Dr. Gifford discusses the evolution and optimization of his PTA treatment algorithm, particularly the importance of treating dissections. Topics discussed include the importance of dissection management to improve patency and decrease the need for reintervention, as well as cases using the Philips dissection repair solution—Tack Endovascular System—in the treatment algorithm.
Hi everyone. My name is Ted Gifford. I'm a vascular endovascular surgeon with Hartford Healthcare. I serve as the co director for the limb preservation program and I'm an assistant professor at the University of Connecticut School of Medicine. I'm gonna be talking today about my experiencing using tax for treating complex dissections and dissections in peripheral angioplasty. So a lot of times people ask me you know what what got you interested in using tech and what what was the impetus that led you to start using this device? And people come and say, well we've got this new technology that's going to help you if you have post angioplasty dissections and peripheral interventions. And my first response to that was well that's fine. But I never get complex dissections because a lot of what I do is focused around bisexual prevention in the first place. And I think that's an ethos that we all take to heart. Most of us don't want to leave behind stents. We recognize that when we do that we create a more complex landscape for the patient. We may reduce future options for therapy. And so I was initially a little um pessimistic in terms of how often I would be using this device because I thought it's just not that often that I get a complex dissection and what I found was that one of my very first patients was a great example of why this technology is so important. And so I want to walk you through that. This was a young patient who had all the risk factors that were well familiar with in terms of complex peripheral arterial disease, they were diabetic they had in stage renal disease and they presented from the podiatrist with non healing toe amputations. You can see that here uh in the clinic they were found to have actually no doubt or signals present non compressible ankle breaking indices. And you can see their wave forms are really pretty pretty abysmal when you look at the ankle and the metatarsal. So we took this patient for angiogram and this is what it looks like on the first go round. Now again I don't like to use a lot of stent therapy and this is an area where in particular I don't want to have to leave a stent in the P one papa tail artery. So I did front cutting a threat to me with phoenix and filter. Just a symbolic protection. And then this was the time period in my practice where I wasn't using a lot of drug code of technology especially for first time treatment options. This was shortly after the large meta analysis and overall our practice that kind of stepped away from using a lot of D. C. B. S. So I used a plain balloon and you know if you look at the pictures, what I would ask is that looks pretty good. I mean is anybody gonna actually put a stent in when that's their post and geographic result. I think the answer is probably no. When I go around and pull people, most people agree that this is kind of what we hope to see after. We do an intervention for peripheral arterial disease. Well, when I went back and looked at this patient, you'll see why in a minute I started to interrogate the the and geographic outcomes a little more closely. And you can see in particular these two very, very small dissections. Now the first one maybe as low as a grade A. Maybe more of a spiral dissection but it is present and then one down below it is probably somewhere between A grade A. And grade B. Both of them very mild and certainly they don't appear to affect the flow in this vessel. I think most people would have left these alone. So the patient goes forward and about six months later I get a follow up message from the podiatrist that the wound has now stalled. You can see that the toe amputations taken place, there's been some granulated at the base but then it's kind of stalled out. Now it looks pale, comes back and gets a recurrent additional duplex with me. And we see that the patient has significant recurrent disease at the areas of previous treatment. So if you recall this is what it looked like at the end of our initial treatment six months before and this is what it looks like now. Now what's interesting to me and what stood out was that right at that area of dissection right where we had just pointed out, hey, would you fix this dissection? That's where the patient seemed to have developed a recurrence stenosis. So even though this looks like a very low grade dissection clinically it's very impactful for this patient when you say oh that doesn't look too bad in terms of re stenosis. This is what it looks like when you put an 0. 