Watch this recorded broadcast of a WavelinQ™ EndoAVF creation performed by Dr. Alejandro Alvarez (St. Louis, MO) with Dr. Stephen Hohmann (Dallas, TX) moderating the procedure as he talks the steps being performed in detail and answers questions from the virtual audience.
Duration: Approximately 52 minutes.
Well, good morning everybody. Um, and welcome to Saint Louis. Um We're very excited to be here today. We've got a great program for you. Uh We've got Doctor Alejandro Alvarez who's already working away. Uh not only AAA good friend of mine but a wonderful practitioner. Um He's got a, well, first of all, I'm jealous of him, um because he's got the crew, he's got here, I'd take him back to Dallas if it did come. But um they've all been with him for a number of years this morning. We have a patient um, currently on dialysis with the right eye j tunnel dialysis catheter, um who uh does not have a current access in his arm. And uh so doctor Alvarez screened him, um, ultrasounded. He met the kind of three criteria that we're looking for. One, is that a superficial vein, uh 2.5 millimeters or greater, that was his clic uh perforator, greater than two. He had that and then the creation zone which we're planning on being and we can switch to the ultrasound or to the fluoroscopy screen anytime we want because that's where he's working away and we'll jump right into that action. Um But um his creation zone site vessels are large enough. So, Doctor Alvarez uses an ultrasound, um access the um uh brachial vein patient had a single brachial vein, which is kind of nice because then it'll let you work on either side. A lot of people have that. That's a fairly common one. And now he's working in the Venus system, he's got two sheets in, he's got a six French in the Venus and a five in the arterial. You could do five in both. He just likes the six in the Venus. Um So if you go to his catheter, um he's got the merit catheter, the 30 centimeter one. It's the impress catheter. It's nice and short to work with and I'm sure the cameras that showing his hands working. Um We'll show that also. Um And then he has his other wire down the um uh brachial artery into the common owner and then proper owner, we'll show those images in just a little bit as well. Um So what he's trying to get now is he's trying to get his wires to line up in nice kind of parallel fashion. One of the things that he's doing is he's got his uh V 18 wire down and it's 100 and 10 centimeter one which is really nice to work with because you can notice his wires aren't hanging off the end of the table. They're very short uh into that space. Um V 18 has kind of a nice, almost kind of glide wire type tip to it, but it's a little bit soft. So if it bumps against a valve and doesn't want to go, you don't, you, you decrease the risk of perforation with it. Um So um hopefully we caught that him working that wire there. That was excellent work. Not surprised. Um So work that wire down. Now you're working against valves when you're coming above, we call this the parallel approach. Meaning coming from the brachial artery and the brachial vein towards the hand. Um Now he's gonna take a venogram here, make sure he is where he thinks he is. Ok. All right. Well, good morning, Alex. Good morning everyone. Thank you for having us um, into your, into your facility. First of all, I told, I said early on I was jealous because you got such a great crew. Um, and they're all welcome to come to Dallas anytime they want, I don't believe. Well, we don't have a forest park, which is their huge park here, actually larger than central park. Little known fact built for the 1904 World's Fair. I always try to throw in some other stuff that you learn and guess what happened in the 1904 World's Fair? What was invented? Um What was invented? Hot dogs. Yes, sir. Wow, about that. I can. Uber driver told me on the way over here, but I'm not gonna share it with Alex. Ok. Um, so you gained access. You did a very nice job gaining access, um, above any tips. Just kind of for everybody. I think access tends to be one of the bigger ones. Yeah, I think I, I, right. And we've, we've learned this doing, doing this and we've talked about it. Access, access and particularly Vino's access kind of dictates how it goes. Um, So what we did here and, and, and I hope you were able to see that on the, on the feed is I usually try to dissect the three structures, the vein, the artery and the nerve separating with the lido. In fact, because we did such a good job. He just mentioned that his fingers were numb. Um And we know, uh and so, uh and we created a little bubble around the nerve sort of like uh a mini block, which wasn't the intention, but it was really nice. And when you create that lidocaine bubble, it really brightens the tip. Yeah, I wanna stop on that one for a point because that's an excellent point. First of all, you, you do yours under local in sedation, right? So we're not regionally blocked. We're not, certainly not under general anesthesia. Um, because that's the way they do all your procedures here. Um But the one thing that really is helpful is that hydro dissection, getting that liquid there, you can really see that needle tip, it clears this absolutely. And so it, it allows also on how to access the vein and, and, and we followed it, you saw, it was really nice in this case to follow the needle as the vein is sting. So you can also tailor the amount of force, not back, stick or anything because that's where I noticed before, before I had the experience that I have now with this where we thought we were in and we see that tip in the middle and when you advance the wire, you dissect the other thing that was uh really nice. And I think uh uh that, that we started doing uh as time passed is that parallel view with the ultrasound to confirm that the wire is there? Yes. So what, what, what Doctor Alvas really did a nice job was getting that kind of the fluid around the vein and then kind of watching the needle go in and then making sure it was actually in the loom and double checking wire fed easily and then switched to the long view. So we could actually watch that come nicely. And that was beautiful. That was very nice. And the other thing that as that as we've sort of hone that skill here, it has allowed us to sort of maneuver that wire through the valves because you can see the valves with the ultrasound. And so you can see where the wire is sent. And so you can just