Ep. 629 Optimizing Prostate Treatment with Embolization Strategies with Dr. Art Rastinehad and Dr. Don Garbett

Enjoy the podcast, but one more? Download our new BackTool app. You'll get early access to episodes, case discussions, and courses all in one place. Just search BackTool in the App Store or Google Play on your phone. This week on the BackTool podcast. I mean, the coil-out technique showed that if you change the pressure on the prostate, it's like the kidney. You clamp the artery, you get soft, the same thing the prostate. You want a soft prostate because then you can push urine through it. I would say I like dropping the coil when I was doing beads and coils. That's why the leap for me is we put out the paper that summary finally got it out in June or July. Then Romeric put out the glue in October or September. I'm like, "I'm in." That transition to trying to take out the entire microvascular torture plus that. In the paper that we had, we put out where we did the receipt of the post-glue embellization. Then we got down to about 200 micron vessels seeing glue that deep. Today our topics can be prostate-order embellization. We're going to dig into it with two esteemed guests that we have here with us today. Both repeat customers, Don Garbett and Art Rustin had. Don, Art, welcome to the show. Don, certainly you just a quick introductions. I'm an interventional radiologist now in Austin, Texas. In Houston for a couple of years went to Oregon, was in private practice for about eight years there where I started doing prostates. Then recently relocated to Austin, Texas. Now with urology Austin and IR centers. Down in Austin. The name of the game is All Processed All Day or. There's a mix. We're probably 90% prostate because we're in a urology group but there's Verico, Seal, Women's Health staff. A little bit of tube management here and there. Then we're doing some other fun stuff maybe talk about about a year. Okay, cool. Just ballpark. How many prostates you're doing a day? Usually four. Usually four a day. I think the audience is going to be familiar with it because we gested the podcast. We're talking like it's three days old now but by the time this airs it maybe like six weeks or something. But yeah, go ahead and give us a brief rundown of the practice. My name is Art Raston and I work at Northwell Health. I'm an interventional radiologist, urologic oncologist. I actually didn't do an IR radiology residency typically. I did a urology residency, two IR fellowships and a urologic oncology fellowship. I practiced at L.I.J in the beginning with my mentor Dave Segal but I moved over to Sinai for a while for the looksteens group. I primarily work in urology only space for interventional but a couple days a month I do general IR to help out the guys. I do therapist deals PAE's really by bread and butter. I also do image guided oncology is like focal therapy for prostate cancer. I think that's a huge area for exploration will be a major part of practices. A side note is my fellow just called me today is like, oh, I did a transglutial cryooblation of a recurrence for post radiation therapy in the prostate. I was like, you went transglutial? I was like, it's much easier. I'm like, Joey, that's crazy. He's like, yeah, it's a perfect spot. PSA went down. So I love my fellows and I have that mix of a practice where it can help everyone learn oncology and do salvage therapies and stuff like that. So I really have a great time. Cool. And since we're talking PAE like ballpark, like how many PAEs you're doing in a day or a week? Okay. So how many can I do and how many of them I'll allow to do those are two different questions? So typically around four you could get done. The problem is is that I have to share the lab with my partner. So I'm limited only three per day and I can roll maybe a varicoseal end at the end of the day and as a less high in the room. So we can deal with a CR or something like that to keep the practice moving. Cool. Understand that. All right. So we'll just get right into it. We'll start out with workup. Art start out with you. Like, um, patient comes to you. Give us an idea of also like your referral patterns. Like are they almost fully baked by the time they get to you or like, where do they like, what's your typical, um, patient that shows up and like how do you kind of just go through the workup for let's. Oh, they call me. I just put them right on this table. No, I'm just kidding. They don't come fully worked up, but I recommend I tell everyone just follow the guidelines, make it easy. You know, do your assessment, physical exam, IPSS, post residual and maybe a flow depending on what their symptoms are to separate a bladder problem versus a prostate problem. The one thing I do do, which is in the guidelines as a subtle that imaging can be acquired PSA and MRI. And the reason for that is is that I want to make sure that outlet obstruction, one of the differentials is prostate cancer. So it's important to do that. And once you package that, you have an idea of how big a prostate is. Then we give them the options and certainly PA is one of them. And that's basically my workup to understand what's going on. I think the important thing is is that we try medical therapy first of it fails. And rule out obstructive sleep apnea. I can't tell you how many patients come in with nocturia that's greater than a third of their entire daily 24 hour volume. And someone gave them flow max and they failed to like, I'm still getting up five times a night. I'm like, how big are those urinations. And if they're telling you they're peeing all night like it's the daytime, they're normal intake. That's probably sleep apnea induced with BNP causing this dioresis at night. And I think that's an important distinction that's sometimes missed in the workup. But yeah, so basics are history, behavioral modifications, symptom scores. And that that doesn't change the medication. Then we move on to medical therapy or surgical therapy interventions once they fail the typical medical therapy. Okay. How long do you give them from medical therapy? Ballpark? Alpha blocker should be about four weeks so you get maximum results. So it's four weeks and then we reassess. And if you're doing it with OAB, those medications like Mabatric, Detrol, those things, six weeks typically to reassess that. Okay. All right, Don, over to you. Same question. Basically, same. I'm in a neurology group. So, you know, they mostly come up work to up already. A lot of them are asking for PAE and may or may not be. They may have another option that's potentially a better option. Hi, BladderNack and all these other confounders. Or they might have like MS or Parkinson's disease or Alzheimer's and they got neurologic issues on top. But often we're just looking to try and get them to obstruct it a bit. So often if it's reasonable, then we'll move ahead with PAE and see how they recover bladder function and that sort of thing. One of the things I wanted to ask as far as like, do you ever, and we'll start with Don for this question, is there ever a situation where you get referred to patient for PAE has high IPSS score severe symptoms, low quality of life. But then you get whatever kind of imaging and the size of the prostate, it's like 30 grams, 40 grams. I think our answer to this too, yeah, definitely. The guys who, you know, they started having symptoms in their 20s and 30s, high bladderNack situation again, where maybe a different type of procedure may help better. But even I think for the most part, maybe you could speak to it too. I think the high bladderNack is like, it's just a situation. It's not always solvable and you might have to just try and solve it medically a little bit. The high bladderNack is an interesting issue when they show up and it's really about the history I've been having this problem since I've been 30. Listen, you didn't have BPH in your 30s most likely. And I don't think a PA is going to help you in this space. And then you negotiate. In sizing the bladderNack will fix this. And you can see this on the sagittal film on the MRI. There's a big high bladderNack. You can see it come up and then it kind of goes out and exits when you look at the sagittal. We can resize the bladderNack. I have a lot of young guys that are in their 40s that are struggling. Sometimes we'll do a resume in those patients. See when we just open up the channel enough to push this and kick it down the road. So their symptoms approve. They're able to empty. And we don't cut the bladderNack. So they're maintaining that a jack literary function because that's what we all care about. All in the podcast. It's important. Some guys are more attached to it than others. But that's a big tradeoff. And