So, thank you all for coming. I think that I'll sum it up best, but this is really a fantastic course. There are a lot of opportunities and courses out there. There are a number that are multidisciplinary and all the rest, but I don't think anything gives the hand-on exposure and the cadaveric experience that you're going to get here. And that's why this place has a very special educational opportunity. So Adam asked me to talk about sort of new technologies in endovascular, new developments in endovascular. So that's what I hope to do. I have a number of disclosures, a number of trials, and some relationship with some startup companies, some of which technologies are shown here. So let's start. What I want to do, actually, is I don't want to just say, okay, here's one technology. Here's another technology. That'll be somewhat what it's like, but really what I'd like to do is give you an idea of what the space is like, because at least for me, this is one of the most exciting things about what we get to do. Everything we do is done through the medium of technology. Even what we see, we're not looking at the brain while we're operating on it in endovascular. We're looking at the screen. Everything is mediated through the technology that we're working with. And as a result, it changes. That has profound influence on the quality of the care we can give our patients. So what I'd like to do is give you a little bit of history, a little bit of where we are with current technology, and a little more about where we might be going. This is certainly not an exhaustive list. There's lots of other neat technologies coming out, and it's not definitive, but I want to emphasize to you all the importance of technology and what we're doing. It's just a continue, sort of like a Moore's Law kind of thing. We just keep getting new and better things quicker and quicker and quicker. You need to stay abreast of that. I'm going to give you a little editorialization, my personal opinion. Some of you may have mentors who say, and I've had mentors who said, well, you really have to get good with a particular methodology, a particular technology. You're good at that. Be good at it. You know how to manage it, and then that's how you practice. I get the logic of that, but the reality is, is this space changes much too quickly and much too dramatically. If you think that you're going to come out in fellowship and just sort of put your blinders on and say, that's what I learned, and now I'm going to do this for the next 20 years, then somewhere between five and seven years from now, you'll be relatively obsolete. Much like trying to continue to do work at your job on a computer that's 10 years old, it's just not going to fly. The idea is sort of to get you excited about, hey, what's coming down the pipe, and hopefully get you excited to pay attention to those things as you go out into practice and continue to do endovascular. Let's start with aneurysms, right? Nothing completely shocking here. Coils were first approved in the U.S. in 1995. With the publication of ISAT and then BRAT, really the use of coiling has expanded dramatically. Both of those trials specifically compared ruptured versus unruptured cohorts, however, it's had a dramatic impact on unruptured cohorts as well. There have been a number of papers published that have shown a dramatic shift in unruptured aneurysm treatment as well. Coils have really become, just by based of numbers, the mainstay of aneurysm treatment in the modern era. It's an excellent modality. It has a low morbidity and mortality, but what I'd like to emphasize to you is it's getting better. This is the point. Be aware that we're always improving with our technologies. So we have all kinds of new technologies, including the hydrocoils. You can see it is like this with a hydrogel core and then it swells and you get a huge expansion of the gel material. And an outstanding paper and study was performed by Phil White and was published, which evaluated outcomes. And what I want to emphasize is this. In this study, in HELPS, the retreatment rate in this study was 3.5%. Now compare that to ISAT, which was an 11% retreatment rate. Now granted, there's unruptures in this cohort, but it's a pretty dramatic difference. So when you're out there in practice, if you're thinking, oh, well, we're status quo with the coils that were used in the 90s and published in papers that were published in 2000, that's not really reality. Nowadays, we get dramatically lower retreatment rates and lower recanalization rates. What about complications? Well, a group actually that a number of us belong to, Endovascular Neurosurgery Research Group, published outcomes across a large multi-center group of centers for over 300 patients. We found that for retreatment, this is patients, so we're talking about those patients that recurred that you're then retreating, extremely low mortality, less than 1%, less than 1% major disability. Does that mean that's always the case? No. Does it mean that the likelihood that there's some recanalization doesn't mean it's the end of the world? You take care of it and you treat it, and we continue to get better. That said, that's just one coil type, the hydrocoils in the HELPS trial. There's tons more. There's Axia MicroFX. There's the random loop design of the Codman coils. There's Ceracite with a PGLA center. There's the Delta coils made to particularly break in a particular way. Matrix, regular coils, Target. There's a Target coil which has claims of improved efficacy. There are new, wider, larger diameter coils, Penumbra 