Alright, excellent. Well, I'd like to welcome everyone to another one episode of the Front Row series. Again, this is new educational content for the official educational website of the AANS, the NeurOU. We're fortunate to have many experts from around the world in the field, skull-based radiovascular tumor and many others. And as you know, the participants can have access to both the live and archived events for CME. And for the first time, people can submit cases for expert discussion. So without further ado today, we're extremely lucky to have three of the pioneers in the endovascular world that have really pushed the envelope in popularizing and developing radial approaches for neurosurgery. I'm George Zinonos. Today, with Dr. Bradley Gross, my partner in crime, I would like to welcome three people that need no introduction. We have Dr. Eric Peterson, who is an associate professor in neurosurgery and the director of neuroendovascular division at Jackson Memorial Hospital in Miami. Dr. Giorgio Osborne is an associate professor of neurosurgery, radiology and neurology. He's also the fellowship director for endovascular as well as the associate residency program director, as well as the co-director of stroke and cerebrovascular center at Barnes-Jewish Hospital at Wash U. And last but not least, we have Dr. Levitt. Dr. Levitt is an associate professor of neurosurgery and radiology as well as associate residency program director at the Department of Neurosurgery at the University of Washington. I'm finding out that all three of them used to be residents together and all took different paths. Again, all spearheading the endovascular developments and in particular, a lot of the advancements that happen with accesses through the arm. So without any further delay, we're going to have Dr. Pearson share his screen. And we're looking forward to a fantastic webinar. For the live participants, please place your questions in the queue. And as soon as we're done, we'll go over some cases and go over questions. And we're all looking forward to it. Hey, take it away. Great. Thank you so much. It's a real honor for me. I've had a really, really remarkable, lucky journey in my neurosurgery career. I was a junior resident at UW and wasn't even thinking about vascular, endovascular. And Lewis Kim really got me hooked along with a lot of people at UW when he came over from the BNI a long time ago. And he connected me with Ali Sultan, who was at that time in Miami and really allowed me to grow quite a bit from those connections. So I love a lot of my journey to those guys. And I tried to pay it forward with Josh and Mike. When I came back to Seattle, I really got my hooks in them and got them into vascular and vascular. And they're both significantly better surgeons and thinkers than I am. So I'm really proud of that. And luckily, they were dumb enough, at least still, to follow me and do my initial radial journey. So I'm really honored to be here today and talk to you guys. Hopefully, we can teach you something. They're going to get into the fun stuff. I'm going to give you a bit of background that hopefully, for people that haven't heard all this, it could be a little bit of an update. The main stuff really I'm going to try to get into is why are we even talking about this at all? Because I think that's a tough place for some people to get to these days. And hopefully, it gets you a little bit more push down the journey. And then they'll give you the fun stuff on how to hear my disclosures. The main one really here, as a lot of you know, is Rissner Vascular is a company that I started that works on radial systems. So a lot of this radial nonsense started here in my office in Miami. We had just done a femoral case. That was a total disaster. Couldn't get in, had to go radial. It was even worse of a disaster then. We had no idea what we were doing. We were putting femoral systems up there and spasms, a mess. So I told my fellow, Brian Selling, I said, look, man, I know the cardiologists have figured out a lot of this, at least from the puncture to the shoulder part. You got to help me out and let's figure all that out. Get it all protocol. Let's put it on a PDF, put it in the lab. So next time it's three in the morning, we have to do this. We're going to have to deal with this again. And he came back the next day and dropped a stack of papers on my desk and said, man, have you looked at this data? Forget that they know how to do it. They've sorted out a whole bunch of trials here that have made this really just an amazing journey for them. And we're not talking about like tiny little trials. These are massive 8,000 patient trials that have shown just on the access question alone, that radial is a much safer way of getting into the system. And I hadn't known any of this data. I think a lot of us are unfortunately pretty siloed. But when you dig into it, it's compelling stuff. It's a much bigger group than we have in neuro, much larger patient groups, much more common pathology. And they've just been around on it a lot longer than we have. Interventional cardiology has been at it a good decade or so before we even started. So they just have a lot of benefits there as far as what they've been able to power. And these are all trials. These aren't prospective or retrospective studies. These are all randomized control trials. And it's pretty consistent that across all outcome measures, major bleeding, radial is a better way to get in. Major vascular access complications, radial is better. And then even just mortality. These are for STEMI patients. But again, it's pretty tough to argue that it's probably a safer way to get in, all things being considered. And that, of course, has driven a pretty big conversion on the national guidelines that really it should be radial first for cardiology. So I sent him to the... There weren't any neuro courses at that time on how to do this. So I sent him to the only radial course at the time, which was one of the Meredith and Terimo courses. He learned how to do everything, came back, said, look, we're doing everything completely wrong. Taught us how to do it the right way. And one of the things he taught us also, my fellow that is, is that cardiologists really talk about you have to commit all your cases at once. You can't just do a case here or there and hope that you're going to get good or your lab's going to get good. It's not going to work that way. So that's what we did. We went all in and we just converted every single case. We didn't do every case that way, but it was a first choice for radial first. And it was painful in the beginning. Our lab didn't know what they were doing. But once we got there, it really made a big difference. And a lot of other people kind of joined in as well. And we all learned, I think, ways of actually doing this stuff for neuro diagnostics, interventions, how to do it quickly, where we kind of bumped up against problems, trying to do flow diversion, prospective data coming out of Pittsburgh. That's been great. TJ has a lot of great papers also. So really a lot of information there. Also been a lot of stuff that has shown not just that access site complications are lower in neuro, but also brain complications as well, which has been kind of an unusual thing we found in some of the retrospective series. This is a paper out of Barrow where they found femoral access was a risk factor for all complications, not just access related complications. And this is another study in JNAS, which is a multi-center study comparing radial versus femoral flow diversion. They found higher access complications in the femoral group, including a death from femoral access. But they also found an increase in all complications, not just access related. All told, they found a triple three X increase in the overall complication rate with trans-femoral flow diversion versus trans-radial flow diversion. So I think it's kind of exciting stuff that we've seen in cardiology. And of course, once you do all the neuro data as well, you start looking at it and there's not a whole lot of surprise there as well. But when I got interested in radio because of the safety profile, as soon as I started doing cases, I realized that once I got good at them, the procedures felt slick. I started to realize that there's a whole other facet to this that really made radial a better method of performing neuroendovascular surgery. And that other facet is this entire bucket of minimally invasive procedures in general, and the patient preference that drives so many fields away from their initially invasive procedures into a more minimally invasive version of it. And I think this is the second reason that I think a lot of people get converted into radio, which I think is even more powerful, at least it was for me. In my opinion, trans-radio should really be viewed as minimally invasive neurointervention, right? For anyone that's learned a minimally invasive alternative to what you are already trained on, you know what I mean, right? Open spine versus minimally invasive spine, open cranies versus the small boutique openings, laparoscopic. The surgical experiences here, these journeys for these innovators and how the people move the way from the openings, it's all very, very similar, right? The procedures are slightly more challenging to perform. There's a learning curve and there's always a bunch of resistance from doctors and surgeons who think that they know best and they don't want to learn any way of doing it. But in the end, always the less invasive nature of the procedures wins out. It's just undeniable. And when I started doing trans-radial, it really felt similar to when I was learning endovascular after eight years of neurosurgery training, it just felt less invasive. I remember the first time I reconstructed an aneurysm endovascularly trans-femorally, I remember thinking, man, that is, that's amazing. Like I know what it would have to take to just to cut into so much temporalis versus this. And you can just see what's driving that from a patient perspective. And once you get a sense of that, you really kind of have that same feeling. When I started doing trans-radial, I had that same Delta. It really felt less invasive. Like there was nothing going on there. I wasn't worried about some big bleeding. And once I got a sense of that, I just felt there's really a no brainer that the field was going to go that way. I just couldn't see it playing out any other way. I remember when coiling came out as a resident and all the open neurosurgeons say, oh, it's unproven. Surgery is a standard, blah, blah, blah. And I was like, there's no way that the technology isn't going to keep improving and eventually coiling endovascular techniques are just going to secure a dominant position. I just didn't see it happening any other way. So I learned endovascular, right? And same with radial. I mean, if you can do the case this