All right, good morning guys. I'm Lucas. I'm sure you guys didn't meet me yesterday. I'm one of the very influential speakers of neurology. So I'm going to talk to you about brain immunization and planning for the procedure and techniques. I want to thank Adam and Errol for having me here and for you guys for coming. I think it's a great course. We'll just hit the road here. So a couple of consultations. So just quickly, I think you're not going to hear me talk about Aruba. You're not going to hear me talk about natural history. But you do know, obviously, when you're choosing a technique, when you're playing, why that patient is in front of you. And I think these are the basic reasons that we see patients with brain AMS. And this is not an issue to this audience. But keep it in the back of your minds. When I present cases, what I'm really going to do is run through cases and different techniques. That's the Martin Braining System. Again, it's a common language. I'm a neurologist. I have to be able to talk this common language with the surgeons. But when you do an endovascular, hopefully, or an idol, an embolization, it doesn't have the exact same applicability as doing a brain-on-brain microsurgery. It's a loose section. But it's important that we understand it as neurologists, radiologists, or interventionists. But this, this is what I'm going to do. And you've heard the other faculty say this, the anatomy, the analysis of the angiogram. So there's lots of different things up here. But from my perspective, when I do an angiogram on a patient with an AM, every single one of these things, I have to check these boxes when I'm done looking at the AM. And say that I understand each element. Because it's going to come into play whether it can be treated and how it's going to be performed. All of these points are incredibly important. I'm going to try to illustrate some of these case examples and just do some individual pictures. So, here we have two very different AMs. Ruptured AM, middle cervical, primary supply. Most of the drainage is cortical. I look at this, and this is a compactitis, but it's in a very elevated location. This is a woman in her 50s who has horrible COPD, and she actually died of a PE before we could even treat her. Here's a young woman I've seen in my clinic, one of my partners saw 10 years ago, incidentally found migraines. And she has this horrible AM. Here's a vertebral injection. Diffuse tinnitus, pica, arthrosis, supply, obviously deep venous drainage. And when she presented, she presented with a headache 10 years later. She has a horrific heavy facial spasm that doesn't respond to anything. You'll see why. Here's her external carotid artery injection. Massive middle meningeal, occipital transosseous supply. And then when you look at this AP picture of external carotid artery, what you realize, if I stop this for you, about there, and you think about the AP picture, now you're seeing the whole idea. It's a puzzle that needs to be put together, right? You don't fulfill all that APM-90 from this injection, or from this injection. You have to put it together, and that's why the angiographic analysis is so important. I think when Joe was talking about dural fistula, he said, you know, we sit down and we look at the images. T-Boris has the patient at home and sits down. I mean, these are complex problems. You can't just shoot a couple of pictures, and now I have my plan. Really, I have to sit down and understand it all. So, lots of times we learn a lot about what's going on with this patient, not just by looking at the image, but the cross-sectional imaging is equally important. So, you're hearing kind of a theme, what's the patient presenting? What is the anatomy? How am I looking at the anatomy? I think Joe's illustration of the LAP-NLCT was phenomenal, because he merged everything, all the information together. The technology that we have these days, you have to do that. So, this is 10 years ago. Sorry, this is 10 years ago. This is now. So, what catches my eye is that the veins are massively engorged around the medulla of our thalamus, right at the exit of the seventh nerve. And why are the veins bigger? Because she's thrombosed this vein, right? There's veins disease. This isn't just an artery going in to a bunch of tangles coming out. It's an active disease process that can change over time. So, these kinds of cells are important. So, just to give you a flavor of how we at the University of Tennessee, since Murphy, kind of looked at ABMs and what are our methods and goals of treatment. And Adam, correct me if I'm wrong or you think differently, but when I thought in my head, how often are we applying what kind of treatment and what are our goals? I think most of the time we're doing, if we're doing pre-surgical embolization, we're doing it for cure, okay? Curative embolization is very rare in our practice. We don't attempt to do that very often. Embolization or radiosurgery, this may even be generous. Stage radiosurgery, again, this may be a generous