35 wire in it. So clearly this is a significant um restenosis and one that needs to be treated. So at this point, especially for patients that had recurrent disease, we were kind of feeling a little bit more optimistic about the use of D. C. B. So I pre dilated and then I used a drug coated balloon and now again you see essentially in the exact same area as before. Something about this lesion is prone to forming these low grade dissections. This looks almost identical to before. You kind of have this hazy dissection up top almost a little spiral in nature, although very short in length. And then you also have this little focal kind of grade grade A grade B dissection below that. Um At this point in time I had just had access to tech within our our system. And so uh to me it was kind of a no brainer. Uh This was a good a good opportunity to try to to utilize this technology. So I went ahead and I placed tax I put four tax total to an additional area of dissection and two at the area of interest. And you can see those here and that seemed to deal with the concern for dissection pretty well now. Unfortunately like many of R. C. L. T. I. Patients, this patient was not limited to unilateral disease all the same risk factors set them up for wounds on the other foot as well. So I had the patient back five months later and treating the other leg and I elected to go ahead and perform an angiogram on that side to see how our previous intervention was. Faring looked good on duplex. But I wanted to kind of get an idea of how it looked on angiogram and you can see that the area that had suffered previous restenosis is now widely patent. So it begs the question, you know, in this case, was it the tack technology that treated these small but maybe clinically important dissections or was it the drug code of technology that helped improve this patient's long term pattern C. And my answer to that is that you really burn no bridges by adding tax therapy to your treatment algorithm. And that's how I've come to approach to. If I see something that I think is going to be clinically clinically meaningful to the patient from a dissection standpoint. It's not the same as putting in a bulky bare metal scaffold with traditional stenting. I'm not placing robust stents in the papa till, but instead I'm putting these very biologically silent tax that the vessel seems to respond very well to over time. So that's what I did for this patient. He went on to heal that wound. But I think it really highlights the importance of some of these small dissections and why tech can be a really useful tool for preserving the patent see in our patient population. So let me take a step back for a minute and just talk about why dissections are so important. Well, firstly we know that dissection really is the mechanism of action for angioplasty. Right? This is what we're trying to do with our balloon. Unfortunately, it just doesn't happen. And it's a controlled fashion ist we'd like the balloon whether the way it's packaged, the way it's inflated or just the morphology of the vessel. The balloon is gonna cause some disruption to that intimate to that plaque. And you can see in this picture here that sometimes it can end up kind of falling down into the lumen like wallpaper. And we know in those really severe cases where it looks like the vessels about to shut down, that if we lose wire access, we're gonna spend the next hour trying to get back across that tie section. But even in small dissections, we know that there's a clinical impact to the patients. Alright. And so we know that if we look at dissected vessels, if we leave these vessels alone, there's a much higher risk of needing to go back and treat this vessel as opposed to as opposed to vessels and lesions that don't have a dissection after angioplasty. Now, let's think about all the other areas where we don't just leave these dissections alone. Right, When was the last time you performed an iliac angioplasty without placing the stent? Or when would you go and do a carotid angioplasty without stenting or into the renal or the coronaries? So much of what we do, we utilize stents because we know that the risk proposition of doing that favors the stent placement, meaning that the patent C. Is quite good without stenting. And the risk posed to the patient if we have a dissection and don't stand it is quite high if we have a patient that shuts down the renal artery or shuts down their inflow from the iliac disease, that's a big deal. But we don't tend to do that with the same frequency in the federal property region. And a lot of that has to do with the fact that we recognize re treatment is unfortunately part of of our jobs, we know that patients are going to come back with recurrent disease. There are other co morbid conditions are being managed more effectively. So we know that whether it's for rest, pain wound or ulcer, we may have to go back in and try to retreat these patients, we don't want to burn bridges. We don't want to have a full metal jacket within the S. F. A. And papa till if we can avoid it. And so that's why I think a lot of the times we've left what we consider to be these non flow limiting dissections alone. And one of the take home message is that I want you to have today is that there's a third option. We don't have to just leave them alone and we don't have to place an aggressive stents. We can treat these very focal dissections and improve the long term patent see of these treated vessels. So what about these so called non flow limiting dissections. You know, is it only the major severe dissections to the right of the screen here that matter to the patients? Well I hope the case that I presented kind