way, really does seem to be better for the patient. And it's a more satisfying way to practice neuro intervention, in my opinion. And when I knew it was safer and when I started doing cases, I really got excited from the impression of it being invasive way to perform neuro intervention. What really hooked me was this. It's just more pleasant for the patients. And this has been shown formally again and again, in the cardiology literature, we showed it in the neuro interventional groups as well. But what's a lot more powerful than this is the empirical evidence of this. This is from a doctor, one of the busy centers in the U.S. who was pretty resistant initially. I know because I kept hassling him to try radial. He sends me this text a few months later, basically a patient came into his office for an aneurysm repair and then asked at the end to be, to have it done radially, right? I mean, patients are consumers now they do their homework. No one wants to look like a dinosaur who isn't up on the latest and safest techniques. So it's tough to resist that sort of stuff. Especially when you think of yourself as kind of a cutting edge intervention as otherwise. Similarly, another colleague of mine who works at a center where they don't always do the diagnostics that on the patient they see in clinic, they get assigned to an attending by date. And he discussed a radial diagnostic with this patient. But then when she shows up, it was another partner who was on for that week who had refused to learn radial. I was like, sorry, you're getting a transfemoral. And she said, yeah, no, thanks. I'm like, I'm out of here. And she leaves. We see this all the time, right? Like people are, these patients are not, they're not dumb. And that information is out there. And it's, there's a lot of people in cardiology that have been pushing it. So where's this come from? Well, for starters, what people can have the occasional bad experience with radial also overall, it's just a much less painful for the patient than femoral. Like in addition to be able to sit up after your procedure really cannot be overestimated. This alone is the reason to do the case transradially lying flat for four hours. It's just miserable, regardless of whether it's an outpatient or inpatient case, people talk about, oh, there's no point. If it's an inpatient, I want them asleep, lying down in the ICU, not moving. I don't know why that would be. Are you worried about the coils moving? Like they don't want to be lying flat. They want to be sitting up like this, texting their grandkids, right? They want to be using the bathroom, like an old person. They don't want to have to use a bedpan, right? So it's not you're at home, you know, having coffee with your family there and I see you and they're miserable, right? So it is better that way. And we've seen this pattern of conversion over and over. There's some initial interest either from a paper or a colleague, and then there's the initial convincing value proposition. So that it seems to be safer. It seems like it might be kind of cool. If people try it and they do a few cases and then they realize it's actually a pretty slick way to do neurointervention, right? It actually feels like a minimally invasive version of neuroendovascular. Then the nurses are coming up and saying, man, this radial thing is amazing. It's so much easier for us. The patients are so much happier. The patients are saying, well, man, that was so much better. How come all their angiograms have all been transfemoral? Where was this? I heard about this radial thing. You're going to do my case radially, right? And all of this kind of just hits the doctor from all these different places. And you really, they keep going and they stick with it. They get better and better. They deal with the learning curve and then they're over the curve. Their lab is better and they get converted, right? And this is one thing that happened to me and it's definitely happened to a lot of others. It doesn't happen in two cases, right? It takes a chunk of cases to get there. For me, it took probably close to 40 to 50. I don't think that's true anymore. It's probably closer to 20 or 30, but you're not going to come in your first case and you're going to be super fast and texts are going to immediately know what to do. And you're going to be super slick with the ultrasound. It's just not going to happen. It does take a good 30 or 40 cases to get good, particularly if you're a lab, right? They can often be resistant in the beginning. If you're not at a cardiology lab, that's radial dominant and they cross-strain text. But once you get good and your lab gets good, you get into the third reason to convert to radial, which is that you realize that there's all these clinical situations exist where separate from everything else we've talked about so far, it's really nice to already be slick at radial access. When you run into some of these cases, a really bad aortic iliac disease, tough arches, obese patients, like what are you going to do if you can't go radial, right? You're going to stick the carotid. I mean, that's crazy. We're trying to get less invasive over time here. Not more, right? Tons of people have already figured out how to do all this. They've worked out all the tech and all the techniques and everything. Might as well at least get good at it so that when you want to use it, you can. You don't have to do it every time, but to just not get good at it at all, I think it's tough to confidence. Things have changed quite a bit since then, right? When I started doing radial, it was literally me, I convinced Pascal and Thomas Jefferson and my two juniors here on this call, or by that point out in practice to kind of start and try doing radial and that was it. And then it really picked up fast. Today, there's a lot of centers that have a majority of their practice transitioned to radial first. It's been a lot of social media buzz. And Philippe had a really nice editorial in JNAS last year talking about things have changed quite a bit for neurointerventionalists in their adoption of radial. And it's important to remember that no one listened to this that hasn't converted. No one's going to have anywhere near as painful a journey as the three of us did. When we were getting good at transradial, it was a real pain in the butt. But it's a different game now. This curve is not what you guys are going to have to walk nearly as difficult. I mean, most of the best practices have been worked out. We have a lot of experience for radial for complex neurointervention, not just diagnostics. Many labs have converted their entire practice. Medtronic has launched several radial for neuro training courses, as well as the first FDA approved system for neurointervention. It's just much easier time to be learning transradial for neuro than when we were doing it. One of my last slides here, I should try to show this almost every time I give a talk on radial. This is from a cardiologist who, big femoralist who was in a focus group, told him, yep, I don't need radial. I don't have any complications. No one in West Virginia is ever going to ask me about radial anyway. And now I'm doing almost my entire practice this way. And my patients are coming in almost daily. Can you go through my wrist? I'm doing complex left main and mitral PCI transradially. This is kind of where our field really is and has been. And when you look at these kind of narratives and journeys, it's like, well, how much more of a roadmap do you want to have mapped out for you? I hope Ricardo doesn't mind me quoting him here. If you think femoral complications aren't that common, it kind of misses the point. The point is, if you're doing enough cases, you're going to have those complications. When I look back at the femoral mayhem I saw in cause and fellowship, I remember thinking, man, whenever I had a complication, I kind of shrugged and said, well, it's certainly a lot better than an open craniotomy, that's just how it is. You gotta get in somehow, right? That's just not the case anymore, right? We have a better way to do these cases. And now with the experience and the data along with dedicated systems and courses, I mean, it's just a totally different place and it's a really exciting place. So thanks for your time. And I'm gonna stop there and kick off the mic. Dr. Peterson, that was a fantastic presentation. Every time I've heard a version of this a few times, but every time it just reaffirms that that is the obvious. I think next we'll hold questions for right now and then we'll move to Dr. Levitt. I hope you can share your screen. I think you're muted. Yeah, perfect. Am I, are you seeing my screen? Yes, it's perfect. Okay, great. So thank you for the invitation and as Eric says, it's an honor to be here and to be talking with you all today. I'm gonna talk about transradial diagnostics through angiography and here are my disclosures. So I think just to echo what Eric said and I just put the slide in, but you never know when you're gonna need this, but sometimes you really need it. This was a patient with epistaxis on some ridiculous number of cardiac interventions that came to my hospital at like two in the morning. He had an impella, an LVAD. Basically every arterial access site was taken except for the left radial artery and I had to do an intervention. So you never know when you're gonna need it. Sometimes you really need it. But all credit goes to the people who convinced me, which is basically Eric and Josh and then one of my colleagues, a fellow actually of mine who's now one of my colleagues, Melanie Walker. This is really where it all started is as Eric said, he's being humble, but I think he really pushed the field in this frame shift here. And basically he just browbeat me until I changed my practice. He can be very pervasive or persuasive and pervasive. So just really into the nuts and bolts and more or less everything that I'm talking about here, I learned from Eric and Josh and then adapted maybe a small amount. But before you start, I think it's just really key to have an ultrasound and measure the radial and the holding area if you're gonna do a more complex intervention. I've gotten away from doing this routinely for diagnostics because it generally is not a big deal, but it is nice to know if you have an occluded radial or some other problem. And then access point traditionally is either two fingers breaths above the wrist crease or in the anatomic snuff box. I put on amla cream on patients, both distal and proximal radial in holding assuming awake outpatient diagnostic angiogram. And then early on, I used to do a lot of pre-procedure Palmer arch testing, barbeau testing. You do not need to do this. This is of historical interest only. Eric has a bunch of nice slides about this in some of his other talks, but this is just not a thing. It's just not a thing. Your hand, the patient's hand is not gonna fall