number. And paleotargeted embolization is also very rare. And this for us, as I would say, Aruba twice, but I would say three times, I guess. This hasn't changed for us much after Aruba. Our stance has been, if you're going to go after an ABM, you really want to try to cure it. And microsurgery with embolization is our preferred technique. So, let's take a minute to talk about that. There has been, in the past, a school of neurointerventional thought that primary embolization, curative embolization, ought to be embarked upon for ABMs. It can be used as a major treatment modality. And that looked pretty bad in Aruba, and I have never been very happy with that kind of result. But there are papers in the literature that suggest that for an ABM, you can just go after embolization. And there are certainly practitioners, particularly in Europe, that's what they do. The ABM patient may not even see a surgeon. Lucas and I may be giving you a distorted view, so if there are other faculty who want to comment on that, since we're talking to an embolization audience about ABMs. Do you think we're off base? Do you tend to agree? I totally agree. I think the way I like to think about it is what if I'm the patient, how I would want to handle it. And I think I totally, I think I totally agree with the approach that we have a short period of very intensive treatment that is aimed at curing the thing. So, you do an embolization, followed shortly thereafter by surgical resection, post-op NGO, you're done. You're finished. And I agree that embolization, to go for a cure, I never, I feel always very insecure with that idea. And as I said, unless the ABM is really simple, one feeder or one vein, which doesn't even need embolization most of the time, I don't think we can cure that. But my question to you is that, you know, this transvenous moraine thing, I mean, I tend to shy away from radically new things until I understand them. And my understanding of ABMs is you stay away from the vein until the last moment, right? That's what you do surgically and that's what you do with embolization. So, to me, to go through the vein and start your embolization in the vein and precox into the nidus and claim that you embolized the entire nidus and then you do a control run from an arterial thing and if you don't see anything else from the arterial side, that means you're cured. I just don't, I just, I don't know. Is it all hype? Is it, is it somebody trying to maintain his great stature in the world of neurointervention? It depends on the ABM. I mean, if you have a small ABM, we've all had them, they're very small, they're very rare are the ones that you can actually cure. And even then, and I agree with you, you know, I'm still nervous about those down the road. You don't really know, do they recur, do they, you know, some people, you know, we can do a poll of the neurosurgeons, how many times do you get cured and you still go to the OR and you take it out. I mean, it's a whole other, but if you're going transvenous, you, you know, that, that's, that's a game where you have to have all your eggs in one basket. You, you, you can't leave any arterial supply and not have venous drainage because 12 hours you'll get a hemorrhage. I just don't see how they promote that. Yeah, I would totally agree. Unless, unless you get all the arterial supply taken care of, that, that ABM is still going to be a living, breathing monster that can erupt. And I would just go in transvenous just doesn't make any sense. I mean, I've had, we've all had it like, like Meryl just said, either small, simple ABMs or the white frontal ABMs that may be big that you can just go to town on because you know, you're not going to hurt them. Not only that, there's always a, even ABMs that look incredibly well-hypolyzed, if you go in and actually resect them, any size of little ABM, there's always, you know, tiny deep perforator feeders that you're, you're taking out at the very end, like on the underneath side. I don't see how those go away necessarily. But you will run across, it sounds like unfortunately we have a fairly uniform faculty opinion, but you will run across people who really think of an ABM in different terms and they'll say, well, it's, you know, 80% embolized, which is 80% better. And I just don't think that's what ABMs are like. It's 80% better for radiosurgery. Well, I don't even know if that's true. Yeah, maybe, maybe not, but I think it may be 80% quote-unquote safer for surgical resection, you're thinking. I mean, I don't know where that concept comes from because if you get 80% of the ABM, it's still an ABM. I will still see patients referred in who've had a previous treatment somewhere and the interpretation from the endovascular procedure will say, during the fistula, 80% of the arterial supply is gone, it is 80% cure. You know, ABM, 80% or, you know, 60% embolization, like, you know, you're eating a pie and you eat a certain amount of it and, you know. Well, I don't think there's something wrong with saying 50 or 60 or 80% just in