when we talk to patients about deciding what therapy they should entertain is options. So then this kind of gets the question that I really want to ask is is there a prostate size to where PAs just not going to work for you? Like if you have a rely you have a liable bill merging. So like some kind of cross section like prostate MRI or like some kind of CT. And you know that you have a prostate less than 50 less than 45. I mean, is there any kind of cutoff or is it always a balance between symptoms and size. So I used to have the limit on my own mind from the all the papers of 50 and don't go less. And then you started delving into less than 50s. And then I started seeing instead of 90% effectiveness. I was seeing like 80% effectiveness. So most of the guys with a 40 or a 30 CC prostate. We're still getting better. And so I've stretched myself down in 30. I don't really have a lower limit anymore. Okay. Art. Yeah. They don't have a diagnosis of BPH. So it makes it a little hard for me to say, hey, what's the indication for your procedure? And that's the trickiest part of. I have done people with an overactive bladder component and a boo and a younger patient in a small prostate. I have done it. When I talk to people and discuss it, it's not my first go to. I really try to move them to the surgical space because. God forbid something happens. And they're like, so you do an embellization for BPH. What's the diagnosis? And you're like, well, the prostate was 30 grand. So that's bladder all obstruction. That doesn't have the indication for embellization. So that's the tricky part when you manage that, I think, as a clinician. And that's the takeaway I give the people. And then when I tell people in their learning, absolutely no. So if you have, if you have done experience, great bang it out. No problem. You can get a catheter anywhere. You've seen all the anatomy. You're like rain man. You look at the screen. You know where the artery is done. I can't explain it. My my residents, I play the game like, did you see the artery? They're like, can we rewind? I go, no. Did you see the run? And can you see the artery? You should be thinking where it is. The see where to pick. it up and they're like, we don't understand. I'm like, I don't remember when it was like the struggle doing this because it's been since 2000. I love the rich man analogy. You're like, "Oh, there it is, it's a struggle." You forget, right? It's like, "I was done." In the beginning, we thought this was a hard case. He's telling me he's doing 30 grand process. That means your skill is an expert level because you can get anywhere. You can go through the prostate, get to the penis, realize you're going too far, try to run and come back and then emboleize it. Now, I do remember when prostate artery came out, I mean, it was like the triple lindy off the high board and now people are making whole practices out of doing these. That's actually a good question. A given straight forward PIE art, how long do you think it takes you from stick to close? I don't know if we should be advertising that. There's a partner. I have a friend named Aaron Fishman in high. We have a WhatsApp channel and we do kind of keep track of how quick we can do things. You know, sub five minute floro is our goal. But if you're at seven or around there, you're doing a great job. Even 15, I would be thrilled at 15 for the top end. That's what we kind of, but we can be in and out of the room in less than an hour. The only thing that really slows me down is when I ask for something and it's not in the room. So I was like, "Oh, man. You need that still? We're out of wires." I was like, "Okay. I'm playing two games in my head during the case. One game is I'm doing the case in my second game is I'm pretending to be my tech in my head. What do I need in that? I'm always like, "I'm doing this." I'm like, "Let's open this other thing." Then I know I got one more minute of doing this until it's on the table. It's the two game. But yeah, less than an hour for anyone, I think Don would agree, is really the sweet spot for the procedure time room time. I agree. I think we book them on the hour. A really hard case now is an hour and very straightforward case is much less than an hour. How about this Don? How do you feel when you go an hour and a half and you're like, "Man, this is taken forever." And people are looking at you being like, "Oh yeah, an hour and a half." The other people take two, three hours sometimes. My back hurts at 55 minutes. I'm like, "Mm." "Tuck, I need the mash." You're asking for the air to get the towel. Listen, my back kills me. Everything is at the same height. I have a bumped up table so I rest my hands like I'm playing pool and it's just like back and forth. So there's no strain on my back. There's three P.A.E.s doing growing, would kill my back. Okay. That's a good tip. I'm a little older than probably Don. I don't know. I don't know. What's the age zone everybody here? I'm 44. I'm 54. I'm 50. Oh man. You're so much. I'm so baby. I'm so baby. I'm so much older. All right. My back. All right. So, back to side. Let's get into the technique though. All right. So one of the things I've been out on radio versus femoral. So, art, radio lists in the vein of the Sinai crew. So let's talk about radio, what you like about radio. In the artery of the Sinai crew, not the vein because that would be a whole different procedure. We don't want to confuse our listeners. That's good. I was not training radio as a resident or fellow. I picked that up as an attending at Sinai through peer pressure and brute force from them. Forseem me. I haven't looked back. I think the older patients, the only challenge one patient is the history of stroke. People have significant choral disease and over 80. Depending on their history, I sometimes get a non-contrast chest CT to make sure that they don't have calcifications in the arch just to mitigate that risk that everyone complains about high risk and non-clinically evident stroke. We all saw that paper and JVIR think a few months ago that came out about a certain embo. They did a pre-imposed MRI of the brain. There was some clinically insignificant strokes, but they were present on the film. That's something I try to take away. At least to talk about the radio access, I prefer that hands down all the data supports, shorter times, less fluoro. I believe it's a menable older patient, the angulation of the order. We all shrink you in our discit shorter, but our order is the same length, so it gets according up. I hate that extra step that you have to go through when you're going growing to get access. Done. I went reverse. I did my first 100 all radial and I did everything radial. I did Y90s. I did the UFIs. I did everything radial. I did trauma embo radial. I joined IR centers and I was like, I'm a radialist. I do this radial and then I went work with Sunny for about a month and I watched his method and I was like, okay, I'm a femoral now. So I switched. I'm all femoral. I went back and did one case radial because it was so much navigation challenge. At the end of it, I was like, should have done it femoral, but I have nothing against radial. I did a lot of them that way. It's kind of a small point of the procedure. At least I find that all roads lead to embollization, whatever you're comfortable with, go with it. I'm curious. What is the technique as far as getting in the Ipsilateral artery? Is it a. Wait, wait, wait. Before we go there, I want done to go home tonight and try to pee on his back because that is the difference. There's data. There's a paper that gravity helps and how the patient after the procedure. I was growing forever. I was growing from 2006 to 2016, doing PAE. So that was all growing. But I want you to go home and try to pee on your back because get a urinal, go try it out. It's hard. So when you want to stand up, the guys come out because we don't use a foley, right? You don't use a catheter or a no. It's a good point. But try to pee on your back. Chris, if you feel so inclined, it's a lot of fun. I don't have to try it tonight. I'll just tell you my experience. No, I can't. I can't be in 30 minutes. Oh, yeah. So with your closure device, you have them standing with a closure device. What do you use to close? I'm mostly a kelp, but I got per close or Andrew's little bit. But the crazy thing about kelp, have you read the IFU? Yeah. Yeah. It says not for early ambulation. We use kel all the time, but it's not for early ambulation. It's one of the drawbacks. If you follow the IFU, it doesn't cover early ambulation. So I'm an angioseal guy in that space. So they can-- Well, if we still is early ambulation, correct. I didn't know that till, of course, someone pointed out