off. Cardiologists have proven this. It's just not a thing. So there's no need for pre-procedural testing. Just do the radial, it's no problem. It's just not necessary. So access is either standard, which is two fingers breaths above the wrist crease up to the mid forearm. If you need to go more proximally, it can go as high up as just below where the radial artery dies below the fascia or distal, which is distal to the radial head and the anatomic snuff box. That's sort of what I prefer for most outpatient diagnostic angiograms. And there's a variety of reasons why, which I think Josh might get into. Ultrasound every time. I think it's just ridiculous to me that anybody in this day and age thinks that they can be better than an ultrasound. And so use a flat or linear probe, not a hockey stick. And then local every time, even for an asleep patient, it reduces the incidence of spasm. So here's what my setup sort of used to look like. At this point now, I actually tuck the arm in here from the start, but you don't have to. The radial is prepped here. You also always wanna prep the groin just in case. You have ultrasound here. Everything's laid out nice. This is all built up so that you have somewhere to put the arm when you're done. And actually Eric's got a nice technical video on the JNIS technical videos with room setup and really just the nuts and bolts of how to just get the room ready, which is one of the big first sticking points, which is, okay, I wanna do radial, but how do I even get ready to do it? There's a lot more than just, I'm gonna use this catheter or whatever. So I'd encourage people to check that out. Then the puncture, I always do a double wall through and through technique. Basically use the angiocath that comes with the radial access kit, which I'll get into next. Using ultrasound, go through the artery, completely through and through, take out the needle, back up the angiocath, as you can see here in Eric's group, Brian Snowing's paper, until you get a return and then put in the wire. And here's a video of my fellow doing it. So you can see ultrasound here. She's going through and through with the needle. She puts the ultrasound away. She takes the needle out, holding the angiocath in place. She gets her wire ready. All of this is included in the kit that comes with these sheets. The cinematography is mine, which is why it's terrible. And then as you back out, you'll see a return of blood. And then once the return is there, either you're ready with the wire or you have an assistant hand you the wire that comes with the kit, and you can feed the wire up straight into the radial artery. She's actually pressing on the radial now because she doesn't wanna lose too much blood. And here she is feeding the wire through the angiocath. It should go very easy. There shouldn't be any resistance. And then you can take it out and put in your, take out the angiocath and put in your sheath. The radial specific options for the sheaths are best. The longest, the longer, the better. So I've completely converted my practice with, again, with Eric's recommendations to the 23 centimeter long radial specific sheaths. I use, there's two that are out there, this Trumo Glide Sheath Slender, which only comes in a 16 centimeter. And then the Merit Prelude Ideal. And the key here, I'll go back to this, is that for a radial specific sheath, the inner diameter will be the same, like a six French inner diameter would be the same as a femoral sheath, but the outer diameter will be thin enough that it's actually a five French outer diameter and a six French inner diameter. It defies the laws of physics, but the radial specific sheaths are really critical. And they also come with a tapered dilator that allows you to push them straight through the skin with no skin nick. So no skin nick is needed. You can just go straight in. Here's an example. So you're, this is a Trumo sheath, but feeding the wire into the sheath, and then you pin the wire. And again, no skin nick needed, no scalpel, nothing, just straight over and through the skin. Again, the cardiology guys have gotten this down, and then you can take out the dilator and take out the wire, and you're good to go. Once you get it in, then what? You hear about the radial cocktail. This is sort of another sticking point. You're like, well, how do I get the artery not to spasm on me once the sheath is in? So this is what I use in my shop, 200 micrograms of nitroglycerin mixed with two and a half milligrams of verapamil, and then a heparin bolus, usually between 3,000 or 5,000 units. It doesn't matter, either intraarterial or intravenous. All of this has been backed up with multiple type, class one evidence, randomized trials in the cardiology literature. You give this slowly, you buffer it in the patient's blood. So essentially take a 20 cc syringe, put the medication into it, then aspirate a bunch of the patient's blood and inject it over at least 60 to 90 seconds. Otherwise it'll burn. And what that does is it really reduces, substantially reduces the risk of spasm in the case of the nitroglycerin and verapamil, and the risk of radial artery occlusion in the case of heparin. And that's why you give those things. So then the next sticking point, once you've got the sheath in, or you've got the room set up, the sheath in, the cocktail in, is what catheter do I use? And this is actually relatively simple. It's basically a sim for the most part. It depends somewhat on the destination. So if you're just going into the right vertebral artery from the right radial, a VERT or a Berenstain works fine. If you're doing the carotids, really I lean on a sim two. Some people prefer a sim one. The left VERT, a sim two or sim three, doing an intervention or a diagnostic in the left VERT is not a contraindication to radial access. People think that you can't get over there. You absolutely can't. I use a five French diagnostic catheter. The four French I used to use is way too flimsy and it can kink. There's a variety of different catheter types. The wrist, the Terumo GlideCath, the Merit Impress, the Cooke Beacon Tip. These are the ones I use primarily for my diagnostic, the Terumo GlideCath or the Merit Impress. You just want an unbraided catheter. And the reason is because that Simmons curve needs to be able to straighten out for you to get the catheter selective all the way into say the internal carotid or the external carotid. Some of the, like the Cordis Simmons two is just too stiff. It won't go, it won't track over the wire. It'll herniate into the arch. The wrist is a great catheter for this reason as well. And then there's three phases to the diagnostic. And all of this is, half of this is cardiology figured it out, it's not any of us. So the arm, the subclavian, then into the arch and then into the great vessels. So going up the arm, you want to shoot a radial angiogram at the very beginning to avoid things like radial loops. And I'll show that in a sec. And then I go up with the J wire. Some people use a baby J, I just go with a regular J wire. That's because there's lots of little branches off of the brachial artery that you want to avoid. And the J wire tends to avoid those. So you just advance that up into the subclavian. Once you're in the subclavian, oftentimes you can go straight into the right vert. It's a very easy takeoff most of the time. And then if the other vessels are needed, then the wire advances into one of three locations, either directly into the right common, directly into the left common, especially in a bovine arch, or into the arch. And so here you can see the, I've got the Simmons 2 catheter, it's in the innominate, and I'm sending the wire out. And the wire here is going to go into the descending arch. Maybe in some cases, it'll go into the left carotid. Sometimes it'll go into the right carotid. Here, the most common place it goes is into the descending arch. And that sets you up nicely for forming the sim, which is the other hard part that people get worried about. And it's really easy. You just advance the catheter over the wire until the large curve of the sim is facing the ascending arch. So I've got the wire all the way down in the descending. I've got the catheter with the large curve facing the ascending. And then I pull the wire out and I push the catheter and the Simmons curve is formed. And there's some tricks to that. It's not always that easy, but most of the time it actually is that easy. And Eric and Brian have that really nice paper in JNIS that shows the different things that can happen when you put the sim into the innominate and then into the arch. The variety of different arteries you can get into, whether it's the right common, bovine left common, forming the sim off of the right common or forming the sim in the ascending or descending arch. And I'd encourage you to take a look at that paper. It really gives you a really good overview of how this works. The left vertebral, if it's the only vessel of interest, then left radial access is really easy. Just drape the patient's left arm across their stomach. Usually it's best to go distal in that case and then just straight up into the left vertebral, especially for things like stroke interventions. If not, a sim two or a Simmons three, which has a longer curve or a stiffer Simmons two might work. You can also get the sim to form in the descending arch or twist the sim so it's facing backwards. And I have a video of that. And then sometimes just easiest to do the simplest thing, which is to put the Simmons into the left subclavian, inflate the blood pressure cuff on the left arm, and then just do a run, which refluxes contrast into the vertebral artery from the subclavian. So here's an example. I've got the Simmons two. I put it in the subclavian and then pushed and it moved the Simmons curve into the descending arch. And then just by turning the catheter a little bit, the tip of the catheter twists backwards and into the origin of the left vert. Very easy, not a big deal. There's many different ways to get there. Don't let the left vert scare you. So those are sort of the main navigation aspects of a diagnostic angiography. And it takes, as Eric said, it takes a commitment to do it, but it's not really fundamentally that difficult. And once you're there, there's really very little that has to change about your diagnostic setup, other than the patients love you because they really prefer not to get poked in the groin. The pitfalls here are radial or brachial artery spasm, a radial or brachial artery loop, a narrow innominate to left common angle, or a Lussorian and aberrant right subclavian or other arch abnormalities, which are somewhat rare. So the most common problem that people get into early is spasm, and there's lots of ways to avoid it. As Eric mentioned, we have gone through a lot of this, and so maybe you don't have to. So the prevention here is use a long sheath, use the longest