terms of context, but in saying that cure, there couldn't be anything more wrong than that. So, there's no such thing as partial cure or anything like that, quantifying how much visually you've embolized. Right, how much radiographic hit. You know, there's literature that suggests if you take over a third of the ABM, that there's a higher likelihood of convalescence. So, whenever I did it, I'd say, you know, it appears at 20% of the flow, but that doesn't mean they're cured, they still need to have their subsequent treatment. Right. It's just a way to keep track of what you've accomplished at that time. Yeah. The issue is that you certainly, we have no, plus there are people who will be like, well, I took out the part that looked dangerous, and unless you're talking about an actual lateral aneurysm, there's, we have no idea what part's dangerous in an ABM. At least I'm not aware of that. Does anyone, any of you guys have insight as to what the dangerous part is relative to the rest? One other thing that Lucas was, we don't want to hijack the conversation too much. I know you want to keep going. But we have. We have. But faculty interaction's good. Lucas said this, but I just, I want to make sure you guys got it. I think the venous side of an ABM is about three times more important than the arterial side. And there's stuff in our specialty where we spend a lot of time paying attention to arteries. But when I see ABMs that have become symptomatic or ABMs that have been ruptured, when I really look carefully, I would say in two-thirds of cases, there is new venous restriction or venous stasis when you look carefully at it. And so I think, for me, I have to really force myself to look carefully at that vein side and try to understand it. And I'll even say I go further. And with an ABM that I'm looking at that's asymptomatic, I tend to be conservative if there seems to be no venous restriction. And if there's multiple veins, there's lots of blood that can get through there. I tend to get a little bit more nervous if on an angiogram this year, compared to an angiogram five years ago, the veins are twisting and kinking and looking worse. Because I think that's how they misbehave. I don't think it's a constant risk of two to three percent per year. I think they get into trouble with the vein side, and that's pretty much it for two-thirds ABMs. The other one-third, I think they develop inflow aneurysms, and you get subarachnoid hemorrhage from the aneurysms. But I don't think an AVM-nitis in and of itself creates any kind of problem. I don't believe in arterial steel. I think it's a venous congestion problem that gets ABMs in trouble. I would ask you guys to look for that, and if you think that's wrong, come back and tell me. Because that's just how my thinking has been evolving over the last decade. And Lucas mentioned it, but just watch it. Watch the venous drainage of ABMs carefully. Any comment on that before we give Lucas's talk back? Joey? Hey. We're talking about tools and techniques. So if the lab is a great place to do something new, if your patient is in a much more difficult and scary place to do something new, and finding a great opportunity to apply new technology or just a new technique that you haven't used is just, it's bigger than choosing your spots to take something. So in a boxing performance, you don't want to meet these guys, right? Any of you guys with an AB? If anything happens to you, my people will be angry. To die in battle is glorious. To die in a tank is disgrace. And with that, I'll give you Dr. Julian's green belt. Thank you, doctor. I'll just send Dr. Smoke. Perhaps I'll stay here. Today we will be removing the patient's appendix. The first step in operation of this particular type is... You don't want to be doing this. You want to know what you're doing the first time around, okay? So I'm going to just try to fly through some cases. We all have different opinions on should things be treated. These have all been treated, so let's leave that alone. This is a 14-year-old kid with a corticoventricular AVM, pretty large volume, primarily cortical venous drainage up to the superior sagittal sinus. There's some deep drainage in the superior sagittal sinus deep venous system. So when I look at this AVM, it's a pretty large volume. If I'm going to help the surgeon who's asking me to do the stabilization, I want to take out particularly the deepest stuff next to the ventricle where he's going to have to reach down. I'd like a decent volume embolization. He's looking to have a dry operation. So you can see the onyx cast. This was onyx 18 with a Marathon microcatheter. We went to several pedicles from this frontal branch and this other frontal branch that comes off the right here, the pericallosal artery. Very important that when you're doing onyx, onyx can take a while, right? You've seen that now in the lab. You want to do interim DSA. Someone else, maybe your fellow, maybe your partner is injecting. What are you looking for? We're just talking about the venous system. You