of illustrates why I don't feel that. That's true. And the data supports that as well. If you look at the thunder registry, what you found is that patients that had very low rates of dissections had very similar rates of T. L. R. As opposed to more severe dissections. So even patients with you know again what we consider to be the non flow limiting dissections of grade A. Or grade B. Have a 33% rate of T. L. R. Over the course of this study over a six month time period. So that's a big deal. And I think that to me that speaks to why we don't necessarily want to leave those dissections alone. Well what about how we visualize dissections? I found that you know, the more that I use this, the more dissections I see whether or not some of those dissections are clinically relevant is something that we're still trying to answer. And I think that that's something that attack has allowed us to address. But certainly if we look with the office and we look with additional imaging modality, we know we're going to see many more dissections than two D. Angiography is gonna see by itself. And that's something that's been demonstrated time and again. So why don't we want to just place bare metal stents and what's the complication that we fear in doing that? Well, I'll tell you my personal feelings about it. Number one is that once we place a stent sometimes whether we like it or not, we get trapped in the stent maintenance, right? We know what that patient suffered the first time around. We know we don't want their clinical symptoms to return. But now we're chasing a number, We're chasing a velocity that we're seeing in clinic. And the concern is that I don't have a crystal ball, right? If a stent goes down in the middle of the night? I can't promise you that that patient is going to be back at their baseline. And in fact what I fear more than anything is that they're gonna m belies. and they're gonna worsen their clinical outcomes. That they're gonna have to come to the emergency room and undergo thrombosis or thrown back to me or some additional urgent procedure in order to restore flow. And so I worry about placing stents because I feel like the complications of, you know, poor stent maintenance or stent thrombosis can be really quite severe for the patients. And in addition, we know that it really just alters the vessel morphology, right? This is a very rigid structure that you're putting into an otherwise elastic vessel. So whether it's stent fracture or whether it's intimate hyper pleasure within the stent because of the flow dynamics that you've changed. I think that, you know, for me, stenting certainly is not the answer. And the bulk majority of the patients that I treat with P A. D. Let me talk a little bit about the tax system itself to kind of familiarize yourselves with how this system works and and the different types of attacks that we want to use and where we want to use them. So the six french tack comes in. Two different kind of treatment vessel range is one of the nice things about this technology is that it's completely self sizing. So I don't have to try to decide whether or not. I want a five millimeter stent or a six millimeter stent. I pick a range of vessel diane and I can use a single skew a single device to treat across a wide range of those vessels. There are six millimeter long lengths and eight millimeter long length so that the six french device that self sizes from 3.5 to 6 millimeters. Those are six millimeter tax versus the 4 to 8 millimeter vessel size range. Those are eight millimeter tax. Each of those come six to a device and they each go over and over 35 working wire. If you look at how these tax are packaged on the device, you can see that they have intercourse markers between the different tax and that helps to identify where the tax are on the system and when they're being placed. Um, as as I said before, the six french system has six and if you look down here to the four french system, the tibial below the new tax. Uh those are four tax to a system. Those are for a self sizing range of 1.5 to 4.5 millimeters. And again, each of those tax are going to be six millimeters in length. One of the things that I think is really important when you're looking at how these tax are packaged on the device is that there's a three millimeter trailing non radio opaque marker on the outer aspect of the covering sheet. But you can see to the right of the screen here and you'll see at the end of the talk. Why? That's important. But um, to put it succinctly you want to make sure that you're watching the complete tak deploy because if you're just watching this radio opaque target band, you'll see this unsheathed past the tech and the tech will still be constrained by the non radio opaque part of the, the outer sheet. So that's an important point to remember. And again, we'll kind of revisit that later on again. The six french device goes over in 035 wire. The four french device goes over in oh 14 wire. Um, and overall these are very versatile devices that can be used throughout a variety of different vessel locations, looking again just at the individual tax. You'll see like I said before, the 26 french devices come in either an eight millimeter tackling or a six millimeter tak length. They have radio opaque markers