sheath you can, 23 centimeters. This all comes from manipulation of a catheter in the artery. The further up you can get into the larger arteries, like the brachial, the better you are. Minimize catheter manipulation, which just comes with experience. Use deep and conscious sedation, so very deep sedation. If you can, the patient should be basically asleep. Treatment, more sedation, more spasmolytics, so injecting directly into the sheath with more nitroglycerin or rapamil, injecting subcutaneous nitroglycerin also works very, very well. Compressing the ulnar artery for a while to force blood flow into the radial artery works well. You can also, I've never had to do this, but you can inflate a blood pressure cuff around the right arm, wait about five or seven minutes at maximal inflation, and then deflate, and all of the vasoactive, endogenous vasoactivity will dilate the artery. Radial artery loops. Evan Luther and Eric's colleague, Bobby Stark, has a nice paper about this, but this is common up to 15% of patients. It could be a real problem. Basically, a radial artery loop is associated with a very small recurrent radial artery, and if you catheterize that, it'll almost always spasm, and so the way around that is first shoot a radial artery arteriogram when you start so you can see it and hopefully navigate the catheter through it, and then there's a variety of techniques to avoid it or to overcome radial artery loops that they go into in this paper, but things like avoiding shelving, using balloon-assisted tracking, some more fancy things that cardiology has come up with, and even just directly pressing on the catheter as it's going through the loop can sometimes straighten it out. One of the other pitfalls is a narrow inominate-to-left carotid angle, so when you have a very narrow gap and a very acute angle between where the catheter's coming down the inominate and then up the left subclavian, very, very difficult sometimes to get the catheter to track up into the left carotid, so one thing you can do is just do a left common carotid artery angiogram if it's not the vessel of interest. Switch to a Simmons 3, which is a longer catheter, and you'll most likely get a better bite and more support. Use a stiff Simmons 2 or a stiff glide exchange, or then use a stiff glide wire exchange into a straight catheter, so things like that or a larger system often helps. Finally, with closure, patent hemostasis is the goal. There's lots of work about this. I encourage you to check out Brian and Eric's paper in JNIS. The cardiologists have figured this all out, but patent hemostasis is the goal. There's multiple products that are specifically designed for this. You don't have to wrap the wrist in a bunch of gauze or tape, and you can do post-procedure Barbeau testing to prove that your radial artery is patent. I'm running out of time, so I'll sort of skip that, but I encourage you to check this paper and see for yourself how to do the closure. That's the other last major sticking point. None of this is very difficult. If I can learn how to do it, any of you can learn how to do it. Thank you for your time. One comment there while Josh is getting set up, when we were first starting this, Brian, I really felt that if you can't do a full six-vessel angiotrans radially, then it really has no future. So when we were doing this, it was every single case got all six vessels catheterized and that's still our benchmark. This is not a, oh, we'll do radial and shoot from commons, that is not an angiogram. So while you don't always need it, the idea that, well, I don't know how I can get a proper angiogram, that's not the case. The other nuance that one of my fellows came up with was shoot the right vert on the way in, because if the right vert is good and it fills up the entire posterior circulation, if you get a left vert that happens to be a little bit more challenging, you don't need to mess around with it too much, right? That's analogous to a right vert that's challenging from a femoral approach, versus if the right vert ends in a pica, you might do what Mike's talking about and get a sim out three out there and really make sure you get a good run, always put the blood pressure crest on the left arm so you can get a good retrograde that almost always obviates need for anything special there. Well, it was another fantastic presentation by Dr. Levitt, and really a two to fours of technical pearls. Now we'll move on to Dr. Osborne, who will give us his view on things as well. All right. Well, thank you, everybody. I really appreciate the opportunity from the AANS to be able to talk about putting together some systems for neurointervention. Again, I want to thank Eric and Mike for joining me on this journey the last few years, and it's been great to kind of figure out how to put these systems together to successfully do all the complex interventional procedures that we do through the radio artery. I think, as Eric really hit the points home, it's just an overwhelming patient benefit compared to doing things trans-femorally and certainly compared to trans-cranially at times. So, again, just wanted to thank everybody. I have a few disclosures, none of which are really relevant to this talk. Just some general thoughts about doing transradial interventions that I have. One is that I think nearly anything is possible, and you can really get any case done through the radio artery that you set your mind through. I think we're still determining what works to some degree. A lot of these systems were designed for femoral artery use and weren't really optimized for the radio artery. Certainly, the wrist system that Eric developed and Medtronic has picked up now has helped with that quite a bit and is making a lot of these interventions easier, but there's certainly some anatomical complexities that still challenge us no matter what. I think it takes some patience to get through this process of learning curve still. When I'm thinking about interventions, I think you can consider radio artery size if you want to avoid radio artery occlusion rates and keep that really low, closer to the 2% to 3% range. I think these are some general principles that will keep that occlusion rate low. I think if you're going to use up to a six-fringe sheath, really a radio artery size anywhere between one and two millimeters is fine. If you're going to go up to the seven-fringe systems, I think two to two and a half is absolutely fine. If you're really going to try to directly stick the radio artery with a long sheath, such as a shuttle or a ballast or Stryker Infinity or Neuron Max, you probably want a two and a half millimeter artery or greater if you want to avoid a higher radio artery occlusion rate. I have a preference for the distal radio access and the anatomical snuff box. I personally find no difference in my radio artery occlusion rates using this site. I think the benefits are that you're sticking the artery distal to the branches of the palmar arch. If you do end up having a radio artery occlusion at this site after the procedure, you can still use the artery proximally. Certainly, when you're setting up the patients, it's just easier to set the patient in a supinated position than it is with the wrist fully rotated to the side or fully rotated flat for the proximal access site. Despite my recommendations on the size, with increased experience, I've really just gone to if I can stick the radio artery, I use a policy. I really don't care about the size. If I can get a flash of blood with my access needle, I'll really put anything in it that I want to and I haven't had a problem doing this. I think when you're thinking about interventions, vertebral artery interventions were really made for radial. These are far easier radial than they are femorally. I think right carotid interventions are fairly straightforward and easy to get your access systems up in. Left carotid interventions can be a bit more challenging, especially pending the arch anatomy. In general, you can get away with a lot less support from a radial access as you can femorally. Your system can be a little bit simpler. I think this is especially true on the right side in the vertebral artery. Often, if you just use a more of a stiff intermediate guide catheter, such as a Benchmark, Sophia EX, and Avian, that's all the support you need. You don't need to put a big shuttle type sheath up with it. I think these sheathless 088 systems aren't necessarily that useful when you're going on the right side or vertebral artery. The left side can be more challenging. You definitely need a little bit more support. I typically use the 088 sheathless system, such as a shuttle, Neuromax, Infinity, Ballast sheath. Since the wrist system has been on the market, I pretty much universally have converted to the wrist system for most of my left side interventions and really all my interventions at this point. This goes through a 7-inch sheath instead of you having to go sheathless in the radial artery. There are several benefits to having a sheath in instead of just this big giant catheter in the radial artery. This system has really made these left side interventions a lot easier and allowed you to use a little bit smaller arteriotomy site. A few anatomic considerations for interventions. Mike has gone over some of these for the diagnostic bit, but I'll hit a few of these points that I think are important. One is that Lussoria or aberrant right subclavian can be very difficult to catheterize vessels in and get up a system with. As I've gotten experience, I've been able to overcome Lussoria on a few occasions, but in general, I know it's going to be painful. If I can avoid it, I typically go femoral in these cases. Again, just the aberrant right subclavian coming behind the great vessels, usually behind the esophagus. Then the subclavian links in proximal to the left subclavian in this type of anatomy. Patients with subclavian stenosis can be difficult to get any reasonable sized system through. This is kind of a rare problem, but you occasionally will see it. If you're going to do left vertebral interventions, sometimes it can be a little bit difficult to get your systems up. If you don't need to do a full diagnostic angiogram, you already know you're going to use the left vertebral artery. Then I just stick the left side, the left radial artery, and I go up the left arm instead. This is quite easy. It's useful to know your vertebral artery dominance. If you really need to use the left vertebral artery, I just do the left radial instead of the right radial and go across the arch. It's just a simpler pathway. Mike talked about the narrow anonymous left ICA angle. This can make placing your guide system difficult in some cases. You just need to know to expect it. A lot of times, you can overcome this with a stiffer glide wire, doing exchanges with a straight catheter. I think I've kind of learned the system is