don't want to compromise the vein, right? So what if you fall short, you take the arterial pedicle, you don't get as much nival penetration as you want? The last thing you want is to shoot into the vein before you've done anything to the nivus. What's the limit of your embolization? You should have decided this before you started injecting. What's your maximum reflux? You need to get that catheter out at the end of the day. So I'm going to show you some bad things, things that happened to me. I will say, when we talk about techniques, my least favorite thing in intervention, I said for a while, was pulling the band on my Marathon microcatheter. I hated it. It made me nervous. I have to tell you, when I first got here, I told them that. I was more used to seeing blue in my fellowship than what we've done in ours as well. In our last pedicle disembolization, I pulled two Marathons from this pedicle. I had another one here in 40 minutes. It's going on forever. We're pulling. We're letting go of the tension. If you guys have seen this, we're pulling. We're letting go of the tension. It took a while. It's getting more nervous. We're not happy. We aren't coming out. We've got to be patient. That is incredibly important in everything that we do. Be patient. This is also incredibly important. What do you do at the end of an embolization? You take a whole head run. You look at what you just accomplished or didn't accomplish. You sit. I remember this. I'll never forget this. Going into the control room, sitting down and looking at this. I don't know why we developed an audience that day, but there was a lot of people in the control room, and everyone was real happy because they're looking at the knives. We're looking at other places, too. Look what's going on here. This is cut off. What the hell happened? That's our question, first of all. What the hell happened? We got the catheter out. It's out. This is cut off. Did the vessel dissect? Is it in spasm? Well, I don't know. I'm going to go find out. I was able to pass. The first thing, I didn't actually shoot the 13-bar. I didn't put that picture up. What did I see? Back around. Posterior carotid callosum comes around and almost gets to this point, giving a slight bit of comfort. Do I still need to get this artery open? I'm able to pass it pretty easily, and we just gave a little bit of breath and go on a head run. We got really lucky. We got the hell out of it. To me, this is a segue into talking about technique. We've known the pitfalls of technique. Probably what I did too long was leave the microcatheter on tension too long and stretch the artery. Cause it to spasm and maybe form a clot, but we were able to get it open. Thankfully, we have new techniques. We'll have other pitfalls, but the development of the Apollo, I think, is a nice step forward. The availability of Apollo's pit was visible. Now, in Europe and other places for a long time, the detachable tip microcatheter allows us a little bit more safety. I'm sure you could do the same thing if you didn't watch your reflux. Reflux past the marker. This is a young guy, comes in with this hemorrhage. Posterior temporal lobe, interventricular. He's doing well neurologically. He does need a ventriculosis, but you can see he's hydrocephalus. Just a point about timing. My personal take about his talk and fellowship, for the most part, for several reasons, is you don't need to treat these AVM patients the day they show up. I'll show you patients I've treated the day they showed up, but not everybody I've treated the day they showed up. That has something to do also with are there high-risk features? What's the presentation? Is it subarachnoid hemorrhage? Are you looking for an angle or is it going out instead? Or is this a parietal hemorrhage from, I don't know what part of the thymus. I do always get angiography when they show up, because I want to know what I'm feeling, but I don't know whether I can simulate it. It's hard to see. You can see straight sinus. It's early. You can see it here, too. There, you see this little tiny, I don't know the proper measurements but this is small. This is also associated with a hematoma. I may not be seeing the whole thing angiographically. To me, that's another reason to wait. I have actually seen that. I don't have a demonstration of that, but if you've ever seen blue eyes injected into a compressed AVM, you're injecting where you think it is on the live road map, but it's somewhere else. Did I run through the AVM? Or is it an itis that I don't see because it's compressed? That's not a situation I want to find myself in. I think waiting is reasonable. I think we waited six weeks, approximately, to treat him. When we talk about surgery, non-surgery, my plan, the way I do things as an endovascular neurologist is never to go out of the room. I've talked about it already. This is, for the most part, a surgical disease. In rare circumstances like this, you may have an opportunity to perform an endovascular curative nebulization. I do think those