0:01

So let's look at this case.

0:02

Patient on the left, brachial arteriogram

0:05

for intended SMA stenting in the

0:07

setting of chronic mesenteric ischemia.

0:09

Now they come back with left arm claudication.

0:12

We have a high index of suspicion here.

0:14

And the reason being is because there's

0:15

a pressure differential between the

0:17

two arms, 43 millimeters of mercury.

0:19

Given that this is the case,

0:20

what are we concerned about?

0:22

I would say we are concerned

0:23

about a dissection or an AVF.

0:26

Consider a subclavian steal.

0:28

Consider the fact that maybe, given that

0:30

this is 20 to 30 millimeters of mercury

0:32

differential, this patient has the findings of

0:35

subclavian steal, presyncope, arm claudication.

0:40

In this case, they have the arm

0:41

claudication, not quite the presyncope.

0:43

But these are things that we want to think about.

0:45

And so in diagnostic arterial

0:46

artery, this is what we see.

0:48

We try to get access and

0:49

we can't get into the arch.

0:50

Because why?

0:51

There's a little bit of a dissection

0:53

flap that's preventing us from actually

0:55

getting in from our access into the what?

0:59

Aortic arch.

1:00

So DSA is performed, and we can advance

1:02

our catheter, our wire, our sheath.

1:04

So, what should we do now?

1:05

So, I would say, maybe consider

1:07

manual compression or a follow-up CT,

1:09

because we can't get our job done.

1:11

We can't get into the abdominal aorta,

1:13

because we can't get into the thoracic aorta.

1:15

So, a week later, a CT is

1:16

performed, and it shows this.

1:17

It shows that the patient had a dissection

1:19

flap that actually had propagated from the

1:21

prior procedure from that brachial artery

1:24

access that they achieved at the prior

1:27

outside hospital visit, extending right

1:29

to the subclavian artery, which was, uh,

1:33

So when we think about sort of arterial

1:34

dissection, you know, you want to think about sort

1:36

of wires that coil under fluoroscopy, if there's

1:39

any resistance to passage, you know, this may

1:42

indicate that subintimal passage is actually

1:44

precluded because we're not in the right plane.

1:47

We're not in the lumen.

1:48

We're actually in the wall.

1:49

We're subintimal.

1:50

We may actually see sites of differential

1:52

contrast accumulation as we

1:53

saw in that sort of neuro IR case.

1:56

We may actually see that there's actually non

1:58

flow-limiting dissections that actually may be

2:00

observed and may actually resolve spontaneously.

2:03

In the case of flow-limiting dissections,

2:05

these may actually mandate an intervention.

2:07

So flow-limiting dissections may be treated well

2:10

with patch angioplasty and/or endarterectomy.

2:13

We could place a self-expanding stent

2:15

from a contralateral femoral approach.

2:17

These are things that we

2:18

want to sort of keep in mind.