Audible Bleeding

Audible Bleeding editor Wen (@WenKawaji) is joined by 5th year integrated vascular surgery resident Kaitlyn (@DunphyKaitlyn), JVS Assistant Editor Dr. Paul Dimuzio (@pdimuziomd) and JVS-VL assistant editor Dr. Dua (@AnahitaDua) to discuss two great articles in the JVS family of journals regarding Post-operative stroke risk after carotid endarterectomy and use of Varithena in treating venous leg ulcers. This episode hosts Dr. Levin, Dr. Siracuse and Dr. Shao, the authors of the following papers:

Articles:

• Postoperative disability and one-year outcomes for patients suffering a stroke after carotid endarterectomy by Levin et al.
• VIEW-VLU observational study of the effect of Varithena on wound healing in the treatment of venous leg ulcers by Shao et al.

Show Guests:

• Dr. Siracuse- Professor of surgery and radiology at Boston University

• Dr. Shao—vascular surgeon at Swedish hospital, Northshore University Healthsystem in Chicago, IL

• Dr. Levin—plastic and reconstructive surgery fellow at the University of California Davis

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Modern-day evidence-based medicine mandates a strong understanding of current local and international guidelines. Surgeons rely heavily on these reports, but what to do when they differ? We have partnered with the ESVS podcast in creating the Transatlantic Series, where we compare and contrast our respective society guidelines. In this inaugural episode, we explore the SVS carotid artery disease guidelines published in 2022 and the recently updated ESVS guidelines published in 2023.

Representing the American perspective, we are excited to speak with Dr. Ali AbuRahma. Dr. AbuRahma is the former president of the Society of Vascular Surgery, the Chief of Vascular and Endovascular Surgery at the Charleston Area Medical Centre at West Virginia University, and the corresponding author of the latest SVS guidelines on extracranial cerebrovascular disease.

Representing the European perspective, we are delighted to speak with Dr. Barbara Rantner. Dr. Rantner is the co-chair of the 2023 European Society of Vascular Surgery Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease and a leading physician at the Ludwig-Maximillian University Hospital in Munich, Germany.

Further reading and links:

• The North American Symptomatic Carotid Endarterectomy Trial (NASCET) & Audible Bleeding Landmark Papers NASCET Episode

• Randomized trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST)

• The 2nd European Carotid Surgery Trial (ECST-2): rationale and protocol for a randomized clinical trial comparing immediate revascularisation versus optimized medical therapy alone in patients with symptomatic and asymptomatic carotid stenosis at low to intermediate risk of stroke

• European Stroke Organisation (ESO) guideline on endarterectomy and stenting for carotid artery stenosis

• A comparative effectiveness study of carotid intervention for long-term stroke prevention in patients with severe asymptomatic stenosis from a large integrated health system

• SVS Patient Safety Organization (PSO) TCAR Surveillance Project

• SVS Vascular Quality Initiative (VQI) & VQI TCAR Registry

• Important recommendations of the German-Austrian S3 guidelines on the management of extracranial carotid artery stenosis (Paper only available in German)

Hosts:

• Laurence Bertrand is a 5th-year vascular surgery resident at the Ludwig Maximilian University Hospitals of Munich, Germany. She is a medical graduate from KULeuven, Belgium, and has a Master of Science in International Health from the London School of Hygiene and Tropical Medicine.

• Ezra Schwartz (@EzraSchwartz10) is a medical graduate from McGill University pursuing a Master of Medical Science in Medical Education at Harvard Medical School. He is applying to integrated vascular residency programs this year.

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We are delighted to review the SVS VAM Diversity and Resident/Medical Student travel scholarships in today's episode. Dr. Ezra Schwartz and Dr. Nakia Sarad speak with three scholarship recipients to explore their reasons for applying, their experience at the 2023 Vascular Annual Meeting, and the impact of their attendance on their goals and aspirations.