around the center band. They self size to either 4 to 8 millimeters or 3.5 to 6 millimeters. The 4 to 8 millimeters have a little bit more radial force than the 3.5 to 6. But one of the things that I stress with the attack devices that it is not a radial force device. So you really want to do aggressive vessel prep and make sure that you've adequately dealt with a plaque before you go to place your tax. Uh the four french device, the B. T. K. Device. Again, that's a six millimeter deployed length itself sizes to 1.5 to 4.5 millimeters. So why do I you know, we throw around this term of biologically silent. And I think that one of the reasons is is because that's what we see in real life too. When we go and replace these tax, I will tell you in the in the number of cases that I've done. I've never had to go back and re treat a patient for instance, stenosis within these tax because it's not even something that we see or concern considered clinically the way we would with traditional stenting. And I think a lot of that has to do with two aspects of the technology. One is that again, it's not a radio force device. It's not a lot of metal that's exerting aggressive force onto the outside of the vessel. To me that's very pro inflammatory. So you're gonna see a lot of these chronic hyper plastic changes. The attack itself is very silent. So you don't see those same hyper plastic changes. What else is different about the tech? Well, I think that the fact that they're placed independently allows them to function within a wide range of vessel morphology. So, for instance, if you look at the distal sf and papa till you can see all these different forces that are exerted on the vessel, right as the patient moves as they sit as they go about their day. The vessels going to experience stretching. It's gonna experience compression. That's gonna experience flexion and torsion. What you want is a device that's going to move in all those different dimensions. And the beauty of attack is that they function independent of one another. So even if you place multiple attacks in a row, you're still going to allow each those tax to function within the plane of the vessel as it goes as it undergoes all these different changes. And just think about how different that is in a traditional bare metal stent where when you place it in, the patient moves and twists. That stent is now having to be twisted and torqued in a variety of different fashions. And I think that's what contributes to stent failure. And some of the more traditional technology. I mean, just as an aside my my threshold for for comfort between placing tax and pop little vessel P one P. Two or P three versus placing traditional bare metal stents is night and day. And again, I've never had a patient come back with vessel thrombosis after tax placement in this area. And I think that's a testament to the safety of the device. So let me give a good example when somebody says, well, what's a good case for me to start out with? How can I get comfortable using this technology? I like to showcase this case because I think it highlights a number of different features of how to use the device when you use the device and how to get comfortable using it for the first for the first couple of cases. So number one, I think it's really helpful when you have a longer dissection and traditionally I feel like I see longer dissections when I have a C. T. O. That I've re crossed. Some of that has to do with kind of re entry techniques. So in this particular patient I had to go into great retrograde. I kind of assume that at some point in my re entry I'm gonna have a sub intimate crossing and that's what I had. So how do you decide that a dissection like that should get a bare metal stent? And how do you decide that a dissection like that is a reasonable candidate protect? I think that one of the big components for me is looking at how the lesion behaves to angioplasty. Alright. And what I mean by that is that if I inflate a balloon, is my balloon going up to nominal pressure at very we're going up to to nominal diameter at very low pressures or am I having to really increase the inflation pressure to get that balloon to open to profile? Am I seeing an eccentric lesion kind of pushed to the side or am I just seeing again the balloon go up in a uniform fashion if I feel that the balloon is going up in a very uniform way and then I take a picture and this is what I get, I feel pretty confident that that dissection is really just that kind of wallpaper tear something. The attack is going to very effectively treat. I don't want to use tax if I feel like there's a real eccentric plaque here that I'm trying to push to the side. So this is an example of that where I've found that reentry plane. You can clearly see this as a very aggressive dissection. I don't think anybody would leave this alone and then afterwards we're gonna go and do the D C. B. S. You can see after D. C. Be prolonged inflation, phenomenal pressure. Um you can still see that there's a significant dissection. I mean certainly improved but I don't think we would be leaving that alone and hoping that the patient would remodel effectively there. So how tax works in this instance is I've got my wire in place. I want to place a number of tax