was like, I haven't even heard of-- I mean, we're 15 minutes on the IFU, I think. Oh, for Andrew's seal? Yeah. For Andrew's seal. Yeah. That's right. Well, also, when your case is 15 minutes, then it is 30 minutes for the standup time. It's like 40 minutes. They can hold your pee that long. Oh, okay. Accept it. They're retaining already. And then you're like, why is a bladder so poor? We just started. Yeah. What's the maneuver? Like, what's the technique to get an epsilonateral sod done? I basically-- I use a C2 from femoral, go up and over, usually first, and then just walk minute up and pull down. Okay. All right. And that maneuver is either going to be less than a minute or it's going to take you five minutes and then you pull a sauce. Oh, okay. Oh, and then you just hook it into the sauce. Okay. Yeah. All right. All right. So, selecting the prosthetic artery in your estimation is how important is your selection for microcatheter, wire, and kind of tells what you use? In that space, I look at what the anatomy looks like. If I went growing, I used a BRT. I think it's from Cook. So it's like the old, the new Ruck. And if I go up and over, usually use an sauce just because it takes a few seconds and I use the LT glide. It's just long enough with a short sheath to float it all the over because if you use a stiff glide or a regular tip glide, it's a little hard to navigate over the arch. So I kind of do that. That's my go to, I love the BRT when I'm in the growing. It just because it allows me to really have a lot of torque ability and really select all the arteries quicker, different branches, it's a bare anatomy. But picking the microcatheter, I use a lot of the liquid, right? So I'm like 99.99% liquid and ball like I look if it's a really small area. I use the lambda from Taroomo or the microvention. It's really going to be a, looks like a difficult okay to one seven. I think it's a headway. That catheter is by far I've been using for more than a decade. You can go anywhere with it. With or without a wire. It's beautiful. Like they get mad at me. It's really like, listen, that's not from us. That's like the microvention group. And I'm like, listen guys, show me a one to the one nine now. But that's kind of the range. I like to use the balloon catheter if I can because I think I can get a better penetration. But there's a cost associated, especially in an OBL maybe different than me in the hospital. But I love the balloon catheter really get the best penetration possible for Don likes that. Okay. Don, what are you? I was going to ask, I ask, I ask, I like using the 2.4 because or even a 2.0 microcatheter because I can put an 0 and 8 coil through it. If you're using liquid, you probably don't need to think about a coil. Is that, but you can get a 0, 1, 8, I get all my micro coils through. And all my coils go through the 1, 7 microvention. So you can get all of that. What's the name of their product? I can't. I'm drawing a blank on my coils. Yeah. Now they're not microvention. They're by Tarroumo, the hydro off the CX, the Azure, Azure, Azure. Yeah, Azure CX, the hydrogeo, it's a, and they have better inclusive rates than most people on the market. So that's cool. So those still fit through the 1, 7. Yeah. Interesting. Okay. I didn't know that. You choose 2, 4, boom. There you go. That's what I'm so amazed by that catheter. It's too small and you still can put a 0, 1, 8 coil through. How often do you drop into coil ballpark? Only for a flow to redirect in rare cases. Rare. Yeah. I use a lot of pharmacologic manipulation. So the verapimil, the nitro for flow redirect. And I think that works phenomenally well and gives you great. The glue really gets too. I'm gonna try not to use the P word because Don accused me of saving too many times so I was hot cat. We're gonna have to count at the end. He wants to try a drinking game. So for all the residents out there, every time we use the P word, take a shot. That's right. So same question though, microcafeter. I'm generally using the 2.4 by Turuma. Just a straight one. But I was taking inventory of how many times I've used the 2.0 where I basically if I got the wire all the way down and the 2.4 doesn't go, then I pull a 2.0 and it almost always goes. You can force it, but I like the 1.9 lambda that has the lambda has the incredible body. Has a body of the 2.0 pro grade, but it has the penetration ability of the 1.7 micro mention. So you really get the best of both worlds. Yeah, go ahead. So we're talking microcafeter. Oh, okay. Yeah. What about the micro wire? Like, what's the, what's the, what's the go to wire that you're using? What do you like to use and then what's like the troubleshooting wire? Generally, I saw he meister. And then if it's such, like, I can't get the wire to spin. Like I can't get it to face one direction or the other direction because of other turns that's already taken. Then I'll pull the Turuma double angle, which generally will still turn. It may not face direction you want, but it's going to turn. The glad wire GT, the double angle glad wire GT. Yeah, the GT. Yeah. Yeah. Yeah. Right. Okay. One of those two wires. Oh, that's right. Because it's a little thicker. The GT. Yeah. I keep saying, give me an O and four. Come on. I like the fathom by a Boston side. It's cheap. It's easy. I use that as my go to because I just try to save some costs somewhere. And then I use the run through. I love the run through. Oh, you like the run through? That's a great tip on it. Yeah. I feel like I can just get that, like, it's, it's just so responsive. It's terms of, I feel like I get like one to one response, like with the run through. And then I might be too rough every time I use that run through, I push it. And then I'm like, this, what's wrong with the wire? And I pull it out and it's like, yeah, you got to put it in gently, like, or you can't get in the hole. And so you got to look, like, I got bifurcles now. I'm so old. So I have to like look down because like what Don's talking about, it's so soft at the tip. Yeah. You can fold it on the way in. So I have to like look and they laugh at me now. I mean, I hate aging in front of my colleagues. Yeah. I'm like leaning in. Like on the monitor. Yeah. The monitor is big. It's just looking at the Dan wire in the hub. Sure. But that and then the EB3 has, it's like the, it's a glide tip. It has a really good body on it. And I think it's the torque ability is really nice if you want to have that similar to the phalemag glide tip. So those are my three big ones, but they're saw-hees in the mix is the O10 because I can go down to an O10 to get it passed to really tight stenosis. Wow. Okay. You kind of mentioned it art as far as like medication administration once you're in the prostate artery standard operating procedure, not particularly tight, kind of a straightforward case. Do you give intracurial nitro or anything else? Always verapimil ripe before we spin. I'm, I set up my room because if it's radial, everything's set up already. So it takes about two seconds to do a spin. I hit the timer. I inject because I want to keep everyone on point for the 10 minutes because that's really what the paper said. It works for about 10 minutes. And right before if I'm happy where it went, like no penis, no rectums are motto in the lab. So no penis, no rectum, no problem. And you know, you got over the door. Dave, that's what you want to see what they gave me for Christmas. Yes. All right. For the viewing audio or for the listening audience. My nurse is bringing surgery in. I think she's hilarious. This is my Christmas gift came in this. No penis. No rectum. No penis. No rectum. And then my software engineer comes in. He's like, what kind of person has no penis on a bag? And I was like, it's no penis, no rectum. That's our motto in the lab. And he's like, I don't get it. I was like, it's just a safety check we do before the procedure. And he, no penis, no rectum, no problem is key. And then you know, I tell the residents, like, yes, I make that joke. But please look to see if you have any odd collaterals that are something's lighten up in the posterior division. Like maybe you're just, you know, just be careful. Like I know we're joking around today. Let's not have any penile ulcers, rectal ulcers. And the rectum we know we embolyze for hemorrhoids. So just don't do a deep penetrating embolization in that space. I do say it a lot. Don't I, Don? You're maybe parodied out of you. Some people say like I say penetration. Well, you know, we'll get a penetration count by the end. We'll have, we'll run it. All right. Some questions you Don. Medications interrupt. Yeah. Generally, I'll use nitro. I've used a wrap mill here and there. So one situation where I like wrap a