going to work for these narrow angles. Oftentimes, this is the one time where I will switch to a braided Simmons catheter and usually use a 125-centimeter link to lead out my guiding system. That stiffer braided Simmons will kind of lock into the proximal common carotid and allow you to track your system over it up into the internal, and you can kind of overcome it. Here's just an example of on the right, you have a nice relaxed pathway, whereas on the left, you tend to get this narrow angle. The more you start getting familiar with these arch types, you can start predicting from the CTA what's going to be difficult. I always thoroughly review my CTA for these abnormalities and make sure I know what my plan is going to be before I try to start an intervention just to make it as painless as possible. Then, always use ultrasound for access. When I was a fellow, I was shamed for using the ultrasound for any of my access, but ultrasound, I think, is mandatory for radial access and just makes your life a lot easier. This is just some engineering work I've done making 3D models out of arches from a CTA, and you can start seeing what pathway your catheter is going to go through. You can start getting good at looking at these CTAs ahead of time and knowing where you're going to get this narrow anomalous to left carotid angle and where you might have to have a challenge and switch your system. You're going to know when you get these impossible arches that are going to be difficult, femoral and radial. This is definitely a case where I'm prepared to go either way. I'm just going to have to experiment with what's ultimately going to work for the patient. Mike and Erica both touched on radial artery occlusion. I just want to hit home the point that this is clinically insignificant. Again, this is why I like the SNUP box, because if you occlude the radial artery at the SNUP box for a second procedure, you can always use the more proximal site, which is usually still open. I think you've got to pick the right tools for the job. I think the two most challenging things we do are flow diversion cases and stroke. For flow diversion, I'm typically placing a big long sheet, such as an 08 sheet. This may give you a higher rate of radial artery occlusion, and it can be difficult to get a system up on the left side. Taking the time to get these bigger systems up on the left is going to prevent your system from herniating into the arch and potentially causing you a lot of difficulties in re-accessing and getting frustrated. Certainly, the new wrist system, which is a 7-inch system, has significantly improved left carotid interventions and made this a lot easier. This catheter system is designed for the curves and transition points that catheters need for radial artery intervention compared to femoral. These systems really just fly up compared to trying to use things that were designed for the femoral artery. I highly recommend using the wrist system if you can get your hands on it. A lot of times, on the right side, you can generally get away with just an intermittent guiding catheter, like a Navien, Sophia EX, or a Benchmark catheter from Penumbra. This is often for people with nice, relaxed arches from the inominate to the left ICA, possible on the left without a bigger sheath or catheter, such as a 08-8 or a wrist. This will allow you to get away with a smaller system when you're doing flow diversion. Again, when you get these tight curves between the inominate and the left ICA, you're going to form this tight loop that wants to herniate. I battle this by using stiffer systems. This is when I'll go to my braided Simmons catheter. The Cordis one is great. Cook makes a braided Simmons as well. This really will lock that Simmons curve into the common carotid on the left. You can then send up a wire, such as a glided bange wire or a stiff glide wire, all the way to the petrous segment of the ICA. Once you've got that in, I don't try to track up the Simmons. I just track my guiding system over the Simmons all the way into the ICA. That works almost universally with a stiff system. As you get experience, you'll learn the push-pull that's needed to get those systems to work. Stroke is extremely challenging as well. You really need to go as big as possible with stroke. You've got to make some choices with stroke. I typically put a 08-8 catheter in the ICA and then do aspiration passes through there. You don't have a great option for a balloon guide system with stroke from radial right now. I personally don't put balloon guides directly into the radial artery. I do have some colleagues around the country that are experimenting with that with some success. Again, as with flow diversion, the right-sided stroke cases are easier than the left. There's virtually no situation at this point where I don't go radial for a posterior circulation stroke. Again, with stroke, you've got to choose a little bit between two suboptimal options. One is use a stent retriever with aspiration from a smaller guiding system such as a six-print system. Then you have to re-navigate the whole system all the way back up every time. Otherwise, you can park an 08-8 system in the carotid artery and keep doing aspiration or stent retriever. Stent retriever plus aspiration passes through that 08-8 system. You don't have the balloon guide if you're somebody who really prefers the balloon guide catheters. Most of the time, my aspiration works really well. That's my first choice. My typical system for strokes now is I put an 08-8 catheter in the ICA. Then I'll usually snake up a Sophia catheter to the clot without a wire. That works most of the time. It can be a really quick case. When you're converting to radio for a stroke, just remember that time is brain and speed is extremely important. Bigger is better with strokes. You do want to put in these large systems. You've got to select your cases carefully every time because the anatomy will win every time. What you don't want to do with stroke is have to experiment with a bunch of systems to see what's going to work because you're just constantly losing time. Stroke should be the last thing you try to do. It's the final exam for radial. Until you are extremely confident with your systems, your speed, your experience, I would highly recommend waiting to do stroke until you've really got all of your other elective interventions down. I'm going to go through a few cases to show you what's possible with radial. This is a case of a ruptured 5-millimeter ACOM that was wide-necked. I thought it was a good case to try a web with for a ruptured aneurysm. You can see it in 3D there and some of the dimensions. My system was fairly simple. I was able to get the wrist catheter up into the petrous carotid, into that horizontal segment there. You can see the red arrows. Then I let out a SOFIA EX up into the supraclinoid carotid for some extra support. Then we go with the VIA-21 for this 5-millimeter web device. That's plenty of support to deploy a web into an ACOM through the radial artery without any difficulty. On my early flow diversion systems, before I had the wrist available, this was a superior hypothesial artery aneurysm that you can see here. In this case, I've got a braided Simmons catheter that you can see leading out here into the carotid. In this case, I just send up a wire, as you can see here, all the way into the petrous carotid. Then you can track this 088 sheath all the way around the Simmons, all the way up into the internal as we're doing here. You don't actually have to track the Simmons up. I just leave it here in place. That stiff braided Simmons is stiff enough that it just allows you to come around this curve just fine. Then you can send up an intermediate guiding catheter into the brain after that. You can see here I've got my nabbing all the way up into the cavernous carotid. We deployed this pipeline here for this aneurysm without any difficulty and then just showing some good flow restriction at the end here. That's a way you can easily overcome these more challenging left-sided cases. A more modern version of this case, just in the last few months, is to use the wrist system. Here's a recent case of mine with a large posterior communicating artery aneurysm. In this patient that I flow diverted. You can see I've got my wrist catheter all the way up into the horizontal petrous again. Then sometimes I like to add a little bit of extra support to the wrist catheter. Here I've got a nabbing leading out there with a red arrow. The yellow arrow is the wrist catheter. Then you get your phenom up and you can have plenty of support to deploy this pipeline here. Then you can see the pipeline in place with flow restriction in the aneurysm. When I've got a lot more tortuous anatomy to the carotid siphon, sometimes the nabbings don't want to track up high enough to give you the support you want. A great alternative is to use a phenom plus which can take those extra curves just being a little bit smaller. I found that the wrist plus the phenom or the nabbing or SOFIA-EX is plenty of support for these high strain cases like flow diversion and web cases. Stroke can as well be done radially. Again, here's a case where I've got my big system in this red arrows NOA catheter. I've got my braided stiff Simmons here that I just get locked into the proximal common carotid artery. We send up a wire and then track the OAA catheter up over into the internal. Then there's my occlusion there. In this case, I just left the OAA catheter in the internal, put a micro catheter up and a stent retriever. Then we pull it and we get a reperfusion. Then you can even do carotid angioplasty and stent with the radial systems. Again, a lesion here that caused a recent stroke. Again, I lock in my braided Simmons, track the OAA catheter over it into the carotid. You can deploy your distal protection device as you can see on the left there, and then do your angioplasty and place a carotid stent, all with plenty of support from the radial artery. So that's the end of my cases. Appreciate your time and I think we'll break for some discussion now. Yeah, absolutely. Another fantastic presentation. Thank you so much again for all this pearls of wisdom. It's such a concentrated amount of knowledge in one hour. We're going to go on to some cases, so I'm going to share my screen. And Dr. Brad Gross, who is my endovascular partner, was kind enough to have some cases for us. Can you see my screen okay? Yep. Yep. Yes. Yep. Brad, I can advance for you if you want to, if you're going to go ahead and present them. Sure. So first of all, this is a phenomenal group of interventionalists and radialists, so I'm humbled to be able to be a part of this. Those are great talks, guys. George asked me to show a, quote, controversial case for radial. And sort of like Josh said, I told him, I said, they're going to say anything can be done radial. It's like saying what could be