400 coils. These are all new things that have come out in the last decade that are dramatically affecting the way we practice and the way we approach what we do. There's also coil assist devices. Let's take a first base of where we are. We talk about stents. This is a neuroform stent used to hold the coils in the aneurysm. That same group did a multi-center collaboration of looking at using the Enterprise stent, a different closed cell design stent, and evaluated the initial experience and then made sure that there was delayed follow-up in that patient population, over 200 patients, total of almost 150,000 total patient days of follow-up. What we found was, I'm going to skip the regular demographics, is this. We had this great occlusion rate. This is key. Only 8% of patients went on to retreatment. Angiographic follow-up was present for over 90% of the patients. What does that mean when I talk about that occlusion rate? This is what I want to emphasize because there's actually a number of papers now that have suggested this. If you look at this, this is the initial coiling occlusion rate. So red bone grade 1, 100% occluded, about 28%. Then the over 90% or so, you have a big chunk, maybe 40% of the patients. Look what happens on the follow-up angiogram. This is without subsequent retreatment. On the follow-up angiogram, you have over 50% of the patients progressing to complete occlusion. This is pretty powerful. There's clearly a trend or a suggestion in the literature. It's also found with neuroform in the MAPS data. It's also found in Michel Piotin and Alan Boniface, two European studies. It's also found in Brian, I was an internal author, but Brian published the UF series. All of those papers suggested that those aneurysms that did have stents for stent-assisted coiling went on to have better delayed occlusion rates. So this is new information we're gaining. You can't be completely anti-something until you start to assess what it means for treatment. This is Brian's paper that basically showed that there was a, I mean 18 is obviously ridiculous, but even if you go to the bottom end of the 95% competence interval, there's a four-fold increase in the aneurysm being completely occluded if a stent was used. Clinical follow-up in 97% of the patients. In the ISIS data, in the Enterprise series, and in that series you'll see, again, procedure-related disease or mortality was less than 1% in unruptured patients. However, in subarachnoid hemorrhage patients, it was 16%, significantly more. So the point of the story is that we continue to improve. More importantly, there's still room to improve further. There are new coil-assist devices that are coming along. Talk about new technology, here's one. This is called the Pulse Rider, which comes from Pulsar, I'm a consultant to. They are working on a trial in the States. They're in Europe. Codman, I believe, is marketing them in Europe, but this is an aneurysm bridging device. For those aneurysms that are too challenging to get into the distal branches, you can park this immediately at the neck, provide support, and then coil the aneurysm off. This is what it looks like, a sort of Star Trek-y looking thing. And here's a case done by Pedro Lilic in South America. You can see the device in place, the coiling, eventual good result. There are other devices. There's the barrel stent. I'm the PI for this trial. This is a closed-cell, mostly closed-cell stent with a widening in the middle so that the stent itself can work like a balloon. So the idea is you have an aneurysm, it's wide-necked, it's a bifurcation. Typically you put a stent, you still have an extensive amount of area that the coils can herniate through. Now what we often do, and there's a fair amount of literature, is we do Y-stenting where we stent into each vessel and come down. Now the idea is with the barrel stent, it will pooch out, sort of like a balloon would if you were balloon remodeling, and protect the neck of the aneurysm and allow coiling. Now everything I've talked about so far related to coils. Are we stuck with coils? What about other things? Well, there's liquid embolic. There's Chuck Kerber's glue, or Kerber glue is what people refer to as the Nercolate, which has had very interesting preliminary stuff in some early reports. That was put on hold recently, but actually it's been recently resurrected, so we'll see where that goes. Or is the other goal to fill the aneurysm? Is that what we really need to do? Do we need to put coils in the aneurysm? Do we need to put glue in the aneurysm or some other thing? Well, probably not, right? Our real goal is to just stop blood flow into the aneurysm, heal across the neck. Well, this is no surprise to any of you at this point, but flow diversion, right? Kalmas first published this paper in Stroke looking at the rabbit models, showed the pipeline embolization device with preservation of perforating vessels off the aorta. And now this has become a very important and often used tool. Here's a case that I did a number of years ago now. Blow out of the carotid, no real neck or anatomy. For a surgical approach, this would be a nightmare. Stent-assisted coiling would be a nightmare. You're never going to get all of the edges perfectly in this context. So instead, here's a 3D sort of showing that anatomy. So instead, you drop a float over. You can see the pipeline across the vessel. You can see the stasis in the aneurysm. Here's a run as you can see the dye clearing and the stasis within the aneurysm right there. Bring her back for a follow-up three months later. Complete