across the area of interest And the reason why I like that when we're getting started using the device is that you get a sense of how the tax deployed, You're not trying to move the device around to deploy each individual tax. You can deploy two or three tax here without moving the device. It allows you to mag up on a single area of interest and again I think it just reinforces both the technology that you're using and the technique that you want to use to treat with tech. You always want to make sure in post dilate. I recommend post dilating the same diameter that you pre dilate. So if I use a five millimeter balloon here on the post dilate with a five millimeter balloon, always recommend using a fresh balloon, a new balloon when you get started and sizing the balloon to the wire that you're using. I think that's very important. People always say, well, can I use the 035 device over an oh 14 wire and no 18 wire. And the answer is sure you absolutely can't. And I've done it many times. I wouldn't necessarily recommend doing it for your first case because there is that leading edge on the balloon and you want to make sure you're watching very carefully as that goes past the tax. But you can definitely do that. I think the most important thing is that you're getting started and you want to use the same profile balloon to the wire you're using to post dilate. So in this case we put three tax right across that we post dilated and this was the result that we got and you can see just what a difference that makes with again, very little metal implant. Very little radio force. We're just kind of moving that dissection out of the way to allow the blood to flow. Um you know optimally through the vessel. One of the things that really appealed to me about using tech technology is the amount of data that has been amassed around this device. Because I tend to be pretty data driven and I always want somebody if they're going to kind of show me a new technology. I say well give me the facts, tell me really what's happening with this patient. And ideally tell me things like patents because that's really what I want to know. Are you willing to look at at the actual patent, see of these treated over time and how the device stands up. So go over a couple of the what I consider to be the real important trials in the use of tax technology TOBA to was the pivotal I. D. And I thought this was a very interesting trial because again this spoke to me as somebody who when I started out using some of the therapy, I was still favoring plain balloon angioplasty. This compared essentially patients with 100% dissected vessels. Right? So it's not like a lot of the other trials that are being compared to where you have a vast majority or undetected vessels. These are 100% dissected vessels and the operator had the option to use either plain balloon or lou tonics DCb. And then these were compared to the outcomes in the levant to trial. And what they found was that there was almost 80% patent see rate um in the in the in the tack treated segments which was significantly higher both for plane balloon and drug coated balloon compared to the previously published data. And again, that's in 100% dissected vessels. So you imagine um you know these are the kind of worst of the worst and they're having better outcomes than in patients that didn't have dissections to begin with TOBA three. The thing I like about this is that I felt like this really mirrored my own clinical practice. Right? When was the last time we had a six centimeter focal sf a lesion that we could angioplasty and then if there was a dissection we could place attack. Well this utilized a different DCP. This utilized the impact DCB but it also included long regions and I thought that that was very um you know impactful to my practice because a lot of the patients that I treat have longer than 15 centimeter illusions and we'll take a look at that data in a few slides. Lastly, the B. T. K. Data. Why was this data important? Well, you know, I tend to be very on label. I really try to stick with um you know, kind of what has been looked at and adjudicated from a data standpoint. And this really is the only FDA approved below the knee implant. So I you know, tend to focus a lot on that because what other options do I have? I mean certainly coronary stents exist and I do use them in my practice in certain situations. Again, mo Mostly when I'm looking at radio force but you know, for other dissections in the tibial space, this is really the only device out there that's going to help improve the longevity for my patients. And if you look at how it compares to some other published registries or published series, you're looking at 78% patent see at six months, which is really phenomenal. When you're talking about tibial disease, we know how refractory those patients can be. So this is again kind of, you know, how rigorous they were in terms of looking at some of their data. These are the benchmarks that Republicans set for itself. When they set forth to investigate below the knee attack implants. You know, they set performance goals at 12% in terms of looking at 30 day safety and they came in well below that for safety events. They looked at, you know, freedom from six month major adverse events and from 30 