coiled. Well, you could technically coil or pipeline anything that you want to. Some things are harder than others, but the more facile you get, really anything can be done radial. So I kind of thought that perhaps I would show some cases and discuss more a how-to and get the panel's opinion on a how-to to a radial. So let's go to the next slide, please, George. These are my disclosures real quick. And then the following slide. This was a case of a 72-year-old who was a grade five subarachnoid hemorrhage with severe peripheral vascular disease. He has a right femoral pulse. His SFA is occluded. He has a poor left femoral pulse. Those are his radial diameters. It's kind of moot for this group, but the bottom line is how would, what would be your system and how would you go about treating this ruptured aneurysm? You can see there's a pain that shows on the left that shows the neck of the aneurysm with the SCA clearly coming out of the aneurysm. And on the right, the reason I show that is there's actually a little pseudoaneurysm. You can see on the very lateral aspect of the aneurysm, there's a little pseudo or rupture point that you can appreciate. So I would, I would love the panel just to kind of, to familiarize everyone, you know, what, what, what system would they use and how would they go about doing this? Obviously through the right vertebral artery through the wrist. Yeah, I think it's helpful to, to, well, I always teach the fellows to figure out what you want to do in the brain and then work your way back, right? Because everything starts up there. So I look at this and it looks to me like that SCA is coming off the neck. So my main concern would be, how do I coil that off and protect that? But aside, you're gonna need some sort of adjunctive device there or a dual catheter technique or something. So you can either use a six French system or a two millimeters, plenty big for a seven French radial sheath. So you can either put up a seven French sheath and then 079 wrist with intermediate or without it'll climb up well into V4 or you could just try to get away at the six French system. I wouldn't do it without a sheet though. Yeah, I would, I would echo that. I think one thing to consider here is the, the straightest shot to protect that branch may not be the vertebral, depending on the state of the patient's PCOMs may be easier in some cases to come trans circulation, come from the top. But the radio would be just fine. My standard intervention setup is probably similar to Josh's and Eric's. I use a seven French long sheath and I've switched over to wrist for most cases. The benchmark I think is also a really competitive catheter for these things. But once you get up into whatever artery of interest, there's no difference really, in my opinion, the way that the case is performed as far as what you can get up and when, especially in the posterior circulation, it's pretty straightforward. I think in this particular case, I think I would probably have a scepter out into the ipsilateral P1 if I was coming up the vert and try and balloon coil it with the possibility that you might need to bite the bullet with an acute stent here. But in a guy like this, it sounds like, you know, the enemy of good is perfect. And so I would definitely not try to turn this aneurysm black. I would, I would really be judicious about protecting the dome, but trying to keep that SCA open. I would probably approach this very similar to Mike actually. And I would just go straight up this vertebral artery here on the right. I'd probably see how high I can get a wrist system first. Cause you, you, you like that extra 0.09 of space. If you can have it for any reason that didn't want to go high enough for support. I think you do this through a variety of six French intermediate guide catheters. And I would use two catheters, one, one balloon that I could stand through either the Eclipse balloon from Balt or the scepter from microvention and then a coiling catheter. And I try it with a balloon first. I think I could get a good enough result. If I had a problem, I need a stent and you can stand through that balloon catheter. So I guess some people would try a web in this too, but I, I probably wouldn't. Oh, Brad, I think you're muted. I guess if you try to land the web kind of cute and short, I didn't web this, but I think that this, this case really kind of brought out to me a real advantage of you can advance the next slide, George. I really liked using, I called it an 0.79, but I really liked using the wrist system for this. I actually sent Eric a text after I did this case because, so my philosophy here was, well, I have a pseudoaneurysm, you know, so what I did was I put a coil catheter into the pseudoaneurysm. I put a couple coils into that. And what's nice about the wrist is it will beautifully fit an 0.27 catheter next to an 0.17 catheter. And you get phenomenal runs through it, which I really can't get through a benchmark or a six French system. Furthermore, I think you can easily get the wrist much higher up than the benchmark. And it's 0.79. It really sort of makes it somewhat obsolete, at least to the radial and well, anyway, I'll leave it at that. But the bottom line is that for, for pipe coiling, which to me was really annoying to do through to standard systems, I really think the wrist is ideal. So my approach was actually to coil off and secure that pseudoaneurysm and then actually lay a pipeline down as kind of the only way to secure the aneurysm and, and keep the SCA open. So put a couple of coils into the pseudoaneurysm. Once that was secured, I felt comfortable giving integral in for the pipeline, landed the pipeline from that, that sort of that's around the turn. So we'll call that a distal P1 slash really P2 segment and brought the pipeline down and then just finished it with a few more coils to keep the SCA open. And again, beautiful runs through the wrist. This is, this is how to do in my opinion, sort of pipe coiling really ideally. You can show the next slide. So again, just kind of, you know, kind of a weak little coiling there. We'll see how this, how this ends up, but at least I was able to sleep about that SCA, I think a little bit better. And again, just a, I think an ideal radial case is simply an ideal 0.79 radial case, which I think everyone was sort of gravitating towards. I think there's many ways to skin this cat and people disagree. I think that's reasonable, but that was how I did this. Yeah. I think the, the key there is that, you know, if you're comfortable enough approaching these things radially, then you're not going to obviate the endovascular option just because the patient's a vasculopath, which if you were on the fence about it and you couldn't get infemorally, and then you take somebody who's this sick and try and clip it, you know, that may not be the best option. So it's just a, another tool in the tool belt. So, and just, I appreciated Josh's sort of introduction about stroke being the next frontier, you know, in Pittsburgh, we, we have our fair share of interesting strokes. And so we've definitely done our fair share of radial strokes. And so we have a lot of vasculopaths and certainly as everyone said, post your circulation, but another thing to highlight, oh my gosh, the bovine left common, it's just like a no brainer. I mean, you know, when you're thinking about strokes, your wire just naturally goes in there. You know, your time from, from the wrist into the left common bovine is the same thing as you're growing to descending aorta time when you talk about time is brain. Let's move on to the next slide. So, so here's a case of a patient who has a left MCA occlusion. And just to ask the panel, when you look at that left common takeoff there, this lady's 80, 85, whatever, would you, would you think about doing this femorally, radially equal? Again, it's a left MCA occlusion, probably an AFib clot. What do you think about that arch? Pro radial, pro femoral equal. They have one of those like early common kinks in it. It looks like it's about to do that. You know, that's a tough failure mode there that often makes it an immediate right turn out. So that's, I think those are tough, see what Josh and Mike think, but I think those are tough radially or femorally. I think the tough thing to think about with, with radio for stroke is that number one, you're not, you have a suboptimal platform in general, right? You've either got to put up a system that you have a chance of getting locked in the arm because it has no coating. And we see this all the time. Every locked catheter is a big OAD in a stroke case. It's always the same, but you don't really care too much about the rate of artery for a stroke. You're worried about the brain. So I don't think unlike all this electric stuff we're showing where it's really nice to have a sheet and, you know, respect the rate of artery, bring them back. It seems an elective case for a stroke. It's, I think that value proposition gives out the window, but then you end up with these locked catheters, having to cut them down, which is a real pain. I also think speed wise, it's really tough to beat a transfemoral stroke at this stage. Like a lot of us are just not as fast, even if you get the same bore system up on the brain. And as Josh pointed out, you don't, you, unless you're even the risk system, which is the biggest system you can get, you can only put a five French Sophia up there. So if you have to do radio for a showcase, that's a different question versus should you do it first? So at our shop, we really do still do femoral first for stroke, unless we don't. Right. And this is a great case for that because one of the failure modes, I think we've all seen is you do a femoral showcase, you're flailing around for 45 minutes, you can't get in. And then you stick the arm and you're in two seconds transradially. And the error there is not doing what Brad is talking about here, where you look at the anatomy and say, well, that's going to be a really tough femoral case. We should go radial. So I think, I think stratifying makes sense. In general, I find that challenging arches are a little bit easier radially than formerly, but a challenging arch is a challenging arch for both except for the bovine, which is the one exception. Yeah, I think as Eric pointed out, this is kind of a recognized failure mode for me for radial for, for a stroke in particular you know, if it was a elective intervention, I'm definitely more willing to be okay struggling to get a system up for a little bit longer, but that you know, acute back turn of the left carotid in that early kink before it straightens out, that's going to accentuate that loop and make it really tight going from the anoma back to the left common for a radial system. And I think you're just going to be herniating that system out all day long. And I think, you know, I'm pretty confident now that I'll eventually get