• Nathaniel Forrester (@Nathaniel_For) is a fourth-year medical student at Emory University SOM from Lawrenceville, GA. He will be applying to vascular residencies in this cycle. He received the Diversity Scholarship to attend his first VAM.
• Gayatri Pillai (@GayatriPillai10) is a third-year medical student from Geisinger Commonwealth School of Medicine. She, too, received the SVS Diversity Scholarship to attend her first VAM.
• Carlo Angello Sánchez Montaño (@carlo_angello) is a first-year vascular surgery resident who transferred from a general surgery program. He is a November 20th National Medical Center trainee in Mexico City, Mexico. He received the General Surgery Resident/Medical Student Travel Scholarship to attend his first VAM.

VAM 2024 will be held in Chicago June 19-22, 2024. The following are links for more information on SVS Awards and Scholarships offered. We encourage you to apply!

• SVS Awards and Scholarship Page
• SVS General Surgery Resident/Medical Student Vascular Annual Meeting Travel Scholarship
• SVS Diversity Medical Student Vascular Annual Meeting Travel Scholarship

Twitter:

• Dr. Ezra Schwartz (@Ezraschwartz10)
• Dr. Nakia Sarad (@NakSaradDO)
• Nathaniel Forrester (@Nathaniel_For)
• Gayatri Pillai (@GayatriPillai10)
• Dr. Carlo Angello Sánchez Montaño (@carlo_angello)

Vascular Origin Stories (VOS) is a podcast series that explores the fun and engaging stories that shaped vascular surgery. Today we are kicking off a new origin stories series: the vascular offspring stories, where we interview practicing vascular surgeons about their vascular surgeon parents.

In this episode, we chat with Dr. Alan Dardik about his father, a pioneering vascular surgeon, Dr. Herbert Dardik. Dr. Alan Dardik recollects many great stories of his father and how he ultimately followed in his footsteps.

Further reading and links:

• Herbert Dardik 1935-2020, Leaders in Vascular Surgery, Journal of Vascular Surgery
• Remembering Dr. Herbert Dardik, The JewishStandard
• Dr. Alan Dardik, Yale Profile

Host: Marlene (@GarciaNeuer) is a first-year integrated vascular surgery resident at the Mayo Clinic in Scottsdale, AZ.

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Today, Dr. David Ebertz (@EbertzDavid), a rising vascular fellow at St Louis University, and Dr. Jason Turner (@JasonTyTurner), a graduating integrated vascular resident from Case Western Cleveland Medical Center, discuss with multiple leaders in vascular surgery about VESS (@VESurgery) and SVS (@VascularSVS). The Vascular & Endovascular Surgery Society, commonly called VESS, is one of the foremost societies within vascular surgery that was started in 1976. Its mission is to improve the quality and safety of vascular & endovascular surgical procedures and general vascular care through education, scholarship, advocacy & leadership. This episode will feature VESS's history, current status, and pearls of wisdom, from finding mentors to navigating social media to becoming a leader within societies.

Faculty Guests:

• Dr. Leigh Ann O'Banion (@limbsalvagedr) - Assistant Professor of Vascular Surgery at UCSF-Fresno, California
• Dr. Vikram Kashyap (@VikKashyapMD) - Vice President and Frederik Meijer Chair, Meijer Heart and Vascular Institute in Grand Rapids, Michigan
• Dr. Nick Mouawad (@NickMouawadMD) – Chief of Vascular Surgery at McLaren Health Systems in Bay City, Michigan
• Dr. Saideep Bose (@academicaorta) – Assistant Professor of Vascular Surgery at St Louis University, Missouri
• Dr. Matthew Smeds (@mattsmeds) – Professor of Vascular Surgery at St Louis University, Missouri

Additional Links:

• VESS Student Mentor Program
• VESS Mentorship Program for young surgeons
• SVS Mentorship Match

Audible Bleeding editor Wen (@WenKawaji) and Matt (@chia_md) are joined by MD/PhD student Rahul Ghosh (@ghoshrx), JVS editor-in-chief Dr. Thomas Forbes (@TL_Forbes), and JVS Assistant Editor Dr. Paul Dimuzio (@pdimuziomd), to discuss two great articles in the JVS family of journals regarding renal stenting in the CORAL trial and metformin in AAA progression. This episode hosts Dr. Baohui Xu and Dr. Gregory Modrall, the authors of the following papers:

Articles:

• Mechanisms and efficacy of metformin-mediated suppression of established experimental abdominal aortic aneurysms by Xu et al.