mill more is if we're in a, in a vascular tree where there's a bunch of stenosis already and we've crossed some stenoses, if you're in that situation and you give nitro instead of perfusing the gland more, you're going to open up all the channels going elsewhere. And you see that once in a while. It's not common, but it, you know, you're like, I'm there. I'm just going to give a little nitro and then you reshoot and you see no prostate. It's going down back to the obturator. And so that, if I'm through a bunch of snowsies, I'll use wrap mill instead and that seems to cause that less or I might just not give anything because I know it has the potential to open up the collaterals rather than the prostate itself. Okay. It's not common, but it does, you run into it sometimes. Okay. But you made an important point. Like we didn't say it, but we give these vascular adjuncts and then we do a DSA afterwards to make sure that you don't open up the collaterals because I've been burned too. You're like, whoa. And you don't go straight down, but you need to make. That first step. And I think that's an important thing for the listeners and the residents out there, the fellows, be careful. Like we are changing the vascular flow and the prostate is notorious for other collaterals that basically the glands built the grow. Vegef is the devil. You know, like Vegef is causing re-vascularization, causing BPH and the DHT that you give that I hydrochistosterone that people have that's built made in the prostate is causing growth. So it's basically just fighting everything to just get bigger and bigger no matter what you do. So what in the scenario where you do either have shunts or maybe pin out collaterals that in the situation where you can't get past it. So you can't get distal to that collateral because that's kind of the, that's always the easy way. What do you do? And is it, is the answer always to drop a coil or yeah, so I'll just start with a, start with you are. A couple different things. It depends where it's coming from. You got to be very careful that your re-throughbramps that goes down to the bulb of the penis. You won't get a peanut ulcer, but you can really cause a lot of ischemia in the bulb of the penis. So that's something you can, you can, it's hard to get to that. So just don't push too hard. Other one, drop a coil and then thirdly flow redirect, keep an eye on it with the liquid and ball. You can see where it's going. You can do your testos and conject and then you're like, I can see how I can get the flow and keep an eye on it. So you can really get that preferentially go into the prostate. So there's, I think those are the three options I typically use and I think when people use a balloon catheter, they can be more prone to blasting it too deep and be careful. Sure. Okay. Done. Similar lines is hard. I would say anytime I see a, you know, basically you're near the prostate and you're shooting a picture there and you're either proximal to the capsular branch or you're distal to it either or when you shoot that if you see a branch going through the gland and it's, not tapering, it's not getting smaller, you may not, on your first injection, you may not fill past the gland but you know that branch goes down. And so now you're putting in your, in my case, I'm putting in my beads or you're putting in your glue and now you're putting your stuff in and now it's going through. So now what I do, if I see that branch, I go ahead and I, if I can, I move my micro catheter down into that branch and give it a good picture and then you're going to see one of two things, you're going to see that it enastomoses with the distal pedendol with a little squirly branch, that little springy squirly branch. And when it's enastomosing through the gland to that branch by a small branch, I feel comfortable taking that down with a coil. If it's going down and it's almost like co-dominant with the pedendol to the corpra, now we really should flow dynamic control this versus coiling it because if they're sort of mutually dependent to achieve erection, I think you probably have a similar motto, we treat your penis like it's ours. I never use that. That's like I'm going to steal it from going. Not a good one. That's a pretty good one. So you could, if you take that down, you could potentially affect their erections. Maybe not, but you could. So if it's got that more co-dominant flow than I'm going to try not to coil it. Okay. You said like you're going to try something like float, redirect. What does that mean? How do you still get the info done if you can't coil, you can't get distal? So you give enough of your nitro, your verapimil. For nitro, it's generally 100 or you maybe go up to 200 depending on their systolic pressure. And then do some test injections and I'll do a DSA with while I've got contrasted beads, even. So I've checked it with a DSA and now I'm putting in the beads. Maybe it's looking great, but you can still now do a DSA again with the beads and see like am I getting fooled? Is it passing right through the gland and I can't see it? So you can sort of reassess while you're doing it. Okay. Understood. I think the DSA topic is that trick is a really important thing that people should definitely do if you're doing beads because once you snack, you can get that reflux and you won't pick it up. But the other thing is that he still can navigate into the transition zone all the way in there like perfected because we know that changes outcomes and embolize from there and that capsule branch is one branch back. So here. as a preferentially avoid as much non-target as possible. - So as far as the perfected method goes, I feel like that was like the method when press it or the first came one of the scene. And is there a reason, like in your guys practice, like aside from when you're trying to do a flutery direct, like why don't I never talk to anyone who does it? Start where you are. - Oh me. - Yeah. - Oh no. I was waiting for Don to try to pick that one. - I feel like there was like a like a pause, like who's gonna end to this one? We both want it, we both want it. Listen, I mean their data showed a data better IPSS response, like let's not negotiate. It does take a little longer, it adds time. But bottea and all his data is like, you guys are nuts, you don't have to do that. I get great results, look at my data. So I think it had in that scenario, they showed a benefit in the contrasting of their approach. But Shavonk has done a great job showing, hey I just blasted in, go to good to go, have a great day, thank you. So I think that's a little bit of the contrast of the technique with the beads. I think my challenge is with beads in general, as we've learned now, it only stays in the microvasture for three days. So I think there's a little higher probability of re-vascularization. 'Cause basically the road is still open, he only closed the end of the street. And I'm trying to clog the entire neighborhood. I'm shutting the whole place down. And that's I think the contrast. But let's hear what Don has to say about how many times he's used the perfected technique. It looks like there's a big no, but. - Yeah, I think early on when that Francisco put that paper out, I was like, oh wow, this is really cool. - Sure. - And I think I was using bigger beads back then. And so we would get kind of early occlusion potentially. And then you'd pop back through and then you'd get more in maybe. But I think, you know, I've stepped down my bead size. I'm at like 200 or 100, depending on what we're doing. And so I don't really, I don't think I really see much early occlusion. And we're generally micro catheter is like, you know, we've sub selected the central gland branch for the most part. And so generally we're already there. We're not getting early occlusion. So you're in the prostate, the central gland branch and you're embellizing and you're stacking back. And you know, you're filling it up like you're cup at the fridge and you're just watching it stack. And so I'll basically treat the whole gland as much as I can get in. And then I stack gel foam behind it, like almost all the way back to the top of the parent vessel. So that ideally theoretically we're getting a longer, almost like a coil out effect, but probably opens up a, you know, a week later or something. - Okay, Art, now's a good time, Zilly. We already mentioned that you're using liquid 99.9% of the time. - Yeah, it's terrible. Are he's killing it with histocryl? That's a, he's controlling the cross. He has papers on histocryl. It's what, 12 cents. I mean, the coil out technique showed that if you change the pressure on the prostate, it's like the kidney. You clamp the artery, you get soft. The same thing to prostate. You