reconstitution of the vessel, no hint of an aneurysm. This is something that otherwise didn't have a good choice. This was a young 30-something-year-old woman. Here's the angiogram. No hint of an aneurysm anymore. This is dramatic. There are other float averters coming down the pipe. There's one in trial right now in the United States called the Surpass Float Averter. It's approved in Europe. We'll likely, well, we'll see what happens in the States. There's a case from Joost de Vries in the Netherlands. Giant aneurysm after the Surpass Float Averter. Complete reconstruction and healing. Float aversion is significant and worthwhile. Now, so far I've talked about coiling and stent-assisted coiling or float aversion. Is there a middle ground? Might there be something that's in between the two that would be better? This is, I think, a very exciting direction we're going right now. Instead of purely float averting, we know there's some benefit with stent-assisted coiling. What's the next direction we could go? Well, this is the Elvis device, which has the traditional stents. And correct me if I'm wrong, guys. But traditional stents have between a 7% to 9% coverage rate, basically. So they're 93% porous. The float averters have a 30% to 35% coverage. And this intermediate stent has in the 15%, 17%-ish range of coverage. So you're getting sort of halfway between the old stents and the float averters. You can still access it to coil, but perhaps you're getting more of a progressive occlusion event. This is not approved in the US. This is a case that was done in compassionate use by Dr. Quilter, Ray Turner, and Chowdhury in MUSC. There's a vertebral artery aneurysm, you can see it. Again, it's sort of dysplastic and a blowout of the whole vessel. They place the Elvis stent, able to coil the aneurysm, like this. They originally jailed the aneurysm. You see, already initially, you're getting some contrast stasis. So they initially jailed the catheter. They lost access and then re-catheterized it. So you could easily get through the stent to get in there. Maybe some of you have used this now in the trial that's ongoing. But eventually, they get excellent occlusion with the Elvis in place. Bring the patient back, and look at this. Look, you can see all the way around the neck. They get excellent coverage. They bring the patient back for the three-month follow-up. Complete obliteration of the aneurysm. Sort of that white line picture with no suggestion of recanalization or flow. Maybe this middle ground is the direction we wanna go. Here's the lateral. So it's- Elvis is approved on the same basis that neuroformin enter primary. Yes, that's true. Elvis has been HDE approved. Sorry, that's relatively fresh news. But that's true as well. So you can still do it in the context of the HDE. The trial is still ongoing, though, for another 15 or so. So that said, float aversions have their own problems. You have vessel occlusion and stenosis. You have inability to deploy in tortuous vasculature. You have the possibility of maybe related, maybe unrelated distal hemorrhages. So what else do we have? Well, there's intrasacular float aversion. This is exciting technology that's coming down the pipe. Adam's the PI of one of the main technology's trials that are ongoing. There are two right now sort of established intrasacular float averters. There's another one that's in its early stages. The two main ones right now, one was a company called Enfocus, which was purchased by Covidian, and then Sequent Medical, who have their own technology. This is the now Covidian-owned device called the Luna. This is one that I was involved in in the past. It's a CE marked in Europe. There were 50 cases done in the post-market trial in Europe. Here's some pre and post pictures. A1 aneurysm, gone. Ophthalmic aneurysm, they deployed it with a balloon to stabilize it. Follow-up picture, completely gone. What am I looking at here? Acom aneurysm, wide-necked. No, sorry, we're at the middle cerebral here. And then here's the Acom. Wide-necked right here, completely gone, obliterated. So very promising. Sequent has over 1,000 or about 1,000 cases done in Europe. They've just started their US trial. They're eight of the first 140 done, but those eight have been done in like the last week. So they're on a pretty breakneck speed. And here's an example of a Sequent case. Wide-necked basilar tip aneurysm. Sequent device placed. It kinda looks like you've clipped it. It's just gone. Just the whole thing's out of there. Right, so now you get flow diversion across the neck. And you get all the benefits of flow diversion in the neck, but you don't have any of the metal in the artery. It makes sense. Are either of these two technologies gonna be the exact final iteration? Probably not. But are they great steps forward to start? Absolutely. What about other diseases? Well, something that's really grown in the last number of years has been stroke. So I'd like to bring this up. I think it's a neat historical paper. But this is a paper published by a neurosurgeon back in 1955. It was actually presented at the first meeting of the Harvey Cushing Society at the time, which became the AANS a number of years before by Keesley Welch. And in this, what they did is if a patient was having a stroke, they brought the patient, did a craniotomy, cut open the MCA, took out the clot, and then sewed the MCA closed. So it was an actual carotid endarterectomy or embolectomy for a middle cerebral artery occlusion. The follow-up paper came a couple years later in the early 60s, 61, by Donaghy, who's a well-known