• Retrieval of renal function after renal artery stenting improves event-free survival in a subgroup analysis of the Cardiovascular Outcomes in Renal Atherosclerotic Lesions trial by Modrall et al.

Show Guests:

• Dr. Gregory Modrall - Professor of Surgery, Division of Vascular and Endovascular Surgery at The University of Texas Southwestern Medical School

• Dr. Baohui Xu – Senior research scientist at Stanford University in collaboration with ShanDong First Medical University in Jinan.

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Today, Dr. Ezra Schwartz and Dr. Nakia Sarad begin an exploration of how vascular surgeons and patients communicate. We will discuss how we share stories with one another and what may get lost in translation. The first episode in this series features Dr. Anahita Dua in conversation with her patients and their experience with deep venous arterialization.

Faculty Guest:

Dr. Anahita Dua is a vascular surgeon at the Massachusetts General Hospital and an associate professor of surgery at Harvard Medical School. She wears many hats at the MGH including director of the Vascular Lab, co-director of the Peripheral Artery Disease Center and Limb Evaluation and Amputation Program, associate director of the Wound Care Center, director of the Lymphedema Center, associate director of the Vascular Surgery Clerkship, and director of clinical research for the division of vascular surgery.

Dr. Dua completed her undergraduate medical studies at the Aberdeen University School of Medicine in Aberdeen, Scotland. She then completed her general surgery residency at the Medical College of Wisconsin and a vascular fellowship at Stanford University Hospital. She holds multiple master's degrees, including trauma sciences and business administration in healthcare management. She also completed certificate programs at the Massachusetts Institute of Technology in health economics, outcomes research, and drug and device development. She has published over 140 peer-reviewed papers and has edited five vascular surgery textbooks.

For more information on the CLariTI Study, click here.

Patient Guests: (Shared with consent)

• John McConnell - patient of Dr. Dua
• Daniel Debovie - son of a patient of Dr. Dua.

Deep Venous Arterialization References:

• Ho, Vy T., Rebecca Gologorsky, Pavel Kibrik, Venita Chandra, Anna Prent, Jisun Lee, and Anahita Dua. "Open, Percutaneous, and Hybrid Deep Venous Arterialization Technique for No-Option Foot Salvage." Journal of Vascular Surgery 71, no. 6 (June 1, 2020): 2152–60. https://doi.org/10.1016/j.jvs.2019.10.085.
• Shishehbor, Mehdi H., Richard J. Powell, Miguel F. Montero-Baker, Anahita Dua, Jorge L. Martínez-Trabal, Matthew C. Bunte, Arthur C. Lee, et al. "Transcatheter Arterialization of Deep Veins in Chronic Limb-Threatening Ischemia." New England Journal of Medicine 388, no. 13 (March 30, 2023): 1171–80. https://doi.org/10.1056/NEJMoa2212754.

Twitter:

• Dr. Anahita Dua (@AnahitaDua)
• Dr. Ezra Schwartz (@ezraschwartz10)
• Dr. Nakia Sarad (@NadSaradDO)

Audible Bleeding editor Wen Kawaji (@WenKawaji) is joined by MD/PhD student Rahul Ghosh (@ghoshrx), JVS editor-in-chief Dr. Thomas Forbes (@TL_Forbes), JVS Assistant Editor Dr. Paul Dimuzio (@pdimuziomd), and Associate Editor of the Journal of Vascular Surgery-Cases, Innovations and Techniques, Dr. Sherene Shalhub (@ShereneShalhub, @OHSUvascular), to discuss two great articles in the JVS family of journals regarding uncommon vascular conditions, including aberrant subclavian artery/Kommerell's diverticulum and vascular Ehlers-Danlos syndrome. This episode hosts Dr. Jonathan Bath, Dr. Peter Lawrence, and Dr. Bernardo Mendes, the authors of the following papers:

Articles:

• Contemporary Outcomes after Treatment of Aberrant Subclavian Artery and Kommerell's Diverticulum by Bath et al.

• Open repair of an infected abdominal aortic aneurysm in a patient with vascular Ehlers-Danlos syndrome by Mendes et al.