rotate the tip and get it past the valves. Another good skill when you have to intervene in any fistula. Really, it helps you navigate the wire easier than the, than the old. Just that. Ok. So we can be access you like a six front sheath I saw, but we can certainly do a five because the only reason I like the six front sheet in the vein is because that s six front sheet uh doesn't slide in and out like the 545 slender. So it stays in the vein coming out as you're working on the artery. Of course, we use the uh either the 45 slender or today I'm using so that I am a fur uh person in the market. We're using a pre prelude. The nice thing I I'm trying and, and I tried it today. The nice thing about this prelude is that in, in big people, it won't kink and that's a nice or it's less likely to kink. It's a little bit stiffer, but advancing it. Once we're advancing it into the vessel, we have to be very careful not to kink that wire because of the stiffness. We have to really uh me. So you got Venus access, I've got the six French sheath, we got arterial access. You have the five French prelude ideal. Um Then you got your wire, you're working your wire down. Can you just tell us kind of strategy? Of where, where, where did you want to create this fish? And what are your kind of thoughts that go into it? Ok. So him specifically is a patient that has a um has a single brachial vein and as you can see on the screen it has, he has a single brachial vein that splits actually into three. Is it splits into the medial common owner, the lateral common owner and, and something that you guys did not see one and something that you guys did not see was the per freighter. It, it has like a third, the the per freighter. We're gonna pull up one of the images. Thank you for doing so. Here, this is a beautiful picture. What you're seeing there is the the perforator parallel to the, to the lateral owner. That vein is the lateral vein, which I thought was the medial. But now I know it's the lateral because we had over there for just one moment. So I can make sure we point that out Alex. I think that's really important um to make sure we see. So um this is your first venogram. So we're saying that here is your phallic vein, right, coming down the perforator. And then we're saying that this is the lateral ulnar vein. We thought it was the lateral ul vein. But as you saw, remember how it spread it was and it turns out it's actually this one here is the lateral. And so he's gonna have, if we're able to create in that lateral, you can see he's gonna have flow into the cephalic vein through that distal there, through the proximal and then the other bridge. So all that is going to be hopefully what we're gonna gain her flow on him. Perfect. Perfect. All right. So now you've got your wires in position and we need the wires in parallel. Um So that way um as the catheters come, we don't really want to cross. Now, there can be a cross with the wires and you'll see as he goes live, there is a cross in the wires but it's more proximal. So um that shouldn't be an issue. So now, are you using a local heparinization or systemic or how are you today? We're, we're not using a systemic heparinization. He is taking a liquid that couldn't be stopped. So, all we're doing is we're fla flushing with saline. It's great. Ideal to ideal would have been to be able to stop the elo quiz. But um we did, we, we didn't uh because he just recently had a procedure done that requires the elo quiz, but this is the advantage of doing it endovascularly, you know. So we're not gonna give heparin today. We're just flashing and it means we hold longer pressure. Always remember. No uh close closure devices when we access the brachial artery. Uh always manual compression. Great. All right. OK. So, so we're opening up our catheters. Um So the wavelength catheters are four French. Um But they go through a five French sheet because they're rapid exchange. So when he loads them up, we'll switch to the camera that shows him actually loading them. So very short rapid exchange tip and they do go over 014 wires, he's using the Nire wire, um and whatever, 014 wire, you have the reason why the NX is nice centimeter wire. Um So it's a very short little wire, which is nice because with the rapid exchange, you don't need much wire. Um And it makes it a little bit easier. So, um, the other thing we will do is we will show the arteriogram um when we have a moment here. Um And uh we're just advancing the um catheter down occasionally you'll notice the catheter will catch a bit as you're going down and that's just as it bumps against the valves. And so he's bringing it down because it's nice to work against the valves with that, with that V 18 wire. Um But then once you're down, then you want to switch to the 014 wire because of course, it goes over an 014 system and that's what we're gonna be doing. Two catheters, right? So you have the arterial catheter and the Venus catheter. Arterial catheter has the ceramic backstop um that you're all familiar with. Um, the Venus one is actually kind of a workhorse. That's one has the electrode um that it gets activated, goes through the uh vein through the artery wall and then hits that ceramic backstop. So he's now advancing that nitric wire down. Uh nitric wire is nice to work over. I find it a little floppy to work against the valves. Um uh One of our good friends, Doctor Mitchell interventional radiologist in Fort Worth. He likes to work with the, with, with that, but maybe it's the finesse of the ir that, that likes that. So, um, I like having that V 18 to kind of knock on the door of those valves. Uh Sorry, uh Steve, you wanted to show the arteriogram? You, you, you keep working. Are you gonna shoot another arteriogram before you? Yeah, we're gonna shoot another artiom. Let's, let's find the, the widest view right now. Yeah, you just keep working. I'll, I'll be sure to narrate everything you're doing. Um So what, what he's speaking about is that now the widest view, sometimes it's called the perpendicular view. Essentially. It's to make sure that we're seeing the wires in profile, not on top of each other. So he's got his uh tech here that's very used to, um, doing this. Now, they're rotating it kind of back and forth to figure out what's going to give us the area where the wires are farthest apart, meaning we're seeing them um, in parallel. Ok. So let me just pull back. He's now just making sure everything's lined