patients need follow-up. They need six months of angiograms. When they're younger, the pediatric population will take care of them. They have to go to the AVM. We'll do an angiogram five years later for those kids. I'm always prepared with my surgical partners. They know I'm doing the procedure. It's basically an OR on standby. We're not starting at 5 p.m. I have a question. Have you taken D-uclip? How long has it worked well for you? My only case of compassionate use for this case is before it was out commercially. The reason they use it in this case, I told you I hate pulling marathon microcatheters, and I was looking at this bend like this, where I just didn't want that traction. I didn't feel like, I didn't know how on top of the nidus I could be with my microcatheter. So, you know, you can plug and push, but then if you travel a long segment, I just didn't, and I'll show you the detachment. So I'll tell you, I'm interested to hear the other five pieces. I've now done about six of them, and for a reason that I don't get, I've actually lost the comfortability of building the plug, because they have not a single, I've done one spinal, where I built it, you know, it was the three centimeter one, and I felt like a three centimeter plug if you pulled it in the top, but for the intravenous ones, five of them, not one of them, they're broken. And I have photos of my, like photos, I'd say videos, of me having it under super traction, the marker pulling away, and pulling a lot, and not popping, so now, I don't feel comfortable enough to build a plug big enough to try that again, because I was so disheartened by that project. Did you also find that it's less flexible than the marathon, so you kind of give up a little bit on how far you can get in terms of your access? I didn't reach that decision, maybe, that that's probably, that might be the case, but. I've only tried to do one place, but. I've never had as much of a problem with the marathon, I think the one time I had a problem was in an external branch where I just, you know, it was my fault, I just let too much re-girch happen, you know, it was a trap, you know, I was there for hours, and so I think if you're conscientious about it, I think the marathon is a great catheter, I think it works. Do you know the external, what's awesome in scepter, if you haven't done scepter plus onyx, man, it shocks me how flexible and far you can get that balloon. I've actually moved to doing scepter intracranially. Anything reasonable, any reasonable access intracranially, I use a scepter. Yeah, and don't get me wrong, I'm not trying to impugn the marathon, because you should understand that the Apollo can also detach prematurely, so there's a time and place for everything. It's a device. I don't mean to lambast the Apollo, because it's really too new, and I don't have it, and there are clearly people who like it a lot, but I was just wondering if the other faculty have larger experience, so far, I have not had good experience with it, so I just didn't know about it. But I'm trying to figure out whether I should try it some more. Like I said, my end is one, but I think this is, to me, was an example of a technology that had a place for a specific patient, and it used it to good effect, and it could have gone horribly wrong, as well. This picture is to show you, it's not very dense in contrast, but you need good microangiography to know where you are, and you should really work your way to the ninus. Here, there's a short distance to the ninus. I often take multiple microangiograms before I get to this place where I'm satisfied that I can embolize now, so I understand the situation. This is to show you, if we are gonna embolize curatively, then we need to do what we've discussed, which is take the arteries going in, take the ninus, and take the veins, okay? That's curative embolization, and that's why I put this on top of here, because I really think we've got the pedicle, we have the ninus, and we have the vein coming out, okay? That's where I was satisfied that I was done. This kid's had, our kid's 25, has had a six-month follow-up, he's gone, he's gonna have a five-year follow-up. And there you can see the PCA. There's a detachment zone, which is well within that temporal branch. That gives me some kind of comfort that when I detach it, it's gonna stay there, but that's what I was really curious to see. And this is, I gotta give Adam, this dude, he helped me a lot. So he did this case, I wasn't, I hadn't done that many cases in Memphis yet, and I said, I really wanna try this, what do you think, Adam? We discussed this in our conference, and he said, yeah, helped us get the IRB to get the device, and I was pulling on it, and I was nervous with Marathon already, and it wasn't coming out, it wasn't detaching, but we were saying, Adam came in, detached it, walked out of the room, so. It's good to have good partners, people that you trust, you know? He walked out before you did the next engine thing, right? So, we just talked about, someone mentioned