want to soft prostate because then you can push urine through it. I would say, I like dropping the coil when I was doing beads and coils. And that's why the leap for me is, we put out the paper that summary finally got it out in June or July. And then Romeric put out the glue and like October or the September, I'm like, I'm in, you know, so that transition to trying to take out the entire microvascular, plus that. And we, in the paper that we had, we put out where we did the, a, a receipt of the post glue embolization. I think we got down to about a 200 micron vessel seeing glue that deep. And glue doesn't get as deep as some of the other embolic. So I think it was 200 out of the check the paper, but it was down to that level. It wasn't down any smaller, but that was a vessel where she detected the glue on the processing. But my goal is to get down. And now I can tell you, with using the Bloom catheter, you can tell right now if you get that little blush where you're getting really good penetration in the microvascular, you can see that. You're like, that patient's gonna hate me, but they're gonna have an amazing response. And sometimes, you know, we're not perfect as an interventional. Sometimes I don't get as deep on the other side. So I have poor penetration on the left, a deep penetration on the right. And that patient is like, that was horrible. What I had a case, incredible penetration, like so bad I blew an artery off when I did the post because it was completely blocked and I'm exploded in an artery. - I talked about that, yeah. - I pushed so hard. But you did a follow-up imaging because I was like, I had two months, I was like, let me just see. And I was like, oh my goodness, the one side looked like it was completely gone. I couldn't believe it. And I was like, I was a little aggressive on the embellization that time. But I think your technique matters. And I think looking at all our friends that are in the space that are doing it, it's really how well you can stack the particles or how deep you can get with your liquid embolic. I'm not endorsing one over the other. I have my preferences, but I think there's a lot to be said to how well we do the embellization because we're seeing as this rolls out, Don's in a giant practice, all PAEs, they need to have good outcomes, they need to control cost and there's this balance that we see in the space. But there's a lot of newbies getting in this and they're having a lot of failures making us look bad in the space. I can't tell you how many times that your role just comes up into me. Oh, this guy did a terrible PAE. There's no benefit, we haven't seen it. But if you look at Don's numbers, like you have to have your outcomes, you have to be on top of your outcomes. Everyone should be getting their IPSS one month, six month, 12 month is just to see the trend. We see the huge drop and then we see a little bit of a plateau and stabilization of the symptoms. We should be tracking that in the IR space because we need to have some metrics to say, we're actually not just doing a procedure, we're taking care of the patient. Understood. I don't even know what the actual was, I was talking so much. I don't really remember what it was either. But I knew I wouldn't ask Nex. It's a lot of penetration, that's all I know. Don's making it worse. I said it without thinking, but Don's just laying it on there. Yeah. Anyone who really is following along with the game, there's a lot of trouble right now. There's a lot of trouble. My question is this for art. Technique matters as far as liquids. What's the technique? What's the delusion? Like if you want to get a little bit, put a finer point on it. All right, so we still don't know. We're Fishman and I. He's at like one to 10 and I'm at one to five right now. I did wrote my paper at one to eight because the key is how well you mix the glue. You can't be lazy. You put the stuff in the bucket, set it up and your little shot glass, which I always love because there's a shot glass on my table. But mix it up. You have to really mix it well because I don't think it really stays in solution as well. I haven't looked into that. But if you don't do that, you're just putting LePyatol in, right? Like you're not getting that glue penetration. And at one to 10, if you do the math, that's one in 11, one 11th glue. You're looking at like an 8% glue. I think that's really low. And Claire Bent, we talked about it. She's cool as hell. She's in the space as well. And she's like, this high dilution, are you really putting glue in or just doing the LePyatol based emolization? So I think there's a, we still have to figure out. So that's one is dilution. Two is technique. Do I get really deep or let it flow from above? I think it really depends on the anatomy because sometimes I've gotten away with it. Just let it flow and it looks beautiful. And other times, you'll get a little bit of uneven glue and then you don't get that distal penetration that you want. You can overcome that when you have a balloon catheter, but when I was starting, I was doing all this with just a micro catheter. And the one thing I would say is a warning to everyone. Be careful where your diagnostic catheter is because if you create that gap or a suction and you plug from above and you zip your catheter, that's all negative pressure. So you could suck the glue right back with you. So that is something that I really, and how do I know this? I've made the mistake, and I really, that's one thing with the liquids because you want that forward flow. It's protection, right? And if you get your diagnostic, which is my rock or my pronumbra, and it's stuck in there really well, or the spasms down around it, and you don't appreciate that, you could set yourself up for the high risk for non-target. Anything else that you want to mention as far as embolization technique done? Like you said, you kind of like talk. I got the impression like when you mentioned it, like you move towards smaller beads. Like you maybe started out at three to fives, and now you're like 100s if you feel like you're safe, and then is there like a escalation? Like you use 100s and you go to 200s, or it's just 100s until you fill and you keep sacking and pulling back. I pretty much, well, I don't think there's any science behind the way I'm doing it now, but it used to be like three to fives that I moved down to 200s. And then if our gland is, if we have a gland that's like less than 50, then we're just gonna open smaller beads. You know, down to 100. And if the gland is bigger than that, then it'll generally stick with 200. But there's no science behind it. It's just, what do I think? How do I think I can get more beads? Because that's how I'm getting my embolization. How do I think I can get more beads and be less prone to early occlusion? - But what dilution are you using, Don, when you decal the-- - Oh, good question. Yeah. No, that is a good question. So I used to take, you know, you get your syringe of beads, and if you remove all the liquid, it's two CCs of beads, right? And so generally you just take that to 20, and that's my dilution, and we just maintain that. So it's essentially 0.5 CCs of beads with three CCs of contrast, just straight contrast mixed. So that's, you know, that's my mix. You might, if there's some reason to dilute it more, like it just, like I put a tiny bit in, and it's just all staying there, then maybe we'll dilute it more. - Okay. - The other thing is, is that the size of your catheter, so he's using two forests to get through it at five. But if you're using a 20 or a 1-9, you can only go up to 200s. I use the hydroperols typically, or the 100s. So that is, I was a huge fan when they started coming out, when these calibrated beads coming out, 100, I was like, this is amazing. But there's papers like, hey, patients have more symptoms. I'm like, the more miserable they are, are probably the better embolization I'm getting, but there's some data on both sides of that. So we really, I think the jury's still out. I wouldn't say there's any definitive saying that 100's better, but everyone is going to a smaller particle, at least from what I've seen. - That's the trend, certainly. And has that been all experience also in that patients who are having a lot of symptoms like within the first 10 days post-procedure? If those patients are having a lot of symptoms like post-imolization syndrome or just a lot of pain and discomfort, those are the patients who are going to be good responders. And the patients who feel like they haven't had anything more likely or not so much. - I think not always, it doesn't always correlate. You can have a guy who's just like, "It was wonderful. I didn't even notice anything. I'm just peeing