20190731 Portal vein stent Boston stent 7 x 27

• s/p liver transplantation s/p Portal vein stent Boston stent 7 x 27 
• artery 接LG看細切CT還好
• 左邊portal vein 疑似因為不夠長被硬拉長，所以有狹窄
• 使用6 Fr.長sheath，150公分軟wire、exchange wire
• sonography 扎不到，對spine位置往central扎，扎到不確定先送sheath裡面的軟管，確定了再送sheath，換.35 wire、換KMP、換sheath，換exchange wire，放支架。
• 張開位置對接到main portal vein釘子上緣
• Stent wire不夠濕會非常難推
• balloon 打到16 
• 打3個tropedo
• 後續發現hemothorax，從T10 Spine水平扎不到，再往上level往斜下扎才扎到。T10就有點高了，往上會扎到pleura其實不意外。最好還是可以從下往上斜扎
• 超音波看到的hypoechoic可能是colon?

20190730 Portal vein self expansible stent

• S/p liver transplant, main portal vein stenosis s/p Portal vein self expansible stent
• 用10 Fr.短sheath
• 對好遠端distal marker後，慢慢off sheath，近端兩個marker最近的那個是enlongation後的長度，中間的是完全張開的長度(?)→所以中間那個marker要超過狹窄處，最遠端盡量不要蓋到其他branch
• 使用clip定位，如過病人有動過要重新定位
• 
  

20190729 Amplatz embolization of splenic aneurysm

•  Pancreatitis with splenic artery pseudoaneurysm s/p Amplatz embolization of splenic aneurysm
• 要over size 30%
• 使用Terumo destination ，前面進入spenic artery，出頭anchor之後，慢慢退sheath
• 退到一定的程度，Amplatz會把另一個圈圈往前拉成型
• 逆時針旋轉detach
• 要隨時注意位置

20190718 Myoma embolization from brachial artery / Epidural analgesia / HAIC

• 20190718 Myoma embolization from brachial artery  
• 先打PCA止痛。
• 從手puncture，使用PTCD micro puncture set。
• 使用 Berenstein 135公分管子(?)，所以要用exchange wire才夠長
• 右邊用micro很難打，下次可以考慮把管子放進去打BEAD
• 使用500 um和700 um，先打一隻500再打700。右邊是500,700 700 700 700，左邊打一隻500就滿了。
• MRI看起來右邊比較promient，所以先做右邊。
• Epidural analgesia  
• 器材：無菌包(裡面有棉花、兩個小鋼杯、puncture set(特殊針筒(release pressure使用、Tuohy needle、catheter、接頭、過濾接頭)。
• 確定要麻醉的level。(子宮 T10 to L1)
• Parturients comprise the single largest group to receive epidural analgesia. For adequate pain relief during the first stage of labor, coverage of the dermatomes from T10 to L1 is necessary; analgesia should extend caudally to S2–S4 (to include the pudendal nerve) during the second stage of labor. Epidural placement at the L3–L4 interspace is most common in laboring patients.
• 摸到L1 Spinous process，往下從L2 (??)  spinal process進去；做記號，消毒，鋪洞巾
• 從spinal process和vertebral body邊緣中間進針(針孔斜面朝上)，進針點在spinal process上緣，垂直進去扎到骨頭後，再慢慢往內上移，若有繼續進去，則使用release pressure technique (使用NS，也有人用空氣)，一旦release pressure，放管子 (有一點點阻力是正常的)
• 放好管子(看針外面剩幾公分就知道進去的深度，再加六公分就是要放的深度)，接上接頭打顯影劑看位置，有往上下散開才是對的，可以打水看看有沒有沖散
• 確定OK，remove needle，小心不要染污catheter，接上接頭與胖胖魚(防止細菌進入)
• 用棉花把血擦乾淨，然後捲一個小圈圈後用op site且貼起來。op site四邊用布膠貼好，然後拉一條長長的布膠把catheter從肩膀繞道前胸(偏右，邊左也可以)，然後連胖胖魚固定在前胸。
• 固定好之後打一隻bolus 的(?)止痛
• Tuohy needle 8 公分，病人厚度4 公分，管子留在epidual 六公分，所以裡面總共十公分。
• HAIC 
• 打完Lipiodol之後(不一定會打完10 cc，看到Portal vein就可以停了，一樣慢慢打)，打水沖乾淨，然後接上豆豆，脫掉鉛衣，拿止血棉，然後拔管。
• 從手puncture壓的時候要壓到快要沒有脈搏，壓的時候有點把兩側皮膚捏起來(中間是血管+止血棉)
• 綁繃帶的時候，先用兩塊小紗布加壓，然後纏彈繃，最後用3M把固定的釘子繃黏起來。在纏的時候要一直確認脈搏。
• 彈繃會帶回家。