day death again set their kind of benchmark for where they thought the rest of the trials were shaking out around 74% 64% for patent C. And you can see that they were able to really surpass that with their trial outcomes. And I think that's a testament to how important dissection management can be in terms of improving your patsy and decreasing your need for re intervention, uh I like this slide a lot because when I first heard about the below the new tech, I thought, okay, that's great. So below the knee, you mean the P three property artery? The tibial peroneal trump. Maybe the proximal tibial vessels. What they found was that almost a third of these tax are deployed within the mid and distal tibial vessels. And I've experienced that as well. I think these tax function very, very nicely in a variety of different anatomical locations. And you can really go down right to the superman leola. Um, tibial vessels. And and and they tend to do very well at 12 months. You see that these had 0% rate of fracture, 0% rate of migration and globalization. So you can place them very, very safely. Again, looking at limb salvage and patients with with rough for classification four and five Clt. I you can see a 94.7% limb salvage rate, which again I think is quite impressive. Out to two years in patients with uh with with severe disease. So, let me talk for a moment about how I kind of recommend one get started using the four french track. And sometimes I recommend if you say listen, I don't know if this is something that I want to try say maybe think about using it when you're getting started in material space and again, why is that? Well there's really no other FDA approved technology below the knee for an implant. I think the four french device is very easy to see with and within the tibial vessels. And again these are long segment occlusion or long segments. Two doses that were often treating. And we find that using plain balloon, you know the six month patton C. Hovers around 50 to 60%. So if we can do anything to boost that to decrease the number of times patients to come back and get retreated to increase the likelihood that they're going to heal their wounds. I think those are really important adjuncts Here are a couple of tips that I have when you're gonna go and treat tibial disease. So you can see this as a patient that had a toe ulcer. They've got an 80 inclusion and reconstitution of the distal AT&D. P. So you want to get your 014 wire in place. You want to pre treat. This is the approximate 80. And you can see now we've kind of gotten it back online and to me at least I feel like these dissections are pretty evident. You can see areas where this disease is going to maybe come back or or the patient's gonna have early failure of your treatment. So one of the things that I recommend doing is before you go intact. You wanna magnify. So zoom in really get a good picture of what you want to treat. Use some type of stable support wire when you're gonna go place your tax. So whether it's Spartak or Grand Slam or some other type of support wire that you can work over, I recommend taking two views. I think that's really important if you happen to be a very added ibis user, I think that's a certain very valuable adjunct for looking at these dissections. I think one of the important things is which dissections are you going to choose to treat? And I use the potato chip analogy, which is that you want to get the big potato chips? Maybe the smaller potato chips depends on how comfortable you are and how many times you've used this device. So to me, I see this large dissection here and I see this area of dissection at the bottom and those are the two areas that really speak to me to try to treat for this. So I go ahead and I place one tactic to tax approximately and you can see I've resolved those areas of dissection as I start to see some other areas of haziness. If I feel comfortable, I may go back and place additional tax. I've certainly done that again. Maybe not something you want to do right out the gates. I think the most important thing is you want to go after those lesions that you think are going to bring that patient back for re treatment early. This is the completion Angiogram and you can see this patient has significant improvement in the distal 80DP flow at that point. So again, you know, one of the things that I mentioned was use of D. C. B. S. But in particular treatment of long lesions. So you can see this is data from october three trial. In this case they looked at less than 15 centimeter lesions and they found that out to one year they had 95% primary patent C. And 100% dissected vessels. I mean that's really unheard of. That's the kind of outcome that you look at at shorter lesions and uh and non dissected vessels. And when you look at uh at at the date for the longer lesions at 15 to 25 centimeters. Again you find that out to one year. Almost 90% primary patent C. And out to two years. Freedom from C. D. T. L. R. Of 83%. So this is really, you know, a very commonly treated patient population and here you're seeing data where they're able to be free from additional treatment as a substantial number. Which is really what we look for when we're talking about endovascular therapy. Is it durable and is it safe? Um you