#Relentless #excusetheclutter #Everest

@t_intheleadcoat @SIRRFS @kmadass @keithppereira @SDhandMD @IRKhalsa @IR_Doctor

@t_intheleadcoat @SIRRFS @kmadass @keithppereira @SDhandMD @IRKhalsa @IR_Doctor

@t_intheleadcoat The biggest part of “routine” has come from being clinical… we see patients for portal hypertension, not ‘just TIPS’ - collaborating with our GI and hepatology colleagues has moved the needle just as much as ICE and steerable needles @ebtapper @md_myer @BlaneyMD

💯

Life saving intervention..looking back 25 some years, couldn’t know in my wildest dreams that I would be able to, but I am fortunate & it has been a privilege to be able to offer it to patients in dire circumstances.

Those are phenomenally consistent case times for TIPS !👏🏾

@t_intheleadcoat @SIRRFS @kmadass @keithppereira @SDhandMD @IR_Doctor Learning all sorts of tricks from this thread

@t_intheleadcoat @DonGarbettMD @SIRRFS @kmadass @keithppereira @SDhandMD @IRKhalsa @IR_Doctor In native tracts I sometimes like using the metal stiffening cannula of new tube as a styler to disrupt crust, and provide ample support for pushing a wire to crest channel. Can also perforate tube with back end of glide wire and then navigate alongside outside occlusion But

@t_intheleadcoat @SIRRFS @keithppereira @SDhandMD @IRKhalsa @IR_Doctor Can see two separate catheters and wires before pulling the encrusted ones

@t_intheleadcoat @SIRRFS @kmadass @keithppereira @SDhandMD @IRKhalsa @IR_Doctor This very recently happened to me! Options- snake a snare onto it and then into the renal pelvis. Put glidewire into snare, remove old crusty tube. Also this is when I found out they made a glidie-er stiff glide than the regular stiff glide (it’s a cardiology wire- I’ll see if

@t_intheleadcoat @SIRRFS @kmadass @keithppereira @SDhandMD @IRKhalsa @IR_Doctor Roadrunner “nimble” wire, the white one. It’s the slipperiest of the slippery wires, hold on tight. If it’s encrusted then run a tough stitch though the external end of the NU and back out through a 12 fr dryseal sheath. The sheath is flexible and hydrophilic enough to glide over

@t_intheleadcoat @SIRRFS @kmadass @keithppereira @SDhandMD @IRKhalsa @IR_Doctor Have two ideas which have come in handy...assuming we have exhausted wires thru stent. 1. Long peelaway sheath with a wire thru the stent to pull and drive peelaway in. 2. Get a buddy catheter plus wire and go along side of stent. @sirrfs @WashUIR @SIRspecialists @sash

@t_intheleadcoat @SIRRFS @kmadass @keithppereira @SDhandMD @IRKhalsa @IR_Doctor Cut a small side hole in the tube and get a glide wire advantage to track alongside the tube and into the system Push the floppy part into ureter Walk it off Exchange

@t_intheleadcoat @SIRRFS @kmadass @keithppereira @SDhandMD @IRKhalsa @IR_Doctor Encrusted? These can go sideways fast if not careful. Often a glidewire can track alongside the stent (similar to clogged antegrade PCN/GJ tubes). 👀 to see what you did

@t_intheleadcoat @SIRRFS @kmadass @keithppereira @SDhandMD @IRKhalsa @IR_Doctor These are tough cases for a routine exchange- and go by many names- reverse PCN- diversionary catheter- and "single J"- if no wire will go through, can always take a KMP alongside it, get a wire up and slowly pull as to not dislodge your buddy wire, otherwise, crossing catheter

#CTO of Nephroureteral stents! Can’t cross with any wire on shelf! What’s your rec to help out your junior colleague to swap them ? May be your trick can come handy & help @SIRRFS one day ! @kmadass I know it ain’t arterial 😁 @keithppereira @SDhandMD @IRKhalsa @IR_Doctor