up. You know, this is one part of it that early on you kind of want to rush through. You know, you wanna kind of hurry up and just find it to get the catheters in as you gain more experience and over time. And I've watched also with, with Alex just taking his time to make sure he really has a good view before he puts the catheters in. I really think that's key. Um The other nice part about the having the 035 catheter. Um Is, is it? Yeah, so we're, we're, we're gonna show it there, we'll get the little arrow on there. Um And you can show this, I this is a beautiful picture showing the anatomy that we were talking about. It is see, we have the common ner the lateral, the common medial nerve vein, the lateral ulnar vein and that perforator extending distally, which is, that's interesting. You say that because at first I think we thought that what was the perforator if we can actually point to come over there, I'll point to it. Why, why not? I can stretch my legs? I'm capable to come on. So, um so cephalic vein coming down this vein is actually the perforator coming all the way down there. Um This is actually a second perforator and then that's joining the lateral ulnar vein. I'd say almost exclusively, the perforator always joins that lateral ulnar vein and So, here's Doctor Alvarez's catheter um in position here. And you can see when he injects here, it both goes down and it will come up there and up this way, this is a very good way of seeing where your blood will flow because he's injecting it where his anastomosis most likely will be if that's where we determine it's gonna be best. And therefore, then the blood can flow down, up and out as well as up. And so I really like the setup. This is interesting and that this is a very long perforator. I'd say I'd say normally you see this come down and join maybe here. Um But it goes maybe twice the distance. Very nice. OK. Let's send this here. All right. So getting back into the position here, OK, go 25. So they're now rotating. Um And they're, they were at 20 degrees now about 25 degrees hitting 30 here looking to see where, where it's gonna line up the best. So now they're going back. So the wires started getting closer. So I told them they weren't exactly in the position they wanted to be in. I think that's what I like. Do me a favor. Just uh grant me these wish. Go to 10. Where, where, what? So now they're gonna come back and this is where I said that early on. I think there's this anxiousness to hurry up and get this part done. But as you, why do you see then more time doing this, um You really take a lot of time on this because it's so easy to manipulate it. Now, before your catheters are in position, once you put your catheters in position, then it, it makes it a little bit harder to see, I think in certain ways just because everything's in place and there's a certain anxiousness to trip and activate. Um, so he's decided 25 degrees is the optimal and that definitely looks like it's displayed the best. Um And that's what I was saying. This is, this is a part early on. I think you kind of rush through or not, you specifically, I think one tends to kind of hurry through. But as you gain more experience, you take your time and really make sure that it's looking the way you want. And I think it's sort of an unconscious thing. You're right at the beginning. We used to, I mean, Damian, who's here with us as soon as you get the wires and you get this, we all go like, ok, let's get the catheters and all that and then we, and then just to stop and this is a good time where we can just make sure we, everything we like, we do see a wire cross that's kind of near the elbow joint, but that, in my opinion, should be far enough away from the creation zone to be ok. I think so we'll see what the artery shows now, relative to the catheter, do an art right now. Ok. So now he's going to connect to the five French sheath, which is in the brachial artery. And we see arteriogram here. T injects. OK. And now nice and big arteries, those look wonderful. And as you can see as it comes down, we'll peak that and be right back. So right now, what I'm gonna do is sometimes we do a double barrel that, that you call it, let's call it. But what we're gonna do right now is a road map. OK? And we're gonna, with the road map, get an idea of what the fission is gonna, a fix of what the fission is gonna look like. And I like it because it also allows us to like sort of tailor the options we have to create an an and I was gonna show real quick. Here's the brachial artery coming down. Of course, it gives off the radial artery. Here's a recurrent radial, then this is the area that called the co I would call it the common owner and this would be the proper owner, er, entero trunk would be another name for it. Most of the time if you cover up that radial artery, this essentially is the same vessel. This is very large, in my opinion, probably like a 3.63 0.7 millimeters in diameter connected to this vein here. That's a big artery, big vein. Um And then now what he's gonna do is road map it and put the vein up into the area. The only place we probably would try to avoid in certain ways to be this recurrent, although it's on the medial side. So that shouldn't be an issue. We got a nice long landing strip there. OK, guys and fix it. So this, this is what I was saying. Uh So it gives us this image, gives me a couple of things moving on here. We really could create anywhere along that common or because we have those two big out flows. Sure. So we're gonna have a lot in his case, a lot of room to manipulate the catheter so that they interact properly. But it also tells me that probably the best place to coil is going to be right here right at the joint where I'm gonna capture any outflow from here and any output from that media longer that will force the flow of them. That's one nice thing about having this kind of common brachial artery, brachial vein, common brachial vein is that if he coils that, then that's really gonna drive all that force up and up the uh perforators to the ST vein. OK. Keto. Let's advance the arterial. All right. So he's gonna bring the arterial catheter into position up here and 930 magnets on each side. Yes, sir. Sorry. And I leave it. I leave the venous catheter in there because that's gonna be my reference. I like that too. I think it also helps kind of remind you of what, what things are gonna look like, make sure you have that widest view. So we