something to work, but I don't want to screw around with that in a stroke. And I'd probably just default to femoral in this case, because I just think I could be faster. And it's really about speed, not about, you know, at the end of the day, being able to do it or not. I agree that same as what Josh said. And just because you can do it doesn't mean you always need to do it through one approach or another. It's just another tool. I would approach this femorally with a VTK. The only thing I would add to Mike's comments though, is that unfortunately, a lot of people, Josh is right, like radial for stroke is the hardest, but unfortunately, a lot of people that do not know how to do radial are forced to learn it at 3am when they can't get in femoral. So we see this all the time where people are like, oh man, I never even learned how to stick. I don't know how to form the sim. I don't even know how to do a proper radial calf, but this guy's got no occlusion. His femorals are out and it's 3am. He's got no occlusions. NIH is 20. That guy's going to die. That is a non-survival injury. That is not the time to be learning radial, right? Like even if you don't believe in all the stuff we've talked about, at a minimum, you should at least get your lab good and get yourself reasonably facile at the technique so that in 3am, you already know what you're doing and then you can decide. That's a very different story than do you do radial first for stroke. You at least need to learn it. That's a very helpful insights from the group. And so this was a case I did early on when I was starting to do radial just with diagnostics. And I actually fumbled with this trans-femorally for 45 minutes. And then it was about 20 minutes trans-radially humorously. And it's interesting that the panel was, you know, reticent about this because they're certainly more experienced than me. But what I've found is that, so one of the tips of the tray is when you do a femoral stroke is sometimes use an 8-inch 65 long arrow sheath to support your 088. And the radial artery is sort of your free long arrow sheath. It's something pretty strong to push against. And so in this case, actually, you could see here that sort of when you have these radials that are angling, excuse me, these left commas that are angling dead away from your subclavian, it's sort of a nicer, more natural push than when you're trying to make a 360 turn from the femoral artery. So again, that little kink that you see in the middle pain is really, I couldn't get, anytime I advanced anything past that, everything would herniate out. But from the wrist, you're sort of pushing parallel to that. So I think that's probably why I had an easier time doing this. Ray, let's go to the next slide. And so, yeah, so whatever, everyone's seen these nice pictures before and after. What was your guide? What did you use for your guide? This was actually a, this was a benchmark SOFIA move, which I, again, I don't know if I, I'll show the next case where I used the ballast, but this was one of those where I used a six, this was way before wrist existed, by the way. This was again, a couple of years ago, but I used a benchmark of 5-French SOFIA and then just a salumbra technique with that. And it worked. Again, I think a wrist would have had an easier time, frankly, than a benchmark with this. But again, I think showing the next case, I just find that when you have these kinks in the left common, you know, again, when you're coming from the femoral, everything's sort of kicking, everything's kicking you back. Whereas when you have the radial as a bolster, so this is another one with a kink a little higher up in the left common. You can show the next one. This is one I did with a ballast. And you can see the ballast got pretty well up there into the left ICA. Again, I think really being able to push against the radial artery, this was a non-bovine configure. This was actually a common origin configuration, which can be pretty challenging actually radial because it's kind of squished together. I just like pushing against the radial. And again, when you're doing the left side and the right arm is paretic, it's fairly easy to work with actually as well. So again, I think these strange left carotids sometimes can be paradoxically ideal in this weird anatomy. But again, stroke is certainly the final frontier. It's a challenge when we get more hydrophilic large bore catheters in addition or iterations of the wrist. I think this is going to be an exciting subsequent frontier because what's great, I don't know about you guys, but when I finish a stroke, I just pull the system out. There's no shooting the groin, there's no nothing. You get the clot out, you pull it out, you're done in a minute, which is a fantastic thing as opposed to figuring out, can I angiocele? Can I this? Can I that? Because these are the most painful groins sometimes, at least in my experience. So. Yep. Yeah, just another kink you push against the radial, but anyway. Yeah, I think the stroke thing is, that's where this has the most to gain. The patients have the most to gain as far as safety, especially TPA and obese elderly patients. It's the hardest, and it's also the one that we should all be working to try and solve. And I think everybody's trying to find the best mix of catheters and devices for this. So hopefully more in the to come, but these are great cases and can show it off. I think I'm still a little reticent to start radial on a lot of anterior circulation strokes, unless I can see up front that like a bovine or something like that, I usually default to femoral. And some of my colleagues are probably more aggressive around the country of doing everything all radially. I think it's just a mix of speed and luck and anatomy. Josh, how many strokes, what percent of your strokes do you do? Radial versus femoral, would you say? And anterior circulation. I'm about 50, 50, probably. For anterior circulation. And again, I make a choice off the CTA. All of our patients get a CTA before they go to stroke. We're not one of these direct angiothrombectomy places. So I have the benefit of being able to prescreen. Great. Brad, that case you just showed with the 879, that's a cat 5. Is that the same aspiration size as a 5-front Sophia? Yeah, I quickly went through this. It's just a go back one slide. This is just, again, a nice thing about the radial. You see there's two kinks in the right common here. This was a right distal in one. So you can go to the next slide. And yeah, so you get the wrists. Oh, that's the backwards slide. So you got the wrist up to the cavernous and yeah, cat 5 is a little bigger than Sophia. It's 058. It's through the wrist. So I use the wrist. You can go to the next two slides forward, George. I think you're going back. Yeah. So you can see the arrows on the wrist there in the cavernous. And then the cat 5 is up in the M1 over the stent reaver. Again, you can never get a benchmark this high up. Yeah. Nice case. All right. Just real quick, just for a little change in gears. I'm just an old-fashioned, humble, skull-based surgeon that doubles a little bit in open vascular whenever it's needed. I definitely don't have your skills. So I rely on my gifted endovascular partner, Dr. Gross, to tell me what's possible. This is a case that we actually shared. It's a lady that presented. The honey has three cats. It has subarachnoid hemorrhage along the basal cisterns. And we got her a CTA. And it did look like she had busy vasculature. They're in a cervical junction. And natural next move is that she got an angiogram. I'm not going to belabor this too much to drag it out. We thought that this was consistent with a fistula, like a C1 fistula, there are multiple fistula points. We discussed about it. I don't know, when you see something like that, first of all, is it something you're thinking whether radially or femorally that you would treat endovascular, is it something you're all dual-entrained, a neurosurgeon is something that you would treat surgically, what are your thoughts about it? I can go back to some of the films, if you would like me, I know I would just glance through it. Is that one vein that comes out of there? Yeah, there's a large varix that goes up. Just one, yeah. We're pretty surgically biased for these, I would treat that surgically for sure. We're pretty biased for this as well. Right. I can go back to the CT scan, what approach, sort of down, it's kind of sort of a junction, it goes down a little bit lower to C1, almost to C2 to some extent. I would do a far lateral and on the side of the vert it's coming off of, I think that was a left vert, I can quite tell. I extend the midline portion of my incision probably down to C2 and be able to take off a lamin of C2 if I needed to to get down that far, but I think a C1 laminectomy and a far lateral and really drill out far and take down a lot of occipital condyle is usually what I would do for this. Right. Yeah, I guess the technical aspect of the surgery is actually not that complicated here, that's what we're planning to do. But what I wanted to ask you is, obviously this is one of the most experienced panel in the world pushing the envelope in radial, but did this change your practice when you do surgery? Is it, you know, many times when we do a far lateral, let's say, people would either adjust their positioning and put people supine and with a great amount of extension, obviously it's a little bit harder for a seven-year-old, or potentially use long sheaths, do you just rely on ICG, do you keep the patient, do you close, keep the patient intubated and then go down and get a formal angiogram? I'd be interested to see what the panel's... I'm personally, sorry, I'm personally very aggressive with interoperative angio and I do almost all my interoperative angios radially now. For any posterior circulation, vascular lesion, radial is far easier than femoral for an interoperative angiogram. So for a far lateral, the upside is the side of the access. And so in this case, I would just throw in a left radial sheath. At the beginning of the case, I drape it into the field, I do my surgery, it's there on a flush, the whole case. I'm a little bit controversial because I still give the radial cocktail with the heparin. I found that if I place the radial sheath first, by the time we position and get going, I mean, honestly, the pharmacokinetics of the heparin is that it's probably out of the system by the time you actually start doing any intracranial, intradural work. For some of my colleagues who all do interops four, some of them asked me not to give the heparin, that's fine, I don't think it makes a huge difference. Particularly if I'm doing a cerebellar AVM or a far lateral, the radio artery sheath is just far easier with positioning than trying to do a long sheath from the femoral artery and wrap it around the leg. I like to know that the shunting lesion is gone before