know, pretty far down here and this is where the tip of the catheter is. So pitch pitch there dear. And I'm trying to get my needle right on top of that saying, and I'm very liberal with you see, I'm to the right of the screen there as I'm putting in the lidocaine. Yes. OK. Now we're using 1 1% you can use 2%. We're using one here. And again, we're gonna use a lot here. And you see that my goal here is to push away the uh um the push Fertilia bait. But actually, we're starting to actually get better uh visualization at the tip of the catheter. Um As we bring in that liquid density, the water density. So we can get more transmission of the ultrasound. So I'm just gonna come in here and I'm just gonna first kind of treat all the way above and below. So basically, just like you would do a GSVSSV and a SA space or whatever, go above and below surround it. That's nice right there right outside and it also have the effect of. So, um, classing that perforator on the device, right, and you can see the vein on top of it right in the middle of the screen looks like we're getting a good compression. Uh, we could take the tourniquet off too. Yeah. Um, we started putting tourniquets on everyone early on because everybody's, you know, you just hate it when they're not, you know, they come in with their hose or something and the, the vein is way smaller than you thought or that you knew it to be. So this is one of our, uh tips, but now we don't want the pressure. So I'm gonna do one more lidocaine and now we're getting some really good visualization of the tip. I'm gonna jiggle it here and the echo density. Go ahead also to show that coil super important if you, you know, to try to locate the tip of that catheter, right. So, um, you get the transition, you can see you get a hint of the plastic there, but that density there is five millimeters and I'm sorry, we can't measure that, but we usually say, oh, I think that's the tip. And if it comes out five, we know it's the tip. So that's another tip, uh, trick here one more. I'm just gonna push the, uh, post your tibial further away and I'm gonna just come in right to the edge again, right to the back edge. Now, remember when we set it up, we said five millimeters, but you can also push it away if it will stay with your toes even further than five. I'm sorry, dear. I don't know, it's hurting and I think we're ready to go this. You know, I like to say this is a miniature version of the DS Esse with Bank. That's how we design, how it was designed. And, um, so you don't have to learn too many new things about it. We also have a foot pedal down here. I'm just gonna use this or that, this table. We have a foot pedal, which is really nice in case you kind of get the hand so you can do either one, the foot pedals right down there guys here. Ok. All right. And we're right at the edge. I'm jiggling. I'm triple checking here and we're ready to go. And so I hit the button. It's a 22nd cycle of 100 and 30 °C and I'm holding rock steady here, not moving, that's on. So I'm gonna index the sheet if you can see on the overhead where I'm not quite on my mark. So I'm gonna pull the sheet back, keeping the device there perfectly right there. And now I'm gonna pull back five. So it's one division here and we're gonna be looking on the screen and also looking, I'm gonna be looking here also. It's gonna look on the, you all can see on the ultrasound, I'm gonna pull back five, you see a code and so that's a tandem and we're gonna treat here. Hm. Sometimes I found depending on the patient, there might be some slack in the system. So you might be pulling back if it doesn't move the catheter. That's why I like to look on the screen too just to have that other confirmation. That is really doing what you believe it is. And I'm always, we're always checking to say is that the coil? Is that the coil? You can see it's a little fuzzy there. It's hard to tell. That's six. So that's the second six. We're gonna pull back to our third location. I'm gonna look here, you look there and right there. OK? Just a little bit more. OK? So this is our last treatment cycle. And you were saying you're watching the jewel of the wasp per centimeter vary. So it varies to maintain the 130 °C. So that's gonna go up and down. So you're saying if it's going higher, then it's a good sign that you're getting coagulation, right? It's a good coagulation. Ok. Um Just to double check, we're gonna come out. So I'm gonna pull this out and we're just gonna pull it out together. So you see how far you can see on this grave and you can see where the device was in relation to the seventh of your cat sheath, the catheter. So why don't we go, uh, look down on it? Ok. Ok. Ok. And so you see the warning track right here and the warning track. Do you see that? Well, the water, it's just like you mimic the same thing as the larger than post. And you see the beginning of the warning track. If you're at the beginning of the warning track, then you've got a full centimeter before the coil. If you're halfway through right at the edge of the warning track, now you've got that five millimeter safety distance. And that's why Xs are there. Do not cross, right? Don't cross into the X's. You see Xs, you know, you're gonna, you know, get something in trouble, you're gonna burn the sheet or you burn a hazard. Ok? All right. So now I, I'll switch with you and you, uh just go open and you know that or we can't see it and we, so we wanna show efficacy, meaning we've got closure of the, of the target vein and we've got Pat C the deep system and arteries. OK. So you do it. Yeah. Is that like we do it? So one of the question is, do you give any anticoagulants or any plant therapy or anything different? And the answer is no, uh nor do we stop any anticoagulant therapy? That's the beauty of it too. You don't have to change anything for the patient. There's no data. In fact, we showed a slide last night. About a study looking at, if they're on anticoagulant therapy, does that affect pain? See, it does not in a retrospective series of different localities. So, just don't stop it. No, don't stop it. So, if they had stents in their heart is that, you know, oh, stitch in their legs and their arteries. Yeah. Keep them on the end of the dual antiplatelet therapy. So, you want whatever they're on, keep them on it. don't change anticoagulants or dual anti plant. Any anti therapy, any anticoagulant continue. It's not gonna affect your, your uh efficacy by the data that we have of main treatment or intervention. So you can still do this. That's the posterior tibial vein right here. Is it pulsing, pulsing. So we have a posterior tibial vein that's patent. We see the deep fascia show the deep fascia which we did not cross. We came right to the top of it. We believe we started right on the edge of it again to keep that five millimeter safety distance. Now show the periphery going back to the left and this is all color. So we should see color. If there's flow, we see no flow, you gotta put color on, on these afterwards, not just A two D because you'll never know right. So we don't see any flow. You see nice coagulation there, a beautiful result. I would say, you know, if I'm looking at this, it's great. I'm really, really pleased with that. Um And so we're very happy. We've got page to the deep system and efficacy on our target area. Published April 29, 2024 Created by Related Presenters Jeffrey Carr, MD, FACC, FSCAI Interventional Cardiology, Cardiovascular Disease, Internal MedicineCHRISTUS Trinity Clinic View full profile
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