got this arterial catheter coming in um have uh 30 magnets on each side, one millimeter by one millimeter by one millimeter. Um And it is very short rapid exchange, we can switch to the camera that shows Dr Alvarez's hands. Um, now he's gonna take that 014 wire and feed it through there. That always takes a little bit of trickery. Yeah. Um, do you have any, uh, cheaters underneath those? Oh, yeah. My ophthalmologist was very nice since he knows I do this. He's been charging twice now. Yeah. So that's one thing about the 014 wires, uh, has no cardiologist. We don't use them as much. Yes, sir. The other thing that I like to do which makes it easier to manipulate the catheters is I look, I don't worry so much about the outside here in my head. I know the arterial, the artery is below, which means my wire is below regardless of whether on the outside is me. And that way I have a nicer time. You know, most of the time we're able to, uh, avoid the wire wrapping around, which is nicer to get those catheters interact, but sometimes it's unavoidable in particular, uh, when advancing the venous side OK, I'm gonna move here. The, the reason I do all these uh here, my dear, let's take this off. The reason I do all this walking around is because my left hand is only good to hold the wire. I absolutely totally understand. Um That's a nice part. That's why I like to see arm coming in this direction also because it allows him the flexibility to go to either side, depending on what, what's best. And if he was working anti parallel, so if he gained venous access at the wrist, meaning radial vein or ulnar vein, then he would also have an option to do that. But um, he's gonna go ahead and advance that um arterial catheter into position. Um And so he's kind of holding the wire and doing that rapid exchange work there. Um I, I always like starting with the arterial catheter. I think it's a little bit easier. Um It doesn't have anything connected to it. So here you can see advancing it in and what he's looking for is the saddle there, the ceramic saddle um of that. Um And then there's the rotational indicators, um or the windows, whatever you wanna call them, it's essentially where there's no magnet in a spot and there's one at the end of the catheter and there's one right near the activation point of it. So he's getting that into position about where he wants to be advances it in to kind of get rid of that energy in the system. Um always trying to avoid stored energy. Uh But getting his um Artero Catherine position, there is 11 of the things that is kind of unusual and I hope we don't jinx it. One of the advantages of the new design of the catheter is that as we're advancing the windows to get the catheters, the, the rotational indicators, sometimes they both, they don't both always look completely thinned out. Sure. All that means is not that your angle is wrong. It means that the, the the vessel is rotating. So you, you should see, you see sometimes the, the, the first or the or the rotational window of the tip seem very bright and you're advancing it and the, and, and, and, and the thinness kind of disappears as it rotates you, then I then turn to observe the, the rotational indicator by the, by the electrode by the ceramic backstop. Yes. So the one closer to where you're actually gonna create the anastomosis in his case, he's thin and we see both windows very, very, very well, we do. But we have, we know a little bit what we were talking about. His anatomy. Also, his venous anatomy is a little bit kind of everything is kind of straight, right? His vein goes a little bit outside. So I'm thinking, I'm thinking, I hope, I don't think that the vein is going to be similar. Sure. Ok. So now we're gonna remove the other catheter. Yeah, we can take the road map off. We, so I think we're gonna get the venous catheter in position next. So he's backing out the merit prelude catheter. That's that 30 centimeter one. I think one of the things that helpful and you can ask your EFS is and remember all this is really for you to kind of focus and, and just kind of get AAA good idea of him working away all the details of which catheters and which she and that don't worry too much about that. You can write it now if you want to, but also EFS will be able to give you all of those um that people are using and at the end of the day, honestly, whatever you kind of have in your, if you have something that you like to use, preferentially, that's totally cool. Also, these are just things that, that we tend to like to use. Um So he's backed out that prelude sheath. Um He's now loading up the um uh the Venus catheter, the Venus catheter has this little protector over it. Um And it's this yellow one. And what that does is that protects the electrode which is actually very supple um very soft. Um So as you go through the hydrostatic valve, so there it is. Yes. Thank you Alex. He's getting that into position there. And so if we have that camera with him advancing, this would be worth watching him advance that. Um, my name is Catherine. Yes, please. One of the things that we do when e even though he's on the liquid. Oh, that's fine. Yeah, thank you. You guys are so good as you can tell my team also points out that my knowledge of anatomy is skewed. Sometimes you see what you want to see, don't we? All right? And they just pointed out which one was the artery and I appreciate it. Well, you know, it, it, it, that's why it's a team effort, right? So this doesn't, this doesn't work in isolation, just like everything else. Ultrasound, fluoroscopy, sedation. Um, efs, scrub everybody. I was gonna say some, some people I, I, regarding anticoagulation for the artery, I, you know, we've thought about what recommendations I would do what you're used to doing in your practice. That's all good. That's it. It's a good point. I agree with that. So he's gonna advance the catheter, you're gonna see. Um, and I think he said that the catheter is on the outside. So therefore the wire is gonna wanna be on the outside also to know which direction it's in. Let's see if that remains true for me advances it. Um, you can see it come into position here and we'll be looking to see which direction the electrodes pointing. Ok. That looks good. It's gonna advance the two catheters. I can see the magnetic attraction between them. Of course, his team is skilled at this and they already magnify up for him. Uh right off the bat without having to be asked. That's