0:00

So let's take a deeper dive into an example

0:03

of one agent that can be used commonly

0:06

to perform tract embolizations.

0:09

There's no endorsement of this particular company's product,

0:14

but it's something that I think illustrates a few.

0:17

Particularly important features of track embolization that

0:20

I like to discuss and share with you today.

0:22

Let's talk about flowable hemostat in

0:25

this particular case and it's

0:28

something that's commonly used at the institution where I practice and

0:31

what it includes is a collagen from in

0:34

Pro coagulate and that collagen thrombin Pro

0:37

coagulant actually stimulates Insight you hemostasis

0:40

that biopsy sites. So let's unpack. Of

0:43

course, we know about the intrinsic and strings it

0:46

and ultimately the common pathway for the coagulation Cascade

0:49

and there are things within the coagulation Cascade

0:52

that are particularly important for performing and

0:55

achieving hemostasis. One of which is thrombin which

0:58

comes in this particular agent and then

1:01

there's collagen which is usually created in

1:04

a little bit of a cocktail at the time of the biops scene

1:07

for the purposes of tracking relation by the

1:10

end eventualists the thrombin converts the fibrinogen to

1:13

fibrin which in turn is

1:16

essentially activation of the coagulation Cascade and then

1:19

there's a collagen that provides a nice scaffold a nice.

1:22

Framework in which the platelets can now aggregate inform that

1:25

solid platelet run plug or that thrombus.

1:29

So what a few things of note when it comes to this specific entity. It's

1:32

usually contraindicated because it's bovine

1:35

derived material. So some individuals

1:38

may be sensitive to bovine derived material

1:41

in which case this thrombin and collagen that

1:44

Source from cows maybe contraindicated in

1:47

those patients. Now if it's blood that's just pulsating

1:50

out. This may not be suitable in that setting or in

1:53

the setting of sheets that are placed in

1:56

veins because of the risk of this actually being embolized

1:59

in the vein, which would then move to

2:02

the right side at the heart and then to the pulmonary arteries.

2:06

When it comes to the complications of this particular agent, you

2:09

can have local and disseminated hyper-sensitivity reactions.

2:12

Again, if a patient is allergic to

2:15

Cow products a bovine allergy, which

2:18

is not unheard of in the medical world an individual

2:21

could result in a hypersensitivity or

2:25

in some situations anaphylaxis to this agent if

2:28

there's accidental intravascular injection, it's something

2:31

that we want to avoid because of

2:34

what we discuss previously because of

2:37

course the agent can move Downstream to

2:40

other sites and if in the case of the vein could move to

2:43

the right side of the heart, there is a theoretical risk of

2:46

developing anti bovine antibodies in

2:49

the post procedural period which could make

2:52

the patient hypersensitive over time.

2:55

So let's look at a video of preparation of

2:58

this particular agent. So here the thrombin

3:01

is initially withdrawn from a vial using a

3:04

non-coring vile axis device.

3:08

this place

3:09

through the norncoring device.

3:12

syringe

3:14

advanced

3:17

and the solution the thrombin solution is gently aspirated

3:20

into the syringe.

3:23

The Second Step would be that the thrombin then becomes reconstituted using a

3:26

liquid diluent compose a buffered calcium

3:29

chloride.

3:31

Now the thrombin is injected into that

3:34

liquid element calcium chloride

3:37

and then aspirated.

3:45

So now this reconstituted thrombin solution is

3:48

then used to hydrate a syringe of collagen.

3:52

That solution is mixed back and forth until thickened.

4:01

As it's moved between both syringes, it becomes

4:04

more and more difficult in order to trap

4:07

it in a single syringe.

4:10

The next step is to get the air out.

4:12

from the

4:13

end of the syringe and that's then gently into

4:16

a gauze in order to ensure that the dstat is

4:19

maintained within the entirety of the

4:22

syringe and there is no air.

4:24

Here we see the reconstituted thrombin

4:27

with the collagen in a

4:30

nice Emulsion that almost resembles toothpaste,

4:33

which is the consistency we want to achieve and

4:36

there is no air within the syringe.

4:40

So what we then do is the solution to send introduce

4:43

under ultrasound guidance.

4:45

using the provided tip

4:48

It's left to settle inside you and so what we

4:51

do is usually about two thirds of the solution is injected at

4:54

the site.

4:56

where the introducer is

4:58

so which allows the solution to permeate

5:01

through our track distal to

5:04

our introducer site and then we then

5:07

using about a third of the remaining solution.

5:11

We then begin to withdraw and inject withdraw

5:14

and inject draw and Jack

5:17

and ultrasound guidance. So that tracked actually becomes embolized.