Show Guests:

• Dr. Jonathan Bath (@MizzouVascular) - Assistant Professor of Surgery and program director for vascular fellowship at the University of Missouri

• Dr. Peter Lawrence - Professor of surgery at @UCLAVascular, served as senior editor for both JVS and JVS-VL previously.

• Dr. Benardo Mendes (@drbermendes) - Consultant in the Division of Vascular and Endovascular Surgery at Mayo Clinic, and is Associate Professor of Surgery at Mayo Clinic College of Medicine and Science.

Additional Notes:

• Vascular Low Frequency Disease Consortium Website

  • Visit here for a list of completed projects and publications.

• The VEDS Collaborative research study is still enrolling! Any patient interested in enrolling should reach out to [email protected] and follow @VEDSCollabo and @OHSUvascular on Twitter.

• JVS-CIT will be dedicating a full virtual issue to patients with genetic aortopathy and arteriopathy.

• Resources for patients: https://thevedsmovement.org/ and https://www.ehlers-danlos.com/

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Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.

In today's episode, Gowri Gowda, Ezra Schwartz and Morgan Gold, and Dr. Sharif Ellozy interview Dr. Daniel Silverberg about his experiences practicing and teaching vascular surgery in Israel.

Dr. Silverberg is the deputy director of the Department of Vascular Surgery and the Director of the endovascular service at the Chaim Sheba Medical Center in Ramat Gan in the municipality of Tel Aviv, Israel. He completed his undergraduate medical studies with honors at the Ben-Gurion University of the Negev in Beer-Sheva, Israel, and his clinical internship year at Meir Medical Center, Kfar-Saba, Israel. Dr. Silverberg performed his general surgery training at Meir Medical Center, Kfar-Saba, Israel, and later at Mount Sinai Medical Center, New York City. He then remained at Mount Sinai, where he completed his vascular surgery fellowship. Dr. Silverberg worked as an attending vascular surgeon at the James J. Peter VA Medical Center in New York for three years until returning to Israel in 2009.

Contact Information for Dr. Daniel Silverberg

Email: [email protected]

Twitter:

Dr. Gowri Gowda (@GowriGowda11)

Dr. Ezra Schwartz (@ezraschwartz10)

Dr. Morgan Gold (@MorganSGold)

Articles, resources, and societies referenced in the episode:

• Israeli Society for Vascular and Endovascular Surgery: https://israelivascular.ima.org.il/ViewEvent.aspx?EventId=3630

• https://www.commonwealthfund.org/international-health-policy-center/countries/israel

• Zhang LP, Silverberg D, Divino CM, Marin M. Building a Sustainable Global Surgical Program in an Academic Department of Surgery. Ann Glob Health. 2016 Jul-Aug;82(4):630-633. doi: 10.1016/j.aogh.2016.09.003. Epub 2016 Oct 1. PMID: 27986231.

Follow us @AudibleBleeding

Learn more about us at https://www.audiblebleeding.com/about-1/ and #jointheconversation.

Endovascular 101

Authors:

Sebouh Bazikian - MS4 at Keck School of Medicine of University of Southern California

Sukgu Han - Associate Professor of Surgery at the University of Southern California. Co-director of Comprehensive Aortic Center at Keck Hospital of USC. Program Director of the Integrated Vascular Surgery Residency and Vascular Fellowship

Editor: Yasong Yu

Reviewers: Matt Chia and Kirthi Bellamkonda

Core Resources:

• Rutherford's Vascular and Endovascular Therapy 10th Edition Chapter#26-28

Additional Resources:

• Relevant Audible Bleeding episodes

• • Holding Pressure Case Prep - AKA/BKA

  • Journal Review in Vascular Surgery: Introduction to Endovascular Surgery – A Prime

  • Peter A. Schneider, MD and Endovascular Skills - history, personal techniques and updates in the 4th Edition

• Closure devices:

• • Angioseal

  • Mynx

  • Proglide

Endovascular procedures are minimally invasive techniques used to treat conditions affecting blood vessels, such as aneurysms, stenosis, or occlusions, by accessing the affected vessels through an incision in a peripheral artery and using imaging guidance to navigate catheters and devices through the blood vessels to the treatment site.