wonderful. Um I think it's interacting. Yeah. There it is. Yeah. So now what he's doing is he's deflecting the venous catheter um off of the arterial to see the deflection of the actual electrode itself. One of the things that was interesting about this uh as you see a advance because the wires were crossing early on the electrode was behind the catheter, they interacted. And as the catheter can also under uh into position, the, the the electrode, the magnet sort of lost interaction. And once the catheters came into the alignment, they interacted really nice. One of the things that because I, we started with the six range in this situation, I'm gonna do it now just for just because we're in the screaming and we're, we're doing well on time. We just saw that the, the catheter is interacting. Let's confirm. And we got an expert on this. We're gonna do what we used to call the perpendicular view, which is or the eclipse view, which is to see that the electrode is completely aligned. Yeah. So we're gonna take the, so we have the catheters like this, he's gonna have them rotated until you can only see one catheter. So it's 90 degrees from this. So we're gonna come around there and this is kind of just an extra step. Um You don't necessarily need to do this. But the catheter Alvarez likes to do this because initially with the six French system, you had to do this. Um And so um yes sir. The nice thing that you see here is like uh you can see here the rotation of the vessel, the catheter is perfectly aligned. You see the, the electrode right aligned with the, with that, but look at the variation of the windows, the distal windows with the proximal windows. Yep. So I think we're good. Keep on going out for a little bit. I wanna see some of keep going, keep going, keep going, keep going. OK. There, stop. That is the true eclipse view. So what we're saying here is that you, you see that these catheters essentially appear as one. And so that's kind of the complete um 90 degrees different from where we started from. So that's what we sometimes you're gonna hear in the, in the literature people. This is excellent. Let's go back my dear. So we're, we're good, right? Let me see that. Let me find the, the, if you rotate the screen back towards Doctor Alvarez a bit there, I moved it to point. OK, let me up a little bit better. Getting everything lined up in position, make sure he's happy with the alignment, see how nice they interact. Yeah, I'm gonna step back over here for just one moment to get the view in here with you. So I'm gonna pull the arterial now. Ok. So now he's got everything lined up here. So the arterial wire comes out fully. So removing the wire um from the arterial side, um You can see that back out. There we go. And I'm removing the Venus side. So now he's taking out the Venus wire staying alive during that time. I wanna make sure you don't see any rotation or anything like that. He already kind of moved the catheter back and foresaw a deflection of the electrode. Now, a couple of things, if you don't want, this almost always happens. And I think you, you've seen it as soon as we pull the wire, the, the, the catheters close up. They do. Well, you always wonder whether you can have a little bit of what we call wire bias where you're being pushed to either side of the vessel. Um And so I think that that kind of takes that out of the mix. The other thing we can check the interaction either moving the Venus or the arterial. So if you feel that you're h or what I've done is if you feel like you're having trouble when you're advancing that Venus and you feel strongly about that location, you can always check the interaction with the arterial. And so we're gonna do that now. Yeah, if, if given a choice, I prefer to move the arterial catheter just because it's easiest to get in and out of his location in case you don't look at that. So you're seeing deflection of that was, that was very nice. Very, very nice. So, I think we're ready. Ok, let's give him 50 of fentaNYL if we can. So warming up to activate. So, the switch and the, uh, yeah, so the, um, venous catheter is now gonna be connected to the Boie pencil. Um, and we've kind of checked the settings. Um, Jessica's making sure, um, that we've got that, um, correct. Um And so the 0.6 seconds. Yeah, and he's gonna talk to the pencil here. Really? Anybody could press the button, but this is the part that I am really selfish. Uh That's OK. This is, this is, this is your, I don't press the button. I did not do anything. I won't sleep good tonight. I didn't do my job. I didn't deserve my, I hear you. I'm gonna over here to see the actual activation as we get in the position. A couple of things we're on right now. Christie, I don't know if you can see where Christie's position. If you have a block, a regional block, you won't, you may not need this, but since he's sedated, we warn him that he might fill us up. And Christy holds the forearm and the shoulder and the shoulder, she puts pressure and only reacts to what the patient reacts to. And that allows for the catheters not to move. And I reckon even if you're under a block or whatever, it's, it's usually, it's a, it's a reflexive type one because activation near the nerve and so hold it regardless. I think it's always a good idea. So we're gonna reactivate. He's gonna hit the yellow button. We're gonna do it. Let's go in real time, move it to cells doing ac OK? I'm gonna activate it. Here we go. Let's do it again. OK. So, activated. So occasionally we need two. In this case, we needed two and you can see it interact. So then there was loss of the kind of distance between the electrode and then the ceramic back. Stop. Um The patient did feel it. Um And uh, it's been given her the sedation. So the one nice thing about these being um, four French catheters and five French sheath is you can inject around it. Ok? Now we, we see it there. We're gonna remove the, the Venus because we have fistula. I left it because I wanted to make in his case on the fir if you looked at the first uh application of the, of the current, it didn't, I didn't see it. It could have, but I personally didn't see the contact and on the second I did. So I wanted to make sure because if you're gonna fire again, you don't wanna move the, the venous in particular, you don't wanna move it at all. Yeah. And it could be activated up to three times I'd say the vast majority of the time you only activate it once. Um But if