0:00

So let's talk about arterial dissection complications.

0:01

3 00:00:03,620 --> 00:00:05,750 So here's a case, 67-year-old male.

0:06

He has a posterior fossa

0:07

and spinal extra-axial mass.

0:09

And so the whole goal for him is

0:11

to receive a cerebral angiogram.

0:13

And so, again, performing the job is part one.

0:19

Achieving safe, sort of, decannulation

0:23

from our access site is job two.

0:25

So let's, again, land the plane.

0:27

So the right common femoral artery was selected for access.

0:28

14 00:00:30,255 --> 00:00:31,325 They have a cello catheter, which

0:31

which is six French passed through over a

0:33

0.035-inch glide wire.

0:35

So when they noticed that there's some

0:38

issue, that the wire's just not going, okay?

0:41

And then they looked and aspirated from

0:43

the Sheathless and they didn't really get flow.

0:45

And so they were like, well,

0:46

what, what, what gives?

0:47

And so let's look at sort of the

0:49

angiographic injection at this particular

0:50

point and let's see what we see.

0:55

Huh. So what do you make of that?

0:57

What do you make of that?

0:59

So what I would say is there's a

1:01

little bit of a spiral dissection here.

1:03

Difference in sort of contrast, layering

1:06

around, abrupt cutoff, so a little

1:10

bit of a flow-limiting dissection.

1:12

Okay? So that is odd.

1:15

So what are we going to do?

1:16

Are we going to sort of proceed

1:18

with closure of the right side?

1:20

So maybe hold manual compression for 20 minutes,

1:22

and this is what was recommended, and the

1:25

patient was recommended for follow-up ultrasound.

1:27

Vascular surgery was consulted,

1:29

and presumably the patient did well.

1:32

So what we sort of need to understand is when

1:34

these dissections occur, they often occur

1:37

from a catheter or a wire moving the catheter

1:39

without ensuring that the wire is leading.

1:42

When we're sort of in the subintimal space,

1:44

because we've created a false lumen from our

1:47

initial access in the wall. And usually,

1:50

this sort of range of incidence is on the order of 0.1% to 0.4%

1:53

51 00:01:53,130 --> 00:01:53,770

1:54

The diagnosis here, you know, on grayscale,

1:57

it just shows us a nice echogenic dissection

1:59

flap, and that is represented as the

2:01

dissected intimal layer in the arterial wall.

2:04

If we have color Doppler, now we can see that

2:06

sort of, you know, nice parallel channel which

2:08

gives us a very good idea of what's happening.

2:10

So the types of dissections that I

2:11

want you to call to mind are

2:14

flow-limiting versus non-flow-limiting.

2:16

The flow-limiting are what we should really

2:18

sort of hang our hats on as some things

2:19

that need to sort of kind of be addressed.

2:21

We may decide that we want to angioplasty it,

2:23

tack down the dissection flap.

2:25

We may want to sort of create tacking down

2:28

with a stent to ensure that it stays tacked

2:30

down as opposed to just with angioplasty.

2:32

If there's sort of high risk for thrombosis,

2:34

which by definition it is because it's flow-

2:35

limiting, you may decide to do the above

2:38

sort of recommendations but also give a short

2:40

course of thrombolysis or not do the above

2:42

recommendations and also perform thrombolysis.

2:45

But we want to make sure that you're

2:46

actually in the true lumen and that

2:48

there is flow through the true lumen.

2:49

If there's no flow-limiting dissection,

2:52

you know, then you may proceed with

2:53

caution, surveillance, or compression,

2:57

and follow up with an ultrasound.