SEPTR, so I think it has a place also. It basically allows you to do flow control. Some of us down in the lab yesterday tried to simulate flow control, where you wedge a micro catheter. It's not flow carrying the embolic agent, it's your finger pressing it and doing it. So, I think this is kind of pseudo-flow control, there's a couple reasons why I don't go into that, but I do see a lot of pediatric patients. I like working with kids, so this is a child referred by one of the pediatric neurosurgeons, and you know, cross-sectional imaging suggests there's something wrong. If you aren't sure whether this is a DBA or ABM, get an angiogram, right? Be sure, it has implications. Obviously, correct diagnosis matters. So, when you take a look at the angiographic images, there's clearly something, there's anitis, and I would classify this as compact, it's kind of wispy. And always shoot what could potentially be the secondary supply to the ABM, right? Although this is a QBA, it's distal enough, it's getting, it's bridal, it's a little branch of PCA, it's close enough that maybe a distal ACA or MCA could go there, and unless you take the picture, you don't know. Again, microangiography. This is, I think, a good illustration of working your way to the nineties. Because this picture is incredibly different than this picture, okay? If you don't pick this up, you're gonna have a problem with your immunization rate. Does anybody want to point out what the big difference is? Any of the fellows? I heard somebody say on the side vessels, what else? Thank you. So that, if you take this out, if you get embolic all the way down here, you may be okay if you get some embolic here, because there's gonna be a patient lateralization, but if you get embolic down here, you're gonna have a colitis again. Now it's our big worry, that's why the surgeon really didn't want to operate, and wanted to see if I could embolize it, and honestly, I didn't know if I could, because I didn't have these pictures for the diagnostic angiogram. This is from the day of treatment. Did you do this patient away? No. I don't do, kids I think would be very hard to do away. I don't use monitoring, I have to trust the anatomy. I think we all have to trust the anatomy, and the other point is, four frames per second is incredibly important when you're doing microangiography, you really need to understand and see the pace that things are moving, so don't be afraid to increase the frame rates. So this was a scepter case, and as Jay said, it's pretty impressive how far you can get the scepter out, and this was a large artery leading to the nidus, so I was able to get the scepter out pretty far, and a couple of points when you're using a scepter, I think it's important, you have to confirm balloon occlusion, otherwise you don't have flow. So you inject from below, so you need a catheter that you can inject through that's big enough, and in a kid, the four-frame system, you're not gonna get a good injection, so you have to upsize to five, and you have to be comfortable getting access to the balloon from both little people, safely. But here you don't see the nidus anymore, the pedicle's occluded, I don't have a dated image to show you the balloon, but it's inflated, and I would inject more than once and confirm that, especially if you have a time delay, you're looking at pictures, all these balloons can deflate, and then a microcatheter injection with the balloon up. Why is that important? Anybody have some thoughts on that? So you inject with the balloon down, and you see the nidus, you see the veins coming out. You inject with the balloon up, and you may be able to, with your hand, force contrast through the nidus to other arterial pedicles, right? So you have an idea of what you're up against, literally, what the competing forces are, and why your embolization may not be complete when you think it is, and that's why you always go back and check the collateral circulation when you're done. So this picture is with the balloon up, and this is our onyx caths when we're done, onyx 18. So again, how do I know that I'm done? I've got the arterial pedicle, is that important? Got what I think is nidus, I'm not sure that's playing, but I'll stop and let me drag it. So what I wanna see is confirmation that I'm in the vein, and just like when we were talking about fistulas, once I've got the nidus up, I wanna go sequentially, pedicle, nidus, vein. Just like when we were talking about fistulas, there you start to see a caliber change, and there I'm pretty sure I'm in the vein. Excuse me, in the vein. So, and you're doing control runs, remember, you're doing control runs. In this case, if you're doing control runs, please remember to deflate the balloon. You're not gonna know what you've accomplished, okay? So, okay. Change in technique. The sound's not working on this one, but can anybody identify this? 80s again? 