Jonathan Iglesias, MD

Did you know cases are available in the BackTable App? This week’s VI case focuses on genicular artery embolization (GAE) and back table preparation with Dr. Osman Ahmed. Explore more cases and discussions in the BackTable App: na2.hubs.ly/H05FhJ70 #InterventionalRadiology #Embolization #Osteoarthritis #MedEd

@canuc_57 @VascularSVS @SIRRFS @SIRspecialists Honesty, sealed pretty quickly even before PTA. 21G micropuncture needle + inner of micro sheath

@JChurches @VascularSVS @SIRRFS @SIRspecialists Jonathan how did you handle the access site?

“The PFA is the most important vessel in the leg”. Severe rest pain. Failed fem-pop about 5-years ago, SFA occluded at least as long. LLE now holding on with fem-fem inflow & collateralized collaterals in the setting of PFA occlusion. Retro PFA + fem-fem access

@SriniTummala @canuc_57 @VascularSVS @SIRRFS @SIRspecialists Miss you, Tumz. Brickell isn’t the same without you

@JChurches @canuc_57 @VascularSVS @SIRRFS @SIRspecialists Great work buddy!

@canuc_57 @VascularSVS @SIRRFS @SIRspecialists Greg, the case above is a PFA revasc performed yesterday to keep the leg alive. You okay, man?

@JChurches @VascularSVS @SIRRFS @SIRspecialists The point is in a patient with chronic PAD and fem-pop occlusive disease, the PFA is the dominant collateral to keep the leg alive. What about this do you disagree with? I’m not sure what your point is here?

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@westleyohman @farkomd @canuc_57 A guy said the PFA is the most important vessel in the leg, @farkomd disagreed, hence this thread. Thread was never about sacrificing the profunda 😂

@JChurches @farkomd @canuc_57 But, an occlusion of those arteries WITH a PFA occlusion leads to limb threat/loss. Greg’s point is a patent PFA can preserve limb viability when those other arteries are occluded. Preserving the PFA in treatment of PAD is a view towards the long term viability of the leg.

I’ve yet to see someone suffer from an isolated profunda femoral artery stenosis. Yet it’s the most important vessel in the leh? Sounds like hyperbole and the typical dogma of vascular. I’ve never had to do a profunda femoral embolectomy for acute limb ischemia Brian

@canuc_57 @farkomd There are multiple arteries in where an isolated stenosis or occlusion can cause significant symptoms. The PFA, while important, is not one of them.

@JChurches @farkomd Well, I guess an “interventionalist” can be IR, IC, or VS. The point of the conversation is the PFA is the lifeline of the leg, not the SFA. Actually they missed that day at intervention school . Any VS who intentionally did that needs to go back to school.

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@canuc_57 @farkomd That’s interesting, Greg. I’ve actually seen it twice. I guess they missed that day at surgery school 🤷🏻‍♂️

@JChurches @farkomd Well, have to tell it like it is, I have never seen a vascular surgeon cover a profunda to open a SFA. I have however seen those pesky “interventionalists” do it.

Anatomy Pearl 21: NASOPHARYNX

To call it or not to call it? That is the question! Do you feel a bit wacky & wobbly when it comes to calling normal pressure hydrocephalus on imaging? You don’t want to overcall it, but you don’t want to miss it either! Here are the signs of NPH 🔹 Evans Index > 0.3 --Enlarged frontal horns relative to skull width → ventriculomegaly. Remember it: “One out of three is too big for me!” 🔹 Periventricular White Matter Change --T2/FLAIR hyperintensity from transependymal CSF flow. Remember it: “Leaking pressure leaves a glow.” 🔹 Narrowing of the Posterior Cingulate Sulcus --Tight high-convexity sulci from crowding at the vertex. Remember it: “The top gets squeezed shut.” 🔹 Effaced Vertex CSF + Wide Sylvian Fissures --Tight sulci up top but enlarged fissures laterally (DESH pattern). Remember it: “Dry on top, wet on the sides.” 🔹 Upward Bowing of the Corpus Callosum --Ventricular expansion pushes the corpus callosum upward. Remember it: “If the corpus callosum is arched, the patient can’t march (wobbly)” 🔹 Temporal Horns > 6 mm --Early temporal horn dilation from hydrocephalus. Remember it: “Big horns before big vents.” 🔹 Focally Dilated Sulci at the Vertex --Patchy enlarged sulci despite surrounding crowding. Remember it: “Holes in a leaky roof = too much water on the brain!” 🔹 APV Index > 0.5 --Increased ventricular-to-parenchymal proportion suggesting hydrocephalus. Remember it: “Glass half full is too much!” 🔹 Prominent Aqueductal Flow Void --Increased CSF flow through the aqueduct on MRI. Remember it: “If the aqueductal flow is super black, the ventricles are out of whack.” Classic NPH imaging theme: enlarged ventricles + tight high convexities + disproportionate CSF redistribution. Hopefully now you won't wobble on the diagnosis of NPH!!

@canuc_57 @farkomd Oh those pesky “interventionalists” always up to no good.

@farkomd Let’s be careful here @farkomd, I agree isolated PFA stenosis a moot point. However never underestimate the importance of the PFA. I’ve frequently seen “interventionalists” sacrifice the origin of the PFA to open a chronic SFA occlusion. Never a good idea. 😫

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This is my favorite study of the year. What a waste of money. But keep telling physicians to see more patients every hour. Because that is working so well….

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