20190702 Mammo localication

• Lesion 很靠近胸壁，雖然是upper quadrant但是從上面進去深度很深
• 一開始CC夾起來約有5公分，Tomo深度就深達3.9公分，照慣例我會加0.5-1公分，不過針刺到4公分左右就覺得頂到板子了，所以就沒有再刺更深
• 上一次在夾LM的時候發現，怎麼差了三公分左右，所以這次就在CC鬆開板子的時候就抵住針，果然針就一直沒進去直到頂。
• 照LM的時候發現針剛好在鈣化附近，所以在拔針以前就先稍微出一點內針，最後如照片所示針剛好在lesion旁邊
• Special remarks
• 靠近胸壁的lesion不論從上或是從下都會很深，所以要用長一點的針，最好能用到15公分的針
• CC在放開的時候怕被皮膚夾住拉出來 (尤其breast tissue沒有很緻密的時候)，這時候再放開CC的時候最好能頂住針以免被拉出來。

 

20190628 Viabahn (Cover stent) deployment

• Hx of patient: extended right oral cancer, progressive enlarged lump at right neck with pus

• Equipment
• Flush *1 
• 150 cm .35  and .18 wire
• 7 Fr. shuttle sheath with Y shape tube, JB2 catheter
• 8 mm x 5 cm Viabahn stent
• Informed consent and explained the risks.
• Stroke, Intra-stent thrombus
• Re breeding, too large of the opening that our stent could not cover
• Tortuous vessel which we could not approach.
• Cover ECA, risk of ischemia
• If untreated, rupture of the pseudoaneurysm and large amount active bleeding.
• Steps:
• Set Flush line x 1, connect to shuttle sheath
• Puncture right femoral artery, then inserted 7 Fr. shuttle sheath with stylet into abdominal aorta
• Remove stylet, open flush line
• Prepare the bi-plane fluoroscopy. Slightly LAO of the AP arm to see the opening of pseudoaneurysm clearly(?).
• Put .35 wire into JB2 catheter, then inserted JB2 with .35 wire into Shuttle sheath
• Put the JB2 into right CCA, then perform road map via JB2
• Confirm the pseudoaneurysm diagnosis and location, then inesrted  .35 wire again, put the wire over the opening of pseudoaneurysm. Then advanced the JB2 over the opening, and push the shuttle into CCA. Then remove JB2 and .35 wire.
• Performed right CCA angiography with 5 ml/total 8 ml. Confirm the location of the opening of the pseudoaneurysm which is about at lower border of 3th vertebral body.
• We measure the diameter of proximal ICA(5.96 mm), distal CCA(7.17 mm) and the distance from ICA to CCA(44mm). Then, we decided to use 8 mm x 5 cm Viabahn. (althought the carotid bulb is 8.4 mm, the 8 mm stent is large enough to cover the proximal CCA)
• Flush the Viabahn and inserted .18 wire into the Viabahn(from tip due to I could not inserted via tail)
• Put the Viabahn with .18 wire into shuttle, push the wire over the tip.
• Put the .18 wire over the opening, then  push the Viabahn to the desired position(From middle of 3rd vertebral to CCA)
• Confirm fasten the Y shape tube, and confirm the location of the stent, and Rapid remove the thread and open the stent.
• Follow up road map revealed only delay flow into the pseudoaneurysm.
• Follow up DSA of right CCA and then remove the Shuttle sheath into descending aorta.
• Check the patient's conditions if any stroke symptoms occurred.
• Sent to patient to ward or ICU.

• The title of next article is Journey in Sri Lanka