Endovascular procedures can be broken down into 4 key steps

1. Establishing arterial access

2. Navigating to target treatment zone or vessel

3. Treating the lesion

4. Closure

Basic definition of wire, sheaths, and catheters

• Wires are thin, flexible metal devices used to navigate through blood vessels and to guide other devices, such as catheters or sheaths, to the target location. They are measured in thousands of an inch

• • A 0.018 wire is 0.018 inch in diameter

  • There are two categories of wires: Flexible and support

Flexible wires are soft and hydrophilic. They are considered the "workhorses" because they are useful for navigating through vessels.

• A common type of wire is called the Glidewire which is slippery and useful in traveling across tortuous vascular anatomy.

• Support wire are generally a lot stiffer and not hydrophilic. For that reason they are used to deliver and deploy devices

• • A common type of support wire is called the Lunderquist which is used for the deployment of stent grafts in endovascular aortic repair

• Catheters are flexible hollow tubes used in conjunction with wires to navigate vascular anatomy

• • Various characteristics include the degree and shape of the taper, the lengths, and the stiffness.

  • They are inserted inside the sheath

• Sheaths are hollow tubes of various diameters that are inserted into a blood vessel to provide a pathway for catheters or wires.

• • They have a one way valve to prevent backflow of arterial blood and a side port that permits aspiration and administration of fluids.

  • They also come with a dedicated dilator which is used to fill the lumen of the sheath and allows the surgeon to insert the sheath safely into the vessel.

• If the wire is the rail and the catheter is the train, the sheath is the ground.

Sheaths and catheters sizing

• Both are measured in French

• • 1 French equals 0.33 mm. French size divided by 3 equals the approximate diameter in millimeters.

  • Another way to think about Fr is roughly the circumference in mm. Divide by 3 instead of 3.14 to get the diameter

  • Sheaths are defined by their inner diameter (ID)

  • Catheters are defined by their outer diameter (OD)

  • This is because catheters go inside the sheath, so the size of a catheter must be smaller or equal to the size of the sheath for it to fit inside.For example, a 5 Fr sheath can accommodate 5 Fr catheter/devices

  • Of note, the hole in the artery will roughly be 2-4Fr larger than the sheath size. This is important when considering the type of closure that will be used at the end of the procedure.

Step One: Establishing Arterial Access

• Preop preparation:

• • During physical exam, make sure there's a palpable femoral pulse to rule out iliofemoral disease

  • Review the CT if available for high femoral bifurcation or presence of vessel disease

• Patient positioning on the angio table, depends on the access site of choice.

• • Typical position (for retrograde femoral artery access) is supine, arms tucked.

  • Alternative access sites (ie. radial, brachial, carotid) may require arms to be out and prepped.

• How do you choose arterial access, location?

• • Depends on location of lesion you are trying to treat and complexity of the path from the access site

  • Size of the access vessel and device size must be considered when deciding on the access site

  • The most common is retrograde femoral artery access

  • When would other access points be used?

  • • Radial artery, brachial, antegrade femoral access. The goal, target location, and path complexity defines the access point.

• Arterial puncture

• • Femoral access:

  • • Look for pulsatile vessel on the US (vein is medial, artery is lateral; "venous penis")

    • Usually access at the level of femoral head for common femoral artery

  • Seldinger technique is used to establish access to a vessel or cavity using needle, wire, catheters, and sheath.

  • E.g. using the micropuncture kit:

  • • contralateral arterial CFA access with s 21 gauge needle

    • .018" guidewire is passed through the needle

    • Needle is removed and a short 4 or 5 Fr microcatheter with an inner dilator is passed over the guidewire

    • The dilator and guidewire are removed leaving the catheter in place to maintain access

    • Bigger wire is inserted through the catheter, which is then removed over the wire

    • A sheath is inserted over the wire

• The overall purpose is to start with smaller arterial puncture and exchange to larger size to minimize complication should the access fail

• Often, percutaneous closure devices are preloaded at this step. We will discuss this later.

Step Two: Navigating to treatment zone or vessel

With sheath in place, a guidewire is inserted into the vessel under fluoroscopic guidance.