know, one of the kind of things that I want to close on and talking about how you can kind of set yourself up for success is that a lot of the patients that we treat they don't have that isolated region. Sometimes they don't even have isolated federal political disease. And so what do you do if you have a patient that has multi level disease and you want to consider using tack or avoiding you know excessive stent placement. So I'm gonna walk through one of these uh these cases for you. This is a patient that presented with an A. B. I. At zero. Alright so they had real real poor flow and some of that obviously was driven by poor pump function. They had an ejection fraction of 10%. So not a patient we would consider for bypass and they had bilateral disease worse on the right rather for classification five they had digital gangrene of all digits on the right foot. Um This is what they look like to start. You can see uh common and profound are open. There is some profound a disease and you can see that the S. F. A. Is included, reconstitutes and kind of some islands of flow as you go down. Um Kind of in one of those there where maybe there's some collaterals. And then as you get down to the tibial you see that the posterior tibial comes back and were able to get a wire through and through and get access down into the distal posterior tibial artery. So what do you want to do when you're gonna go treat? So the first thing is you want to complete all the adjunctive therapy um that you're gonna use. So whether you're gonna use that direct to me or in this case we just use a bunch of aggressive plane balloon and drug coated balloon angioplasty. You can see that when that's done. The proximal tibial peroneal trunk and the proximal, the distal pop. It'll have some spiral dissections in them where we re catalyzed those areas. You can see that kind of one of our re entry points. Like we talked about in the distal sf A. There's a dissection there and you can see that up here in the proximal sf A. There's a pretty bulky recalcitrant uh lesion. Not even really a dissection. This is where I kind of talked about. Is this the right anatomy for tech? I would say the first to the one on the left and the middle one. Those are great attack options. This last one here. You know, you want to go at it again with another balloon you want to try to address and say is this really as robust as I need it to be. Um And if you feel like there tends to be a lot of recoil, that's a case where I might consider placing an adjunctive stent. So once you're completed with that, then you want to always work distal to proximal. If you if you identify dissections that need to be treated. Don't start up in the SF and papa will start down in the Tibbles first because you want to try to avoid crossing the recently placed tax as much as possible. So in this case you can see here we placed some tax in the P three papa till and in the tibial peroneal trunk and then we post dilated those. Now again, if this is your first case you may want to exchange for an 035 wire for your sF A pop interventions. But if you do that, you want to make sure that you have a good visualization of that. Just a wire. You don't want that. Just a wire to go down until your recently placed tax. If you want to treat over a lower profile wire, you can certainly do that. But again, I just recommend that when you go to post dilate you use the same profile balloon as the wire that you're treating over. So whether it's a 14 oh 18 just to prevent tak migration. And again you can see that dissection dealt with. And then lastly up top you can see the run off after we've completed it the region again. And then up top we elected to place some bare metal stents in areas that we felt like needed the additional radio support. So to summarize this is a case where this patient had essentially flatline A. B. I. S. Before really advanced disease. We were able to treat over 400 millimeters of length of vessel and uh and do so by leaving behind only a short amount of actual extent by by using the tax therapy and you can see what a difference that made in their digital wave forms at the end of the procedure, interestingly, that first case that I highlight that one when I kind of showcase that sub interval dissection and deploying tax on a road. That's the patient's contra lateral leg. So you can see kind of again, a good kind of pre imposed for what we were able to achieve. I wanna summarize everything by kind of trying to highlight a couple of pitfalls that I've experienced as I've gone and use tax in my clinical experience. So one of them is that as I mentioned, there's an inter core marker band that separates the different tax and sometimes I'll want to tax to be close together. So you can see here in this dissection, I maybe want to place attack here and attack a little bit lower And I feel like the natural spacing of the taxes further than I wanted to be. In that case, I end up pushing my device forward a little bit as I go to deploy my second tech. And one of the things I want to highlight here is you can see the straight line that you should have for the radio opaque marker bands of attack and now that these marker bands have kind of shifted on their public witty and what that is telling me is that I've