20170713 Basilar artery stenosis s/p Wingspan stent / TACE / TACE / Left ICA aneurysm / S/p liver transplant decreased hepatic flow / Pelvic congestion syndrome /

• Basilar artery stenosis s/p Wingspan stent 
• 自費項目：氣球(兩萬多)、Wingspan支架(16萬)、Angioseal
• 氣球每一分鐘打1 atm，放開時先放到0不要負壓，以免氣球縮放太快造成perforator 血管被阻塞
• 支架放4.5 (近端最大?)
• Wingspan比一般頸動脈支架還要硬?會慢慢張開 
• 報告: 
• selective endovascular revascular procedure with balloon angioplasty/Wingspan stent implant of the symptomatic basilar artery stenosis patient were performed. the indications, limitations and potential complicatinos ( including thromboembolic stroke, acute vessel rupture and hemorrhage, stent migration and improper position, delayed brain swelling and delayed hemorrhage) of these procedures had been explained to patient himself and patient's families. the whole procedure was done after the consent form is obtained.
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• Findings:
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• 1.a 6F Rt femoral sheath was put as usual.
• 2.a 6F Neuron guiding catheter was advanced into the distal portion of left cervical vertebral artery. the initial diagnostic angiographies show a short segmental  stenosis (70% based on area) involving the middle portion of basilar artery. a prophylatic 3000 units heparization was given, then 500u per hour.
• 3.pre-dilatation with a Gateway balloon (4mmx15mm) slowly was performed; following a self-expansible (4.5mmx15mm) Wingspan stent was deployed after pre-dilatation. the stent was delivered coaxially via the guiding catheter into the left VA and covered the stenosis segment and also the mid-basilar completely. the stent was deployed smoothly. n 
• 4.the post-stent follow up angiogram showed reopening of distal basilar artery and patency of posterior fossa arteries.
• 5.we have informed the clinican and the family about the result of this procedure. patient was sent back to SNCU for post-stenting nd blood pressure contral. the post-stenting medication include plavix ( 75mg per day ) for six month and aspirin (100mg per day) for life long were informed. we will follow up this case closely.
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• Impression: basilar artery stenosis s/p succefful Wingspan insertion.
• TACE 
• 兩側都有viable tumore
• TACE  
• CT 沒有看到viable tumor
• 先做診斷，確定有腫瘤再開藥
• 或是做MRI看看(之前經驗)
• Left ICA aneurysm supraclinoid
• 動脈瘤剛好在轉彎後不遠往下projection，看起來不好做，micro很可能容易彈出來
• proximal CCA稍微tortuous不好上去，講解要先講清楚
• 這個位置外科不喜歡開刀
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• S/p liver transplant decreased hepatic flow 
• 術前的CT有SMA replace血管，記得去看開刀接到什麼血管上面
• 開刀接在SMA上，spleen完全不可能搶到血流，和家屬解釋要注意
• 這個CASE沒有動到GDA以前的血管，可能通常都不會動到，所以術前有異常數後應該不會有大變化
• 去看手術紀錄，的確沒有寫是怎麼接血管的，只有寫重建動脈血流
• Pelvic congestion syndrome 
• 做完子宮和軟巢切除術後，疼痛
• 溝進靜脈裡面，發現靜脈往pelvis走沒有往上走，用10%的 glue把左側的靜脈塞調
• 使用RUC把右側靜脈用coil塞調
• SIM2疑似可以當作LOOP用，可是很難用(可能是ARM太短)