you know the advantage is uh Doctor Alvarez didn't feel that he could see a complete obliteration of the tissue between the electrode um and the ceramic backstop. So I wanna make sure he took another picture or another activation. Um And then took a picture. Um One thing you don't want to do is activate and then move them and reactivate because you most likely have gone through the vein, maybe not through the artery. So what you wouldn't want is two venotomies and one arteriotomy. So he's now removed the sheath, removed the Venus sheath first. Um I'd like to do that to decrease the pressure and all the blood to flow out there. I was gonna take a shot here. Uh Sorry. Uh There's a couple of nice things that have happened with him. We got a good fistula. We saved the angle. Uh Let's go. Can you put on the, on the screen the previous one? Uh or can you put them side by side still of this one? And the other one, it's because on the, on the first one, you see that flash that sometimes is confused with extravasation and not even a minute later. Look, look at the first one. Look at the difference. Yes. So Doctor Alvarez is speaking to, I'll go over there so I can point to that there, Alex Horse, but you can see it. This is before I remove the first one. So at first you see a little bit of this kind of haziness um that can happen in this area and then after waiting just a few moments of actually taking out the that so you see a resolution of that haziness and you're seeing the blood come up, fill directly out that perforator. So, um that looks good. Um I think I'm not worried about that bridge. That was there. Originally, I think that distal bridge is gonna eventually open up the one here kind of spasm. Maybe we have excellent flow in that lateral to the, to the, to the Yeah. So he's injecting in the artery blood coming down, going across the ansis up and now the clic and there was this other one here that we mentioned before. I agree with you. I bet once all the spasm resolves it fills out there also uh save the angle. So the angle is really important because that's going to be the reference if we have to do interventions in the future to say the angle of the sea arm of which it was created at. So it was created at about I think 20 degrees, 25 so 25 degrees. So he'll write that in his note, he'll probably also put down that it's the uh the lateral ulnar vein to the common ulnar artery. So that way and then there's the main, do you put the perforators in there or do you got anything else you addict to? Not always. But in this case, I will because it's because I know that if we don't put it in and we don't read it when we inject contrast where it's gonna really be confusing. It's confusing. Even still to this day, the images can be a little bit confusing. They can, I mean, I mean, you've done, I know over 100 of these but even even looking at them, it takes, it takes at least 15, maybe 20 to really get that picture in your brain of what you're looking at. And that's where having kind of your clinical specialty that is so important to have, I think early on just to kind of share ideas of of where kind of or what you think is connected. The other thing that is nice on this, on this image and we'll move, I'll move on with the Bermuda. Look how big the common alert that we've always talked about. It almost the size of the or is the same size as the brachial. For sure. The nice thing is I think that we get the advantage of that big vessel to get nice flows that we use here in the US. And yet it doesn't compromise the flow into the radial artery. So it's really nice, excellent looking good. So the flow is going down um across the all common ulnar artery to the lateral ulnar vein up then out the perforator and it looks like his main outflow is really cephalic. So, um, big, big Juicy Cephalic. Um, so now Doctor Alvarez is going back into, I bet the venous side with his catheter in preparation of uh coil embolization. So he's gonna get that into position. Now, as far as coiling, coiling is another one of those that really, you know, whatever your kind of, um, standard, um, uh, practices is fine if there's a certain coil that you like or something along those lines. Um, certainly can use that. Um, and coil is one that my theory for, for what I do here is coiling is like you've said, it's like politics. Everybody would have an opinion. I think here what I concentrate in the co, I just wanna force the floor to the surface. So when I coil, I do not want to, um, erase with the coiling, the creation of the fish. So you can always come back and coil it more coils or, or do what we need to do. But I think on this, that's all I look for. Yeah, I agree. You know, the idea being that coiling is really increasing the resistance in the deep system. So more flow goes out the superficial system. You're not, you know, not coil off an aneurysm, you're not coiling off, um, some sort of kind of other vessel, um, in any way, um, what you're really trying to do is just increase that resistance. So here he's gonna take a picture just to make sure. So there, that is what we were talking about. I'm behind, see, I'm behind, I'm way behind. I usually try to go a little closer, but I am behind far enough that I don't think we're gonna get any other collateral. Like I might sometimes use an eight, especially on the bigger part, but I'm gonna use the six first because I think that coil, if, if we oversize it is when the coil goes straight. And so that way I can get it to coil there and if I need to put a bigger one or, or pack another one behind it, I just go ahead and do it. So, once again it's the brachial artery coming down. This is this common, er, there's our anastomosis there and comes up here filling up and out the spin, there's the radial artery still filling nicely and the rest of the vessel is still filling well down there. Yeah, I think he's gonna have a good fistula. Yes, I do. I, all righty. We're getting everything lined up here. No, you're good. You're good getting that coil in position here that lined up. We got nestor. Um, you know, the other thing is if you don't necessarily coil a lot. Um, so I know as far as vascular surgeon, the main things I coiled was maybe the, the inter iliac artery for aneurysm, that sort of stuff, a lot of the other smaller kind of coiling stuff not necessarily did as much of. Um, and so if you're ever kind of like, hey, I want kind of, you know, a little more practice with this, have