80s? Yeah, it's a good range of motion. It's too bad this guy's not working. He's got a nice 80s fro right there, which is nice. Okay, so, we talked about not treating patients, and weighting, this is not a patient you wanna weigh on, right? And I think you guys can see this, this is a very sick patient. Guy comes in with ruptured atrium, he had multi-compartment hemorrhage. He's actually got some subdural. He's got midline shifts, big parietal component, interventricular component. And, you know, there's blood everywhere. There's probably some subarachnoid blood, and we're not surprised when we do our immediate angiography that he's got this. Actually, he has CTAs, and we can see this, the CTA, and you can see that there's probably a symptom. And I think this is a good example of compressed anitis. There's a lot of mass effect. You see this early vein, but you don't see a big compact anitis, but I wouldn't be surprised if it's there. But that's not what's important right now. In my mind, this is a very high risk in your architectural feature, the one that needs to be dealt with immediately. Honestly, we're dealing with this ICP crisis at the same time, and we have a plan to fix this, and get our butts to the OR, okay? Then decompress it. So how are you gonna fix this? What is the technique in this situation? So again, microangiography, very important. You're working your way there. You can see that pseudoaneurysm, but you can also see some normal blood vessels. And personally, I think you can inject an embolic from here. He's had a bad injury. You probably won't know for a long time whether you've hurt him with non-target embolization, and who knows how much he's gonna recover. But I would say, if you can't get closer, get closer. Because you wanna be on top of the abnormality that you wanna fix. And our brains are so richly muscularized that if you do non-target embolization or proximal ligation in an artery, I wouldn't be surprised if it fills from another pathway, ruptures later. This is more along the lines of what I wanna see right before I inject the glue. You're right on top of the abnormality. You can get a result like this. I still leaked some glue a little out, distally. But I know that I filled that pseudoaneurysm, but that thing's not gonna bleed again. So, a little bit similar but different technique. And I guess I should point out a little bit about what was the glue dilution on the last injection. I don't want it to go very far. I'm right on top of the problem, so I'm happy with the 50% dilution, one to one. It's gonna set up quickly. I just get my microcaptor out of there. I don't want it to flood. I just want it to fill that hole in. This is a little bit different. This is another ruptured AVM. And this patient, again, does well clinically. Sent home to recover. Comes back about a month to six weeks later. And angiography. A little busy over here. A bleak picture. Clear abnormality. But I would never really understand this AVM until I get to a picture like this with a microcaptor, and this is a marathon. And even in microangiography, you should try to look at primary and secondary arterial supply. All the things that we talked about before. Your eyes would go here, and see this, and see here. Like, this is where I want to put my microcaptor. But this goes to the AVM, too. I'll show you a picture of that, or a movie of that in a second. There's one projection of that, actually. This one's probably better. Watch this. Let me turn the lights down a little bit. I don't know if you guys can see that. But this was my point about projecting hard, and trying to see what's going on. So, this is the AVM, and this is the microcaptor. And this is the AVM, and this is the microcaptor. And refluxing back a branch. When I inject soft, at the beginning of the injection, you see this, then a little harder, and it comes back, and you see that secondary supply to the nidus. It's easier to drag it. So you know how well it projects. You can see it come back. There you go. Blue, forcing contrast through the nidus there. So, at the end of the day, it's still injecting blue from that location, a little bit more diluted. And I feel like I filled up the nidus. Some stuff leaked into the vein, which is kind of what I wanted. I wasn't sure that I'd be able to cure this, but I had a very low threshold for the OR, as we've all discussed. You need to be confident. It's a ruptured AVM. You wanna know that it's gonna be cured. So, this is something I appreciate the surgeon's comments on, but, you know, a small AVM may be difficult to find in an operating room. And one of the things that we do is, here's the pictures before and after. So it looks like it's gone, but remember that secondary supply, you never filled up that range. You never really penetrated the vein well. Even though we didn't see it, we took a dyna-CT to localize our blue, and that can be married to your brain navigation in the OR, whether it's the brain lab or stealth, to help resect this. So I think that's a technique that can be very helpful. Let me just fire through this last case and then open it up to questions or comments. So this isn't AVM pathology. This is