I leave the OR. There's nothing worse than coming back. I think ICG or fluorescein misses things up every once in a while. It's pretty darn good, especially for a fistula, but for an AVM, I think it's entirely inadequate and so I like to know that it's gone before I leave the OR with an interop. And Josh is being modest, but he published a series of transradial interoperative angiography and really highlights the benefit of that approach, especially for left-sided lesions, posterior circulation, and I would say the most important is the patients who are prone. Basically anytime I'm worried about doing either an intra or postoperative angiogram, I just put the sheath in at the beginning as Josh does and I give it to anesthesia to use as their arterial line and it solves the problem of intraoperative or postoperative access and also reduces the case time because I can always put in my radial sheath much faster than an anesthesia R2 can put in their radial R line, just saying. And I give the cocktail as well, including heparin, I don't think it makes any difference, but the setup there can be really beneficial. We have a hybrid room here, so it's pretty easy for us, but everybody knows in my cases the sheath goes in before the case starts and the intraoperative angio becomes much, much easier if you go transradial, especially for a case like this where the left-sided lesion is the left-sided radial artery is up. Eric, I know in Miami at least Jacques has been a little bit hesitant to do this, to do angiograms in a case like that, mainly because of all the logistics involved. I don't know if this has changed or how your practice has changed since a couple of years ago. Yeah. I mean, it's really about the fluoroavailability or fluoroscopy availability is terrible. The workflow is terrible. If we had what Josh has and Mike with a proper biplane hybrid, I mean, that's totally different. We have finally a monoplane hybrid room that is very difficult to get. We're always fighting with vascular to get it, it's booked out for months and doing it on the regular kind of spine, fluoro, radial doesn't solve that. That just helps the access. The films are garbage. It makes you want to kill yourself. So we do very few intraoperative angios. However, for this, I probably wouldn't do it either because it just seems more straightforward. But for an AVM, even with all that pain, it's tough for me to get on board unless it's a really simple grade one or two or something where you're really sure to leave without supporting them. So we tend to do it. But yeah, radial for an intraoperative angio, no question. So that was about a year ago, actually, sort of when it was first started. Again, the technical part of this is not that complicated. Essentially find all the fistulas points, just make sure that they're not connecting to something important. Just three quarters prone, like far lateral approach. I'm not going to belabor this too much, but there were multiple fistulas points around the C1 nerve root that were clipped. We did ICG as well at the end. Again, all those fistulas points, there's a bird coming in at one, two, three fistulas points there after using electrokinesiology, it was still this feeling that we took. But then we had put in a sheath from the beginning and Brad did a beautiful job getting the angio and trough. Here's Dr. Gross performing his magic. So we felt much better. It was just trying to feel there, but we felt much better closing, leaving the OR, knowing that everything was fine. This is a year after, actually, she just had her one year follow-up a couple of months ago. So I guess just a couple of questions, Brad, any questions for our panelists? Well, one quick disclosure is a little bit before I did that case, I think I'd done another radial before that, and I texted Josh Osmond and I said, hey, Josh, what's your setup for this? And he sent me these beautiful pictures. I think part of a testament to the success of radial is not only the publications and the feasibility of technique, it's really the accessibility of these experts that, again, you can learn a lot from them and they're very accessible. Eric Peterson's showing all these text he gets from all over the country. I mean, that's part of a testament to the success of this whole movement. So I'm grateful for what I learned from them. And this is just a perfect example of just how you can learn from these guys. I know it's late. So just a couple of questions and I think we'll wrap it up. One for Dr. Peterson, Eric, again, you spearheaded the whole thing. What are some innovations that you see sort of down the pipe immediately regarding radial approaches that you're hopeful and excited about? Yeah, I don't know anything coming down the pipe, but I can tell you what we need for all the budding entrepreneurs out there. I mean, we need a good stroke solution. There's no question. There's no system that's going to be one all and be all. And we specifically attacked what we thought was the biggest opportunity and obviously the one that wasn't time pressure sensitive. But we still need to be able to do radial first stroke well. And right now, forget the trial to show that it's the same and getting people on board. We don't have a system that you can get up there without getting it stuck in the arm and still do a proper 071 or bigger aspiration thrown back to me. And that's kind of how it has to go. So I think that's one thing that really needs to get solved. So that would be my next kind of thing for people to look at. A question for Dr. Levitt. You beautifully showed us your setup, how you evolved a little bit in doing things. For people that are very locked down in starting, as you said, people may have issues with just getting going with everything. What's your advice for them to make the jump? For people that have significant concerns, what would you tell them? So I was one of those people early on. And I think that part of it is, as Brad said, is the accessibility of people like Eric. I think if Eric just charged by the text message that he got about people asking questions about radial, he'd probably just retire. He's been very giving with his time. Josh and myself, obviously, we're all happy to, anybody who needs any help, we're all happy to talk with them. And we're sort of evangelists in this. We just want everybody to do this because we think it's better. For me, I think the thing to start with is get your equipment set up ahead of time. Use these webinars or other materials to understand the stuff that you need so you're not asking for something that you don't have. A lot of the stuff you can find maybe in your body IR suites or whatever. And none of it's particularly expensive as far as the sheets or the catheters, or it's pretty easy to get your hands on it, but just have those available. Try to avoid the mistakes that we made starting out as far as using the wrong type of catheter or the wrong type of sheet. And then when I started, I primarily started doing diagnostic angiograms on intubated patients because there wasn't a lot of time pressure there. You could take your time and try. But really, the thing that spurred me on was I was on some conference call with Eric and a couple other people, and he was just telling the group, like, look, you can't just dabble. You can't do this on some of the cases and not others. Just jump in and try it, and what you'll find is that it's not really that hard, but also the patients really appreciate it. So my advice is just try it, get the information you can ahead of time to prepare, and then just do it. It's really not that big a deal. It's not brain surgery, right? It's like, if the cards guys can do it, we can do it. Excellent. And one last question for Dr. Osborne. You very nicely showed us how many things you thought were limitations in the beginning, and then you just found them not to be, and then you gradually expanded your armamentarium. You just became more aggressive with cases. You learned what to look for. Can you tell us just a few things about sort of the learning curve? You know, you told us that the stroke is probably the last frontier, and I think every one of the panelists spoke about it, but in terms of graduation, how do people start doing cases? And Mike spoke a little bit about doing a sleep diagnostics, but why don't you take us to the latter a little bit about what you think is the proper advancement? Well, I do agree with Eric that, you know, you should go all in, and I think it just takes a commitment to research kind of what tools you need. I think, you know, going to, you know, a radio course is a great start just to learn little pearls about access and getting up to the subclavian, and then I think making sure your lab's ready to do it. I think you've got to commit and just go all in, and I mean, I started with diagnostics, got really comfortable with basic catheter work, and then, you know, you start tackling your intervention systems. I think, you know, elective interventions or subarachnoid hemorrhage is a great place to start. I think those are going to be a lot less forgiving for simple coiling, simple, you know, liquid and bulk embolizations where you don't need as complex of a system, and you're not putting up a high-strain device like a pipeline or a stent retriever up that's going to try to herniate out your system and cause you a lot of early frustrations. I think once you get, you know, a little bit more comfortable with these more, you know, simple cases, you know, even like middle meningeal artery embolizations and, you know, epistaxis, and then maybe some more simple coilings or an AVM case or a dural fistula case where you have a simpler mycocatheter system, then you can start tackling your photoversion cases, and I would start with right-sided cases and most of your circulation cases first, and then I would start tackling my left-sided cases, and then I think once you're at that point, you know, you're really confident, and then you can start going for stroke when you've really got your speed down. Well, I can't thank you enough for your time and all your wisdom tonight. Again, I'm not an endovascular specialist, but I certainly learned a ton tonight, and I'm sure everyone, we all, for a long time to come with the accessibility of all this gold on the website. Thank you, Brad, for sharing your cases, and I also want to thank again Shannon and Sam and the whole educational subcommittee. I want to wish everyone a good night and look forward to seeing everyone in person for a change at some point. Likewise. Thank you guys so much. Thank you. Appreciate it. Thank you. All right. Thanks, guys. Yeah. Thank you very much. Much appreciated.

radial approaches

endovascular neurosurgery

patient comfort

complications

procedural efficiency

training

transradial interventions

aneurysm treatment

stroke interventions

ultrasound

challenges

minimally invasive procedures