your coil rep come out and have them bring their stock with them and have them, you know, get some ones that you can kind of work with and make sure that you're happy with it, kind of the deployment of them. Um, you know, there's, uh, as far as Dr Alvarez has Nestor, um, he has tornadoes. Um, he's got a very nice setup here, a very good cart that has pretty much everything that he wants on it, which makes life, um, good for him also. So here he put the coil in for watching his hands advance and so he's gonna push the coil down in position. So if the coil is, for example, if the coons are lining straight and migrating towards where you don't want it, what I found is most of the time, if I hold the cat and I hold it, it brings the coil back with it. Sure. Yeah. One of the things you see is that, you know, we've, we've disrupted the valves by, by passing the wire in that direction. Sometimes the coil then wants to kind of go past the valves as well. Um, other times they'll get caught on it right off the bat. Um, so he's just backing it up, making sure we get a nice. So he brought it back a little bit, make sure it's cornering up the way we want it to. There you go. So, trying to get the tip a little bit sure that the coil starts taking form. I don't worry if it doesn't pack tremendously. Well, I can always, I know that coil is gonna be my, my, this, I'm gonna use it as a wedge for a second coil if I have to. So, but with that being said, this is looking very nice and so we got it there. Let's see how it does. That looks great, Alex. So that coil actually for him saying he doesn't care how it's packed, packed perfectly. Um um Let me take another injection, the artery, we don't put another one, look at the difference and again, look what happened when we increase the magnify this just for my because we ma give me a map. So what we're gonna look at is I think we're gonna look at that distal perforator um to get a better idea of what that looks like there, you know, she had good lined up and of course, he's injecting through the artery to watch it fill. So look what's happened, see already with the resistance that perforator, he hung over and point to that for us. And I'll point to that Alex once we get it peaked. So we're seeing the kind of here's your coil there, of course. And so the flow is coming down and already you can see this getting bigger as well. So here's the jelly bean or the anastomosis um comes across, it's filling up and out. But also what we're with, Doctor Alvarez is mentioning is you're starting to see this come back to life there. Um that spasm there and you know that that just takes some time. I I bet. But if you came back and imaged it later, you'd see this one and that one and the other thing is, and we take anything we can, there is flow, going back into the, into the media and it's breaking up there. So she's got the, the other nice thing about this, that, that there is a, you know, as time progresses and I've seen it already in a couple of fish that figures out the anatomy is not the same as originally. So some of these vessels travel, but they find their way and the flows don't change. And if they, if they change, we have options for sure. And I mean, you always have a route, you know, you could always come back through this. If you ever had to treat this area or something along those lines, you'd be able to work your way back in there or, you know, you have a variety of options the way you've created it. Yeah. And what we've noticed that we have a little case report coming later on, we always have options on the distal, these those distal veins, planking veins are going to grow and they are not a disadvantage. I used to be very aggressive at coiling to keep everything for that. Not anymore. I try, I really obsess making sure that the cause of them uh getting big is not a stenosis because they, I think they allow us the possibility of creating an additional fistula from another approach in that site, which then again gives the patient another opportunity to avoid surgery and keep other options open and still without affecting that. So, and those are things that we've kind of learned. But look there, you can see it there, the, the the the flanking veins, increasing, flanking veins coming down there. Yeah, we're good. That looks wonderful. All right, I think that looks wonderful and it's really good. It looks really good but isolated. See, you know, that's good when he's already like, I think that's thank you. We're done here. Um We're gonna let him kind of um get everything lined up when I, I remember you guys when I used to uh get this feeling, I still get it. But I'm more because I gotten over 50 now. So I'm more calm but before I used to go like boom, boom. So I think it goes for that. This one went really good actually, that's totally reasonable to do the dance on this one. And so now So we've accessed everything, we created it. We're gonna let them keep working here. I'm just gonna narrate us out here in just a moment. If anybody has any questions you can send them over. Um, but first of all that was a phenomenal job. Um, and I mean, I think probably Doctor Roberts could do that about 20 minutes, uh, based upon the amount of time that we built and to just chat and show pictures, um, and come along there, um, he's now getting all the wires out, I'll take out his sheets, then he's gonna hold pressure. Um One of the key things that we didn't mention kind of as he accessed the, um, brachial artery was to make sure to push away that median nerve, um, to have that away, but also where his access point is, it's close to the humerus. So when he actually removes that arterial teeth, he'll be able to hold pressure, um, over that humerus. Um And so he's gonna get into position, make sure his back's comfortable here for this. Um And, um, and once he's holding pressure, then I'll bug him for a couple more questions. Alex. Um, you've done now, what is this? 100 and 107107? Excellent. It's about the same temperature as it is in Dallas right now. Um And, and so he's taking it up. So any, any kind of words for anybody first getting started on this as far as, I mean, you made this look really smooth. I mean, this was, this was like butter. I mean, this was wonderful patience, choosing the low hanging fruit, make sure that uh uh the long hanging through don anything. If you have any doubts that uh I may not be able to get there, that's not the right patient at that