veningal and malformation, but it gives a good illustration of high-flow fistula embolization. And as you know, sometimes in a PLAV and a NIDUS configuration, there's intranidal direct AV shunts. If you find your microcatheter next to one of those, you're gonna wanna use a specific technique which is similar to what we do here. So I guess the last thing in terms of technique is catheterization. We were talking about the pull, forward tension, or the movement of the wire back and forth. So when you see that kind of tortuosity, first thing is what kind of microcatheter you're gonna use. Right? I don't think it'll be very easy to get a PROWL-14 to take all these zigzags down here, okay? And this is where I think the Marathon or the MAGENE flow-directed microcatheters can really help you get to these places. But those places are deep in the brain and your wires can be spheres in these situations, in these tiny vessels. So one thing I would recommend, and you can do this in any vascular treatment, external broad, catheterizing an aneurysm. If you can, leave with the microcatheter without the wire out. Sometimes you can get away with that. In my mind, that's safer. So we're already very distal, 180 turn, 180 turn. And you can see what this MAGENE microcatheter is able to do if you just push it without the wire. Extrude it. You can do all that. And then, what Dr. Hamilton mentioned the other day, you release that tension when you pull the wire back. It'll travel even further. You can do that slowly, okay? No rush, but you do that slowly. Now, boom. You're right in front of the fistula. So, when you talk about high-flow embolization techniques, we're talking high percentages of MVCA, you can consider a coil basket, but you're gonna be limited. If you can only get a flow-directed microcatheter there, you're not gonna be able to deploy the coils. Do you wanna say something? I use Tantalum almost every single time. I will sometimes ask the anesthesiologist for hypotension, and have them prepare to give valsalva just in case you shoot glue out where you don't want it. And I'll show you an example of that. Image or syringe is just another visual cue for you. At the lab, we talked about injecting the sugar water under fluoro, so you can see the conditions, especially if you change the blood pressure. And we talked about this already. You wanna know your maximal reflux point. You wanna be on a blank load now. So this is that embolization, actually, this is not. This is one that doesn't go exactly how you want it. What do you do when the glue starts to fly? So here's a microcatheter tip, right by the point of fistulization. So look at this, this is not good. It was flopping in the breeze. So the right thing to do here is actually inject faster, because it wants to fly away, not stop. And what you need to do is fill up that pit. So if you watch, right there, it's gonna get fatter in a second. Fatter, fatter, fatter, fatter, injecting faster. And this was an error on my part. This was high flow, and it was almost 60% glue. So I had to inject faster to slow it down. Or coil. Or coil, but again, this is so deep that the only microcatheter we get there is a marathon. At least, maybe other folks can get bigger coiling catheters there, but I wasn't able to, and didn't plan to. So similar situation. And one of the things that you'll see is if you compare the position of the microcatheter at the initial catheterization, then we actually back it up a little bit, because you know the flow's gonna carry the glue forward. And I don't mind having the microcatheter tip against the artery wall, because as soon as the glue hits, it's gonna start to polymerize, and that's a good thing, because this is a very fat pedicle, and you'll see, as the glue comes out, this one thankfully comes out at a better pace. And it carries forward. There it goes. And you can see how it kind of fans out as it enters the vein. So that's exactly what you want to see. And then it's starting to reflux and widen and approximate the size of the artery. And now I know I'm done with the microcatheter out. So, this is not a contest so I can compare it with better looking my kids' or Jay's kids' T-shirts and pictures. But this is to remind you that we're all kids. We love our job. My daughter, you put her, when she was one in my car, she wants to drive it. She doesn't know, you know, she doesn't know that she's gonna crash it, because she doesn't have the foundation to drive it. So just like everybody else, I will leave you with the idea that you need to understand anatomy. We love to play with toys. You need to have a foundation to adapt these techniques and then start small and work your way up. I've had the good fortune of really good partners in an environment where you can kind of grow into your skill set. And I encourage you to look for that kind of similar view if you can find it, because that makes the job even better. So, I'm gonna stop there and thank you for everything. Thank you.

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