Interactive Transcript
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So let's look at this case.
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Patient on the left, brachial arteriogram
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for intended SMA stenting in the
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setting of chronic mesenteric ischemia.
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Now they come back with left arm claudication.
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We have a high index of suspicion here.
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And the reason being is because there's
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a pressure differential between the
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two arms, 43 millimeters of mercury.
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Given that this is the case,
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what are we concerned about?
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I would say we are concerned
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about a dissection or an AVF.
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Consider a subclavian steal.
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Consider the fact that maybe, given that
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this is 20 to 30 millimeters of mercury
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differential, this patient has the findings of
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subclavian steal, presyncope, arm claudication.
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In this case, they have the arm
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claudication, not quite the presyncope.
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But these are things that we want to think about.
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And so in diagnostic arterial
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artery, this is what we see.
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We try to get access and
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we can't get into the arch.
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Because why?
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There's a little bit of a dissection
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flap that's preventing us from actually
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getting in from our access into the what?
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Aortic arch.
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So DSA is performed, and we can advance
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our catheter, our wire, our sheath.
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So, what should we do now?
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So, I would say, maybe consider
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manual compression or a follow-up CT,
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because we can't get our job done.
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We can't get into the abdominal aorta,
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because we can't get into the thoracic aorta.
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So, a week later, a CT is
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performed, and it shows this.
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It shows that the patient had a dissection
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flap that actually had propagated from the
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prior procedure from that brachial artery
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access that they achieved at the prior
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outside hospital visit, extending right
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to the subclavian artery, which was, uh,
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So when we think about sort of arterial
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dissection, you know, you want to think about sort
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of wires that coil under fluoroscopy, if there's
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any resistance to passage, you know, this may
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indicate that subintimal passage is actually
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precluded because we're not in the right plane.
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We're not in the lumen.
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We're actually in the wall.
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We're subintimal.
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We may actually see sites of differential
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contrast accumulation as we
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saw in that sort of neuro IR case.
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We may actually see that there's actually non
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flow-limiting dissections that actually may be
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observed and may actually resolve spontaneously.
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In the case of flow-limiting dissections,
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these may actually mandate an intervention.
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So flow-limiting dissections may be treated well
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with patch angioplasty and/or endarterectomy.
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We could place a self-expanding stent
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from a contralateral femoral approach.
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These are things that we
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want to sort of keep in mind.
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