moment. Just get really good patients and, and, and not to be of an issue, you, it's, it's always a bad start to a, to a sentence. By the way, the best, the best first patients are probably going to be men. Well, and, and statistically speaking, K do, I mean, it's just based on size and vessels and anatomy. So I would think I would focus on men. Uh You know, that's where you're gonna find those easy hanging fruits, women. We've had very good success and we have about the same uh the, you know, the same proportion of, of, of female patients as Koki and all that, they're more difficult, but the vessel is a little bit smaller. The Chris has done, I have done 100 and seven and Chris has done 100 and two with me. Those uh would you agree that usually with, with women, we have to uh hustle a little bit and, you know, work a little bit harder to get to where we want. Now, how do you work with your, with, with your clinical and EFS specialists as far as do you look at the ultrasound images together? How do you guys, I mean, you guys have a great team here and, and, and we're missing kind of one other member of the team that's almost always with us. Um So shout out, I know she's out there watching. We do, we, we look even if, if, if, if jazz with our uh clinical who's standing next to him, he's not, he's not here. We um we get the films, we get the ultrasound, we schedule the patients and when Jess comes in, we make sure that one of us brings her, uh we definitely text her. We have a couple of, we have so many patients and so we arrange for her to come and we, and we look at the films together and we kind of have a plan. It's also important for, for, for Jess and Carla when they're here, it's really important I think for them to know what we're seeing because they also are thinking of how we're gonna approach this. It's, you know, in the end I made the decision. Sure, but they have so much experience because they go to other doctors and do this special as one of the best things is they just like what they see me do here, they take it to their partner doctors and, and share what we learn. They do the same with me. And so when they see something similar, they go like Hey, we did this at that place. What do you think? And then, ok, thank you. And you, you get a lot of ideas, the best approach. And what's interesting is early on, you know, the, the, the specialist had about as many cases as we did, right? Because each one was just one at a time. And so if you had done 30 or 40 they had done 30 or 40 but now they've kind of logarithmically expanded that where there's, now, I think, I mean, Carla hasn't she been part of 400 ish or somewhere? I mean, so as you know, it's just, there's certain things that repetition does help anatomy rec recognizing, hey, maybe this, hey, is that, so the one thing that, that also, I don't know if it's seen so well, although I have sung their praises because I actually really like them. But is your team. So everybody kind of is playing a part in it. People are interested in it. People want it to be succe, not that people don't otherwise, but, you know, everybody from, you know, from sedation to, to the cr to, to looking at films, everybody's kind of working in unison and all the stuff here. Notice nobody had to leave the room for anything ever. Um And so those, those little things make a big difference for me, right? What we did here and, and our, the way our set up is, is, is, is that's feasible. Right. But everybody gravitated, we have three artists. The two artists that have sort of a specialized of doing this with me are Megan and Christy. And as you can see if you, if you repeat presence in the streaming, it's always Megan running the cr and Christy helping me with the electrode. Christy. Christy is also the person that does the ultrasound. So she, she does the ultrasound than me. It's OK. You can say that we'll highlight her here. She, she's phenomenal. And so when we're here a lot of the time or the majority of the today was particularly smooth, but a lot of the time we're both like, hey, I go back and forth. Did we really see this? What do you think be? And, and she tells me like, yeah, Alex, I saw this. I don't know why we're not seeing it here. And so we go with the ultrasound and try to look for what she has seen or what I have seen. I'm Megan has become extremely and you can tell now after many that she is not proficient at running that cr that is because the cr is heavy and not letting it vibrate. And so now I can like, we can do the things smoothly. Hey, do you want an eclipse when she started running the arm? And I said, hey, I want an eclipse. Her eyes will roll to the back of her head. We will tell we won't tell So, yeah, the team, you know, my success is probably 10% me, 90% that is, you know, they are the people behind uh behind the scenes making everything easy. So that, that moment that I'm uh that I'm performing, everything is easy, but the work has been done by them. Yeah, to make sure that our very well. So we're giving a shout out to the nurses making sure that they have kind of adequate sedation. Um And not only do they have a little baby girl on the way. Um, but um, they do a phenomenal job with that. And so as you can see, that's, it's, it's really, it's really a special thing that they've got here. Um I'm gonna let him pressure, um, and make sure your patients happy and sedated. Um, we do appreciate everybody's time. Um, and watching us today, uh, this could not have gone better. Um, excellent job. I think key points are making sure access is good. I think there's certain times that, that, you know, as far as watching this, you know, we, we take a break during a lot of times to show stuff, but the one times where I'm really focused and I know Doctor Alvarez is two is number one with that access. Um Making sure we get a kind of good clean access that really sets the tone for the procedure when that goes. Well, the rest of the case goes well and then making sure your view is really what you want it to be and make sure those catheters are lined up and then of course, kind of going over the anatomy and kind of ST, you know, kinda strategizing where exactly you wanna make, uh, the anastomosis. So, with that being said, uh, we're the Missouri meet in Mississippi, Saint Louis. Um, we appreciate your attention and look forward to seeing you next time. See you guys later, see you later. Ok.
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