• Continuous fluoroscopy is taken with the C-arm during key steps to visualize wire movement

• • The C-arm can be portable or built into the room

  • X rays are emitted from the X-ray generator below the patient

  • And the subsequent image is generated from the image intensifier above the patient

  • Radiation safety:

  • • wear protective gear which is made of lead. In addition, use the tableside lead shield whenever possible

    • minimize use of continuous fluoroscopy whenever possible

    • limit use of magnification, and digital subtraction angiography

    • keep the image intensifier as close to the patient as possible to minimize scattering

  • The C-arm can rotate around the patient to get optimal viewing of the vessels

  • • Frequently used terminology: 30 degrees RAO which stands for right anterior oblique, describing the relationship of image intensifier to the patient

Common projections used for lower extremity angiograms

• Iliacs: 20-30 degrees contralateral anterior oblique

• Femoralsl: 20-30 degrees ipsilateral anterior oblique

• Trifurcation and tibials: anatomic anterior-posterior or 20 degrees ipsilateral anterior oblique with feet in neutral supine position

• Thoracic aorta/distal aortic arch: 30~45 degree LAO

• Renals: AP

• maximizing image quality by limiting patient movement and with breath holding and collimating

• Contrast

• • Two types of contrasts: Iodinated contrast vs carbon dioxide

  • • Iodinated contrast has better resolution but patients can have allergic reactions and are at risk of contrast induced renal injury. Therefore, CO2 is preferred for patients with compromised renal function in which an image is created by transiently displacing blood. The downside is that it has lower image resolution than iodinated contrast, and rare but potentially serious complications of air locking.

  • Power injection vs manual injection

  • • When using power injection, you have control over pressure, the amount of contrast, timing, and rate or rise of injection. It allows for rapid filling of large arteries at high flow rates. Manual injection is more efficient for small vessels since you can control dilution and volume

Types of Wires

• Characteristics: wire tip, stiffness, diameter, and length

• Guide wires

• • To assist in catheter placement, navigate different arteries, cross lesions, and deliver devices.

• The most common sizes used in vascular surgery

• • Large .035" - generally used for the aorta and iliac.

  • Small .014"/.018" - used for smaller branches like the SFA

• Length: from 120 to 360cm

• • Based on distance from access site to the lesion

  • Long enough to reach target lesions and beyond (inside pt) and deliver catheters (outside pt) but not too long that it's falling off the table and slowing down exchange

• Flexible vs stiff/support wires

• • How do you decide which wire to use?

  • • Typically, you start with flexible wire inside an angle tip catheter to navigate to the target vessel. Once you reached and crossed the target vessel, the wire is exchanged to a stiff/support wire, which allows you to deliver

  • common brands and models used that every medical student should know and the settings they are used in?

  • • Example answer:

    • Glidewire (Tumero): a floppy wire with a hydrophilic coating which is useful for navigating stenosis and tortuous vessels and is used in a variety of different vessels.

    • Lunderquist (Cook): it is very stiff and used for endovascular repairs of AAAs

    • Rosen wire: support wire with a J tip with intermediate stiffness. Less stiff than Lunderquist. Used to catheterize visceral and renal arteries.

    • Bentson: starter wire, that's short in length with a very long floppy tip that prevents vessel trauma.

Types of Catheters

• Main purpose of the catheters

• • Allows to approach the target vessel based on the shape of the catheter

  • Allows wire exchange from flexible to stiff

• Sizes are based on Fr (4-5)

• • 5 Fr are the most common.

  • Microcatheters are for embolizations (2.5Fr)

• Nonselective (Angiographic catheter)

• • Common types are omni flush, pigtail, and straight

  • They have multiple side holes along the tip so they can inject high volume of contrast into large blood vessels like the aorta

• Selective catheters/Guide (shape) catheters

• • Have an end hole only with no side holes so they can cannulate specific branch vessels

  • A variety of lengths and shapes depending on the curvature and tortuosity of the pathway to the target vessel.

  • • Catheter with specific shapes can align your vector (the force you are exerting by pushing the wire forward at the access site) to the stenotic lesion.

  • Type of catheter that can be used to cross to the contralateral side at the aortic bifurcation – generally the omni.

Types of sheaths

• • Size range: 4-26Fr (larger available for endografts)

    • Size is decided by the device you have to deliver to the target lesion

    • Length is based on the support required from the procedure. The distance from the access site to the target site determines the length of the sheath required.