great." Any concobalt boys, you have a guy with really bad post-op symptoms. - Okay. - And you know, four months later, he's like, I got a little bit improvement. - So that's a distinction of what was their baseline symptoms or what's their baseline problem? - How much bladder problem did we have versus how much prostate? And there's certainly confounders. - I have a guy, IPSS32. It goes down to 10. His quality of life is a five. He's, I'm still getting up once a night. I go, I'm not a miracle worker. He's like, you're telling me, you don't go all the time now. You can hold it. You're not looking for a bathroom. All these things are different. And you're still giving yourself a five as you're really on hand. - Yeah, the goal post is a moving target. - Yeah. - That's a real thing. That's a truism like a cross medicine I feel like. As soon as you stop feeling terrible, it's hard to remember. And that's why I think actually keeping score, like at Evan on IPSS score, that you can have him fill out before and after, like with something more quantifiable is so important. - I mean, in GIE, in GIE, it's similar. You know, you got a guy who comes in with a, you're working with a cane. - Sure. - He's walking with a cane. You treat him GIE, comes in six weeks later. He is walking without the cane. How you doing? - I don't know if I got any improvement. - Absolutely. - I'm not sure. - Let me go to the limb. So let's talk about outcomes. Like what should the metric be? Like whenever it done to you guys keep track, either within all of our centers or within each institution, like what exactly are the goal posts for you guys? - Well, I think the really qualitative, you know, you've quantitative IPSS measuring, and that's measured at the routine points in time. But qualitatively, if I talk to him at three months, and they are not getting up at night anymore, I mean, that's a win. Boom, for me already. I mean, that's an easy data point. You know, I was getting up five, now I'm getting up once. You're good. I'm daytime, I think they're, hard probably knows better than I do as a urologist. But daytime, you know, they can, they're drinking coffee, they're doing all kinds of stuff. They're drinking sodas. And so they may still have frequency. They may have overactive bladder stuff on top. And so that, also that can confound like your results. But I think the night, I love the goal post of the nighttime symptoms in general. - All right, same question to you. How do you try the outcomes? - I do your flow PVR at one, three, six, and 12 months, consistently, I don't bill for it. Like I said, the other podcast, 'cause it's a data point for me. I like to capture that, and I like to have everything standardized. I have patients like, yeah, it's not that much better. I go, look at, this was your flow. It's four times higher. Look at the peak on this. And he's like, yeah, you know, probably that's better too. So sometimes it's like, we spend time, I explain them where they were, and where they are today. And I think that's important. And then patients, if you give them the expectations of where they are, that they do better that way. You're gonna be miserable for two weeks. You're gonna, at one month, it's gonna be like night and day, we stop your meds at a month. So getting off meds, no retreatment at least five years is really my goal, like to see where that is. We do have patients that, hey, you have a giant median low. We might have to have that removed. But overall, PAE is first for me and a lot of these categories, even in the non favorable candidates we discussed earlier, because we didn't even talk about it. What do you tell your patients, Tom? I wanna hear Don answer, I'll tell them. What do you tell your patients the benefit of this procedure is and then the risk in like three sentences, hey, this is what you're gonna go through. And I'll tell you what I tell patients after they say they're having the procedure. You heard my podcast, so you know, but I just in case people don't listen to bulls, so I really think you made a big drinking game out of this. So these two podcasts are probably gonna go way up. (laughing) They're gonna go back to the other way. Yeah. So what do you tell them, like how do you gauge that, but when you're going over the risk and what the benefits are, and then after they say yes, the procedure, then I give them better benefits. So that's what, you know. - Undersell. - Yeah, no, that's true. I think in the initial discussion, look, we're gonna very qualitatively, we're gonna improve your life quality. You're gonna be going less, you're gonna be going easier. You're gonna be able to go to a urinal and not spend 10 minutes there. 'Cause that's like the performance anxiety issue hitting home there. The risks, you know, I say there's basically four risks to this procedure. They're all less than 1%. I see like 0.1% ulceration of the skin somewhere or less about one in 500 patients might need a catheter because they're gonna go into retention because they had a huge post-foid residual beforehand. And then, you know, maybe one in every 50 to 100 are gonna have two weeks of dysphoria rather than one week. I kinda give them that. But there's really, you're not gonna have retrograde ejaculation. You really, the risks of this procedure, there's really not much that goes beyond two weeks, essentially. The challenge is that if you look at the risks and imagine I start with this, here's your choices. You're gonna have a whole lap. Up to some papers saying 19% ED, right? Retrograde ejaculation, even higher. The ropes that you showed PAE's had some retrograde ejaculation, but there's still unmeds. There's a lot of confounding variables there. But in general, I think you're, as you said, retrograde ejaculation is extremely rare. But the confidence, yeah, there's zero in confidence, right? I accept if they have urgent confidence 'cause all of a sudden they can't control 'cause they can pee so much easier, the bladder's still squeezing too hard. So I finish with the hall of counseling like you do. And I'm like, by the way, 50% of our patients have better erections. And the guys look at me, they're like, Doc, why don't you lead with that? Because I'm listening to all these details. And if you tell me that first, everything after that, and it's low risk, I'm in. So like, I hate that. So I don't wanna sell that because that's the huge difference in the procedure. So I'm a urologist. I do these other surgical procedures, right? I wouldn't infer personally. If I had urinary symptoms and I had an enlarged prostate, PAE's first on my list. And better erections, we showed in our paper with the glue, 50% of time. If that already comes off through pedendal, and I think there is a correlation, we haven't studied it, but the bigger the prostate is, the more flow redirect you get to the penis, you have a firmer erection. These guys come in, they're like, your shim score is still about the same. He's like, "But Doc, you know, "you can't be higher than a five already on firmness, "but I can tell you I'm way much firmer "than I was before the procedure." And I think that's something that, we don't market it that way, but it's something that's important for the patient to know after they signed up, oh by the way. So then you can get some data points to see if it's actually happening. - That's cool. - I don't market that. I just say it should not affect your erections, but I do hear that and post out some facts. - It's not the facts. - It's gonna make it better, most likely. But I don't wanna sell them on there. They can come tell me later. - Right, right. - And then they can tell their friends at the retirement club, they can tell their friends, "Hey, go see this guy. "He fixed my erection." - Have them lined up. - They're like, "My erection's a little poor. "Can I just get a PAE? "I know that's gonna help. "I go, whoa, whoa." You know, you pee fine. And so people are asking for it so they can get a better erection. I did hear someone who was trying to treat BPH by doing varicoseal umbellizations. How about that, Don? Have you seen that paper? Oh yeah. - Well that's not here. - It's out of someone from Texas and the Middle East. There's a, and they're doing varicoseal umbellization for BPH symptoms. - I don't understand. - They claim that it changes the hormone profile to make it better and the less testosterone going to the prostate. It's suspect. I had a patient ask for that 'cause like I don't want a prostate ereimelization but can you embalize by gonadal veins or my varicoseal? What do you didn't really have a varicoseal? It was like a grade two and he's like a little sore. He's like, "This could help my BPH." And they brought me the paper. - Oh goodness. - And then there was