sort of early generation vascular surgeon. I like this one a lot. He said, if you're gonna do a craniotomy and go in and cut out the MCA and take the clot out and sew the MCA closed, using a microscope is a helpful tool. So this is sort of, that's how people 50 years from now are gonna look at my talk, right? They're gonna be like, that's ridiculous. But that's what this paper was about. It was the diagram of the complex new technology that was helpful for cutting open the MCA and taking the clot out. So it gives you perspective on how far we've come. This is how we treat stroke now. This is the modern endovascular suite. You guys know these numbers, leading cause of disability, extremely expensive. Projected numbers are gonna go through the roof as our populations age and we continue to get fatter and behave worse about taking care of ourselves. Here's just an example, 48-year-old guy. This was a gentleman who was spelunking. I learned about a spelunking, but this is like going under into caves. This guy was over 1,000 feet underground, hanging out. And something else I learned is you always go with four people. Like if you don't, I mean, the standard is you always have four people. Because to do it, a lot of times you need someone to help, like to lift you up over a precipice or a cliff or whatever when you're down there. And if someone gets hurt, you need four people so two people can get out and somebody stays with the person who's hurt. So there's over 1,000 feet down, all of a sudden the guy becomes unresponsive and is just like staring and they can't get him. So the two of the people leave, his girlfriend stays with him. They have to drag him out in a basket from underneath the ground. It took them like three hours to get him out of the cave. Then in 45 minutes he was in the, he got helicoptered in in ten minutes and a half hour he was up in the suite. He had IV tPA, here's his perfusion imaging. Complete carotid occlusion, used, you can see the top, there's clot right there. We went up with a micro catheter and did a run, there's clot right there. That's just competitive flow, but there's a cut off of the MCA right there. So I used aspiration with a big large board catheter to suck out all of the clot of the ICA, then went up to the MCA, which was still occluded. Did a thrombectomy procedure using the salumbra technique, a stent retriever with aspiration combined. Got this result. Here's the clot that we pulled out of his MCA with the two devices combined. And more importantly, he, at three months, was a modified Rankin F2, and this was him and his girlfriend, actually. You can see he has a significant facial, but otherwise he's ambulatory and living his life. How do you get those hands to look? Yeah, I don't know, I don't know. He's good, he's good. Is that your under? Yeah, exactly. So there's lots of new technologies and we get better every time. I mean, for those of you that are familiar with IMS or trials, right, one of the big complaints was the older technology. This is what happens, you don't want to become obsolete. With newer technology, we see dramatic differences. Both the Trivo device and the Solitaire device have been demonstrated in a randomized trial, Swift and Trivo 2, published in Lancet, a high quality journal to have significantly better outcomes. There's new aspiration technologies, the ACE catheter, which is 060 distally. Whoever thought we would bring an 060 catheter into the distal MCA, it's crazy. The stents have improved, the way the stents are designed to grab the clot and pull them out. Here's another left MCA occlusion. This is with the Solitaire deployed. You can see the clot sitting there pasted against the wall with the device in position, pull it open, total recanalization. We published a paper maybe a year and a half ago, looking at the peer reviewed adjudicated studies that were published, looking at recanalization rates with stroke. What we've definitely seen is the technology is improving, we're getting better. In the Mercy days and the IATPA days, we hovered in the 60% range, now we're shooting up into the 90% range. And there's new technologies coming around the corner. This is a device with a company, Lazarus, which I worked for, this was a case done in Europe, with two opposing baskets that'll enmesh the clot around it. So the idea is you don't fragment it or break it up at all, but you get around it and grab it. So there's one basket and the other one. Here they are getting pulled closer together to enmesh the clot, like that. They pull it out, there's the clot caught in the two baskets. There's the follow-up imaging with excellent reperfusion. So there's all kinds of new technologies coming around the corner. This is just a touch of what there is. They're exciting. Like all of these things I showed you, I personally think I can't wait to get my hands on that. When I found out Adam was doing the sequence study, I'm like, we have to have that, I got to use that. I can think of three aneurysms in the last six months that if I'd had that technology, I could have done a better job for my patient. That's exciting, but the truth is right now, we're only at the tip of the iceberg. We're talking about an antique microscope compared to what's gonna be available another 20, 30 years from now. So it's good to stay abreast of these things, stay involved, and play a role in the whole community as we move forward. Thank you very much. Thank you.

endovascular procedures

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healthcare professionals

aneurysm treatment

stroke treatment