    • Common lengths range from 5 to 110cm

    • What are some of the common sheaths used and for which procedure?

      • For endovascular aortic repairs, Dryseal sheaths range from 12Fr ~ 26Fr with lengths of 33cm to 65cm.

      • For visceral and renal artery intervention, Ansil or Raabi sheaths range from 5Fr to 9Fr, with lengths of 45cm to 90cm.

      • For lower extermity work, Ansil, Raabi, Balkin sheaths ranging from 4Fr to 7Fr with lengths of 45cm to 110cm.

      • Steerable sheaths can actively articulate the shape of the sheath, allow you to navigate and treat more challenging anatomy.

Step Three: Treating the lesion

• The lesion has to be crossed with wire and catheters before treating the lesion. They may require the need to exchange sheath

• Stent and balloon sizing is measured by diameter in millimeters x length in centimeters

Balloons

• Generally need to exchange wire to stiff support wire through the catheter, then the catheter is exchanged over the wire with the balloon mounted catheter

• Balloons have a wide variety of diameters and lengths

• Nominal vs Burst pressures

• • Nominal: pressure is where the balloon will inflate to the labeled diameter

  • Burst: pressure where 99.9% of tested balloons ruptured

  • Typically you inflate to nominal but can go higher depending on the type of lesion

• Compliant balloon vs a semi-compliant vs non-compliant balloon

• • Most of the time, we use a compliant balloon, but in certain situations where we need high pressure dilation, we use non-compliant balloon. This has to do with the nature of the lesion and risk of vessel rupture.

• Additional features

• • Cutting balloons have microblades on the wall. So the idea is to perform control rupture of calcified atherosclerotic lesions, so that the expansion happens more evenly.

  • Drug coated balloons are coated with paclitaxel to reduce the risk of neo-intimal hyperplasia So, it is sometimes used in peripheral cases where the surgeons feel that the lesions are more prone to developing neo-intimal hyperplasia or areas that have restenosed.

Stents

• small mesh-like device made of metal that is used to prop open a blocked or narrow blood vessel. It is inserted through a catheter and deployed at the site of the blockage to improve blood flow and reduce the risk of future blockages.

• balloon expandable vs self-expanding stents

• • Balloon expandable

  • • Better radial force at the time of deployment

    • More accurate deployment

    • Mounted on balloons, so it is more difficult to track them across tight stenosis.

    • May cause damage to the surrounding tissue due to balloon inflation.

  • Self-expanding

  • • Usually more flexible in tortuous vessels

    • More resistant to kinking

    • Higher risk of migration or dislodgement during deployment

    • Post-dilation is often needed

• covered stents vs bare metal stents

• • Covered stents

  • • Covered by PTFE, polyurethane, or silicone

    • May be more resistant to in-stent restenosis, compared to bare metal stents.

    • useful in ruptured vessel

    • EVAR/TEVAR/FEVAR devices are essentially fancy covered stents.

Step Four: Closure

• Hole in the artery is outer diameter of the sheath, and is bigger than the sheath size since sheath is measured by inner diameter

• Manual compression

• • Direct pressure with fingertips

  • Enough pressure without bleeding, but not too much that it cuts off circulation

  • No peeking!

  • Timing depends on sheath size, coagulation status, and vessel health.

• Closure devices

• • Extravascular plug

  • • Angio-seal: sandwiches the arteriotomy with a biodegradable anchor and collagen sponge. https://www.youtube.com/watch?v=XhgAs2SxNjA

    • Mynx: utilized a small balloon to create temporary hemostasis within the artery and covers the outside with a polyethylene glycol sealant. https://www.youtube.com/watch?v=_kcJM1lnQo8

  • Suture-based

  • • Sometimes placed at beginning of the case for large bore access

    • Proglide: https://www.youtube.com/watch?v=Wol22SlEpxE

• Complications

• • What are the most common complications that you experience and how do you mitigate them?

  • • Access site

    • • Hematoma, pseudoaneruysm, AV fistula, occlusion, infection

    • Navigation related

    • • Dissection, perforation, thromboembolism

    • Systemic

    • • Contrast induced AKI

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