a recent follow up paper. So I don't think I'm ready to go that far in the spaceship but people have tried to market that as well. - I want to shoot it down but I have no nothing about that. - What's so ever? - Yeah. - We'll link to the-- - To be continued. - To be continued. We'll link to the article. Last thing that we're gonna cover, I know we're coming up with the hour. - Potential reducer procedures. You guys are both have-alium operators. Son, let's start with you. Any patients that you are seeing for the second round for consultation of second prostate artery info? - Yeah, I think probably fall into two categories. Number one, the anatomy was so challenging that we only got one side done. It happens very rarely. And in those cases, I'll bring them back in two, three months depending on if they didn't already improve 'cause often in some of those cases they'll dramatically improve by two months anyway just from one side to him about. But in the other cases, say it's a 200, 300 CC prostate, we're gonna have to get the other side. I'll just book them to come back in a month or two to get the other side. And then we already know the anatomic challenges. We can, if we have to access the other side instead or whatever it is. And then, so that's the first technical challenge issue. If it's not a technical challenge, but potentially a size thing. So I've seen a couple who were upwards of 200 CCs and maybe there are three, six months out and they're getting some improvement. We kind of have a look. better target for them and they're following up with their urologist in between, you know, me seeing them at the three months and then they're seeing them at the six months. So they're not quite that improved and they'll have a discussion of like, do we want to go down the aquarode or do we want to do a simple or what do we want to do? Sossumize. You know, let's talk about about all that stuff. And the patients will usually say, I'll go back it, can I do the embo again? Yeah, I think in a prostate that huge, I'm sure we took down a lot of volume on the gland and we can look with ultrasound and see, yeah, okay, it's down 40% inside, 50% in size, but they're still obstructed. So we can rea I think at, you know, six months, we know from the MR studies that they've re-vascularized all that tissue generally by then. So I think it's a reasonable time to come back, re-embo, try to size it down again. If they had some improvement, I think it's worthwhile if they had no improvement, then I think it's time to bark up another tree. Understood. Alright, yeah. Alright, same question to you. I used to be like a purist, like I did the PAE, didn't work, you go on to something else. And I was that way for a long time. But now I have patients five years out coming from with particles like doc, come on, I have five years was phenomenal. Just getting a little worse. Let's give me a chance. And these are the guys I did with particles. I'm like, sure. So I have a patient's been moving me for seven years now. I did a redo on their after particles and coil out. So we had it, he had one side, the vessel was high hypertrophy, and there's flow around it. And other was a secondary artery. I did glue. He said the comparison between particles and glue. He said glue is one month, particles three months, the same feeling. So he felt like particles took a little longer to achieve maximum effect. And that makes sense. If you take out the entire prosthetic arterial trunk, there's no pressure on the prostate. So immediately guys pee in the pack, you know, they haven't peed in three years that are doing CIC. But then over the next two weeks, there's a lot of swelling and changes. So I do get people the chance to reduce since I use MR, there's a lot of vascularity, vascular prostate tissue. I'm like, Hey, we can go back. But the difference is in those redo cases, I do 3D angiomapping, just to save myself time. Because I'm like, let me just inject from the internal and the epsilon side, or you can do it the top and do both. I typically just do the one side, do the spin, map it, and then you know, REIs in the Pena Kava. That little sucker is notorious for being the where the flow has come back. And I always evaluate both of those. And I will retreat. But if you have a giant median lobe and you have us recurrence of symptoms, maybe just take out I turn the median lobe and the patient still ejaculate or whole up the median lobe and the patient still ejaculate and those happy as anything. So I take an account of what the prostate looks like, taking to do an redo with 3 centimeter median lobe in the bladder. Let's be serious. We're not magicians here. Poof. Your median lobe's gone and they ain't happening. Chop it out. One of the things that Don mentioned that I wanted to run by you guys. And this now I really will promise it'll be the last one. So you do your injection on whatever side you start out on and you see nothing. You see no flow to you're injecting the left and you see no flow to the left. What are you doing that situation? Are you then just moving on to the right? Walk me through that scenario if it is in the practice and then what you do with it. Are you saying you like you injected the hypo and you don't see anything or you've inspected everything? You can go either but I was thinking like you injected the hypo. Yeah, so I mean it's a little bit of an inspection algorithm. So you know you do your hypo injection in like our rainman analogy you're like there it is. Go get it. But occasionally it's your rainman doesn't light up and you don't know which one it is. So I just go through wherever the wire goes I injected. So it hits the obturator injected. And you got that little synthesis branch that comes across once in a while that thing takes over for the prostate and you know loops around and it does the other side of the prostate or something. And then but if it's not that then you hit the superior vesicle and you just inject it because it might not be filling off your hypo. And then voila the spirit the umbilical has taken over the prostate which which does happen. And then you don't see any of those then I just run the catheter down the pedendol and shoot that zoom out run it way out and you've got a peanut cava on many cases and you can get it that way. The PAD patient who's got a whole bunch of stenoses and occlusions. Then there's just kind of a stepwise approach. You shoot your hypo the anterior divisions occluded. You run it out really far and you see like your something coming back from somewhere. You don't know where it's coming from. But you see you know vessels in the pelvis. And so then right. So then you go to the external you shoot the external. But I'll zoom out so that I'm including uh you know the inf the inferior begastric which might have an obterrain on it. And you're including the profunda. So you include all that you run it out way out and you may see one of these branches coming back to get the gland. So that's in the in the the vascular disease patient. But you can also have healthy vessels and you just don't find it. In that case yeah go to the other side do the other side. You're probably going to find the the the opposite gland feeder as a normal thing. But you may end up finding that the other side is feeding the whole thing. Or you know the obterrator branch bone branch has taken over the left side of the prostate. You might find some collateral. So generally move to the next step quickly. You got to move through the algorithm to keep going. So move to the next step. Check the other side treat it. Look for the other thing. I think I can count less than 10 times where there wasn't an artery from somewhere. Yeah. Hit in the other side. Okay. It's same thing but I'm trying to balance using the technology versus interrogating all those arteries. So if I'm in the anterior division and I don't see anything and the patient's older if he's 55 I'm going to look. But if he's like 70 80 I'm like we're just going to spin quick. And that'll give you at least enough information. Longer spinning they don't have double hip replacements. You're good at their age right? Yeah. So the combing beam CT really doesn't work in it's so limited that with artifact looking at the prostate when you have bilateral hip replacements it's like you're out of luck just work it out. But rule out coronamortis always look at your scans if you have some pre-op imaging that'll save you a ton of time. In tear get the vessels you want. Sometimes I spin and map. It's say it's that takes me like six seven minutes right? Spin. Everyone goes out of the room. Everyone go back in. You click around. You look you're good. And I think that saves me a lot of time. Some people like I argue with Tim