kind of twisted this tack a little bit off kilter by pushing it forward a little bit, so that's something you want to be cognizant of. If you're manipulating the deployment device after you've already deployed attack or if you're coming in with a larger profile balloon and you're worried about catching the edge of attack. The nice thing is, is you can post violate this and it will see the attack very nicely. If you're ever concerned that it's not gonna, you know that the patent is going to be compromised, You don't feel comfortable leaving it, then you always have a bailout. That's the nice thing about this technology. You can place a bare metal stent across that and that's something that you might have done from the get go. What about having to go back through recently placed taxes? You've heard? I've mentioned a couple of times your wife said, well I really don't want to go back through these unless I can avoid it or I want to be cognizant when I'm going back through it. Sometimes it's unavoidable. Either there's a disassembly that you didn't notice up until this point or just present at the end of the case or you see a refractory lesion or a refractory dissection. You know, you, I have to go back and treat you can safely do that. You can absolutely go back through recently, place tax, but you want to do so carefully. I had a mentor that used to always say you have to know when to go fast, You have to know when to go slow. And I think that could be a model for this. Um, this device because you really just want to go slow when it's appropriate to go slow in this case. Wire access was law across these tax. And so when we're regaining wire access, there was some overzealous manipulation of the catheter and you can see that the catheter went down without the wire and now has dragged tax down into the p one papa papa till. So that's a case where you know, real attention to detail and watching how the wire and the catheter going down cross these tax is really crucial. Once you've stabilized your platform then you can kind of go on and retreat and you've gotten past that difficult part. But as your crossing with either the wire or the catholic, you want to be very cognizant of that. And in this case we were just able to stand across those and that patient to find something that it's important to be aware of. Um Finally I kind of wanted to highlight the uh the, the way that the tax appears, they're being deployed. I alluded to this earlier. So again, you want to kind of look and see a fully deployed tack kind of has this very symmetrical appearance where the distal most portion and approximate most portion of attack are uniform of their appearance. You can see here this is what a partially deployed tax looks like even though this target band is clearly up past the proximity from this tech and the reason for that is that it's still constrained in this non radio opaque trailing catheter edge. So you want to make sure that you don't move the device until this marker band is a little bit further back towards these radio opaque markers or essentially until you've seen both the distal and proximal aspect of this tax open symmetrically and then you know, you can go ahead and and pull it back a little bit. People always say how many tax should I place when I get started and what I would tell you is that something that you know, I've really learned as as I've gone along. I used to be very, very frugal in my task placement. Again I said, well I want to leave this little behind as possible so I might try to put one tack or to tax and I've since become a little bit more aggressive in how many places and part of that is because again they behave in independently. So they don't tend to have as much eccentric force on the vessel as as a longer bare metal stent would. So what I recommend doing again is you want to position yourself for success. So Mag up on the image. I don't use a floral fade or some type of road map when I go and deploy tax. I really want to see the tax being deployed. So instead I'll use a dry erase marker and I'll mark on the side of the vessel where I think those tax should go and then I'll go ahead and drop those tax and you can decide whether or not it's a longer dissection, maybe over two centimeters of length. You might want to leave a few tax. If it's a shorter dissection, maybe you just put a tack at the, at the top and the bottom and if it's a very focal like grade A or something like that, you want to put a tack in, then one tax will certainly do for those. So I hope that you've learned something today. I hope you kind of understood how I've come to use this device and why I think it's been so impactful to the patients that I treat. I've always thought of myself as a minimalist when it comes to endovascular therapy. But that doesn't mean that I want to leave lesions behind that I think are going to compromise the clinical success of what I'm doing for the patient. And I think the attack has really allowed me to do that safely and in a wide variety of vessels including below the knee, which I think is really an advance for are difficult to treat patients. So I want to thank you for taking the time to listen. And I hope you learned something I'm always available for questions and I hope you'll reach out. Thank you.