McClure. He does a 3D map of the pelvis and then uses the navigation to cut down on the fluorotime. I go but how much fluorotime do you have to cut down if we're sub 15 minutes all the time? Sure. Sure. Sure. Like we're just gilded in the lily here but yeah. It's on the workstation for eight minutes. Yeah. Funny just that right angle. So I think that those that's my algorithm and I don't waste a ton of time I go to the other side. And sometimes if you jacked hard on the other side you can at least see the reflux to think what did I miss and that can help you. Half the time you struggle you can find it from the other side if you can inject hard to have a good isolation of the PA. That's a good tip. All right that's all I got but we got cases. I've got a little heading here. So this is a direction J catheter. What you see here is the hypo run on the left side and it's a superior vesicle coming off the obturator. Right. It's not run out all the way that that's obturator going straight down. And you see like sort of a little spring shape. It almost looks like you've got a fibromuscular dysplasia on that thing. Right. And so the wire goes in but it keeps buckling out. You'd think it would just follow. And then the micro catheter won't go. So then basically just pull the J direction micro catheter and this is it. I don't know if you can see the tiny little tip. I can see the tip. Like they see two dark bacteria in right. Exactly. That's in the vessel. As soon as I put that in it went in the wire went down and once the wire goes in there the whole thing straightens out and your micro catheter just flies in. So that's there's cases where you can use this. It's not common to pull it but there are some special cases to use it on. So this is one example. The J tip direction. Yeah. And then you can see on this picture how you know now the wire goes it's got support. Yeah. It just goes through. How does the J track going cheering? You have to get enough wired. And then that little J is shaped like this. Right. It's almost the right angle. So as soon as the wire gets far enough the J goes like this. Okay. And then once it goes from this to this then you can push it. Okay. If you try to push before that it's like pushing a sauce it'll just push you out. For the listening only Don made his hand into a C and then he straight it out a little bit. Or do you have only one to show? Yeah. Let me just go over like what it looks like what you expect. I'll show you a nice picture of a glue embo to start. I didn't prepare my slides. My homework's probably not as good as Don's over there. But um all right. This is a great example of glue penetration. This is a picture of our scoring system one two and three. It's basic. You have zero none. But look at how nice you can visualize the how deep the glue is penetrating. You even have some staining of the BPH nodules around here. And a patient like this is going to be very symptomatic. And I can move this off to the side. But this was a great picture. You can see how long the case took me. There's not a lot of urine in there. So this is how we know how long people take to do cases. How much urine do the patient make? It's great. So it's going to post that. That's not bad, right? That's like 200 cc's. That's not bad. Beautiful penetration on both sides. You can see that capsule branch here on the left coming down. So this is typically what we want to see. And this was done without a balloon catheter. Today I'll tell you a technique wise the difference is I would have probably left more glue in the PAs as I came out. Just to avoid any recanalyzation really take out those stumps on both sides. Cool very nice That is very cool. Yeah All right, I got go ahead if you want the crazy Twitter case to it You have a crazy Twitter case. I didn't know about this. Turo. We're all the good-eyer happens Yeah, I got to viscerate it a few times and look scenes that I have to get thicker skin because my feelings got hurt He's like Twitter's a dangerous point. I love it It is it is you can definitely get a viscerated everyone wasn't complimentary of your technique and how you did everything So this is a this is a surprise occlusion So there's no hype oh so follow the catheter up to the aorta All right, I'm there and then look just Screen left of the aorta you see that little thing there. Yeah, you're like what is that and I kind of ignored it But I was like wait a second. I think I know what that is so that I got a I don't know if this was a C2 or something I just went up it's a sauce. I went up hooked it did the injection and I run it way out and you can tell better when it's live But you're watching this flow and you know, it's just squirreling its way down and suddenly I see a straight vessel at the end of all these squirrels I'm like that's the hypo Right so then this is later in the run you got that looks like your height Okay, so we just have to track our way through so then I just pick you know a road map That shows me where to go and You got your whatever micro catheter and you hopefully your sauce holds itself there So then you just keep pushing through buckle a wire push It's probably gonna take the biggest vessel Yeah, and eventually you run out of you know nothing's moving and your sauce is pushing back so then Take the wire out put a command wire down everything straightens out come on the Straightens out watch this holy shit all of it's straightened out So then it flies through and I get there and I'm like oh dear god. There's this branch going down I Don't have that picture here, but yeah, it was going to the penis. I'm like After all this and I just pulled the GT at this point and I'm like please go to the prostate and the GT went right in And then boom we're there and then I did an AP I don't have it here But it was the whole gland. I was like this fantastic. Wow that ended up a happy ending and it didn't have to yeah That was it was amazing Yeah, it went from like the moment you take your picture and there's no hype Oh, there's like a sigh in the whole room and we got to this in about 45 minutes and I was like you slap your hands together You take off the glass then you're like that's how you do it. That's so bad. That's pretty good You just need a cheerleader saying you did a great job like that's like I have a tech in the case He's the only one that pays attention everyone else is like yeah Yeah, I'm like that's you know like hey, did you do this? I gave them meds? You know, they're not paying attention to you. I'm like I just need a little love like what are we eating for lunch? Yeah, you know all my breaks coming up. I'm like the tech is like I look I get in and I look at the tech the tech looks at music Are you trying to rain man each other? You're like it's that one, but that's what's great about our techs I love my tech so I have so many great techs like Mike Joe Chris I've two mics. So we let's say I really see a said Mike's name. So he feels like I love him Federico all of them Michelle they're like what what is that and I'm like thanks for paying attention because it gets lonely here Just being the only person that's cares about success. That is that's an empty feeling. I got to call out my techs too Becca Nasa Leo Wonderful. That's good. That's a good way. All right guys. Let's put a pen in it. This is for our afternoon I got to say a big thank you to Don and Art for coming on and doing the good work without great guests like these two You know what would back table be so to our audience. Thank you everyone for listening We'll see you next time on the back table podcast Thank you guys so much for tuning in if you haven't already please be sure to subscribe follow and break the show Let us know how we're doing and what we can do to improve it We work really hard at making this a valuable resource for you and we want to continue to do that Take a picture feedback Lastly tell a colleague about the show. We think they'll like it if you have any questions or comments direct messages at underscore back table on Instagram linked in X TikTok and Blue Sky Backtables hosted and produced by myself Chris Beck and co-host Ali Beheadie Michael Boraza Sabine Dond in Aaron Fritz our production team is led by Kieran Yannin Aaron Bolz Gabe the Gritzio Josh Spencer and Jaden White design and digital marketing led by Brian Schmitz social media PR by Danada Kavuto administrative support provided by Judy Della Cruz. Thanks again and see you next time Backtable now offers a personalized specialty feed inside our new app Whether you practice IR, faster surgery, ENT, urology or oncology You can follow curated playlist and explore case discussions download back table and tell your learning experience on your phone via the Apple Store or Google Play