Hi everybody, welcome to the symposium. Thank you for coming. My name is Tai Kobayashi. To my left here is Elias Dayoub. In the room we have Mike, Trent, and Paige as our nurses, and we're going to be showing you an example of a radiofrequency RDN today. So we're just going to start with arterial access in the standard fashion, just making sure that we really pay close attention to the technique. We're utilizing ultrasound. We've already established where the bifurcation of the femoral arteries were and where the arterial course dives into the retroperitoneum, so you'll see here that we're just going to get standard femoral access under ultrasound guidance. So what we're looking for in general is, you'll see here, what you want to note is T12, which is where the ribcage starts. This is L1. This is L2. The majority of the renal arteries will come off between L1 and L2, so you kind of can see that we've positioned our catheters so that the pigtail is ready to shoot right where the inner space between L1 and L2 are. What we want to be careful of in general is to ensure that the catheter and the field of view is large enough that you're going to pick up any accessory renal arteries you can come off of. Accessory renal arteries that may come off a little bit further down towards the L3, L4, L5 space. So we just want to make sure that everything kind of fits into this particular picture here. We are going to take this on digital subtraction angiography to make sure that we account for all renal arteries. And so we're going to ask our staff to step back here just to save the staff from radiation here, okay? So to me, it looks like there's two single renal arteries. I don't see any accessories coming off at L3, L4, L5 or anything like this, but we'll confirm with an aortogram. This one, actually, these arteries come off a little higher, right, because they come off right at the top of L1. So what we're doing now is we're using a short 55-centimeter IM guide catheter to select to use for selective angiography of the renal arteries. Come a little higher here, Les. Even a little higher than that. Yep, perfect. In general, you can use a six-wrench IM guide. You can use an RDC1 or the two most commonly used guide catheters. We've always found that the IM guide is very simple to use and can engage both renal arteries with one catheter. So we're going to go ahead and do that. So one of the key tricks to start spacing out where the branches start coming off is to skew your view a little bit ipsilateral towards the kidney. So in this particular shot, we'll take a 50-50 die selective angiogram here and mag up a little. Okay? Yep. Stay on it. Off. So some of the things that you're looking for are exclusion criteria of the particular artery. So you're looking for FMD, you're looking for renal artery stenosis, you're also looking for renal artery aneurysms. Renal arteries that have atherosclerosis, what we were just discussing is that the superior branch here is going to be not a target. So we treat the whole thing as a main, but we still want to be five millimeters away from any sort of atherosclerosis in general. This is actually pretty reasonable anatomy. We just start here, do this, sorry. We'll start. So the targets here are going to be relatively straightforward. Superior branch, the inferior branch, and then the main five millimeters before the area of stenosis. This superior branch to the renal artery is too small to treat, and so that'll be our treatment plan for the right renal artery. We'll flip sides and take a look at the left. All right, so again, similarly, there's one left renal artery here. So to me, agreed that there's going to be three branches. So Elias already pointed out the targets here. There's going to be this middle branch, superior branch that actually turns and dives downward inferiorly, and then the inferior branch here, all three will be targets, and then the main. So at this point, we've had a procedural plan. He meets no obvious exclusion criteria outside of what we already talked about. So we're going to move forward with renal denervation. So why don't we start the heparinization process? Why don't we give him 8,000 heparin right now, please? Prior to the patient actually coming onto the table, what we should just remember is that we should prepare the patient for the spiral firm study and moving forward with our case. And so what we've done prior to prepping the patient is we put on a grounding pad to ensure that this is not something that you're doing in the middle of the case. So the patient already has a grounding pad in place. So the idea here is that, you know, any non-jacketed wire can be used. We do use the Medtronic Thunder Wire. It's an 014 wire that is provided by Medtronic. And we're going to be wiring the renal arteries, all the targets. And remember, the idea here is to go distal to proximal. So that's going to be our plan here. Okay. So this is the device itself. It comes in the little plastic kit here. As the logo says, you just want to pop the top off. This goes to the generator. So I'll put that to the back of the table for now. Gently pull out the spiral catheter. You'll notice that the spiral catheter gets its shape from the spiral that it makes. It comes with not only the handle, but it also comes with this orange introducer tool, which straightens out the spiral, like so, so that it's easier for you to get the catheter onto the wire. Once the wire is in place, this is an RX port. You can bring the orange introducer all the way back to the handle. And then just like a standard PCI, we use the RX port to deliver the spiral catheter. Okay. So go a little further out if you can. This might be the most superior branch that starts up and then drives down. So can you get the wire out any further than that? Okay. That should be far enough. So why don't you bring your spiral catheter upwards. And you need to pay pretty close attention to your guide catheter, because it looks like it's out in the aorta ostium. So just be careful. The more you push upwards, the higher it's going to go up into the aorta. Nice. Okay. Now go a little further, and I'm going to counter clock your catheter just a little bit to straighten things out like that, and I'll start pulling back your wire. Okay. Just some forward tension there. Yep. Nice. Perfect. Okay. So four up here, get off. So let's review that. So that is the superior branch, and we are clearly five millimeters away from the ostium of where this takes off superiorly, and I think we can actually treat all four here. When we start talking through the case, you'll notice that we're going to be talking about turning various different electrodes on and off. That's one of the unique things about this particular catheter is that you're able to control where the energy output is going to be and which electrode it's going to. So now what we're going to do is we're just going to connect the catheter to the generator. So I'll hand that off here, and I'm going to show you what the generator looks like on the screen. That looks perfect. And then in addition, the generator can be utilized in several different ways, but one of the ways that we utilize the generator in regards to controlling which electrodes go, you can actually manually do it from the generator itself, but we elect to use the remote. So I'll take the remote, guys. So here we have a sterile sleeve that we're just going to put the remote into, and that'll just sit at the back of your table when you're ready to generate. Okay, so some of the things that we're noticing on the screen already in the generator screen is that you'll notice that there's impedance levels that are being shown, which are in the 200 to 300 range, which is normal. We want to see this. That tells us that we are abutting the wall of the arteries. What we're going to do next is we're going to take a confirmatory shot that we like where our placement of the catheter is, and we will then choose which electrodes to turn on and off. So we're going to do that, but we are going to be utilizing some intra-arterial nitroglycerin prior to so that we enlarge the arteries as large as possible. So I think we have adequate sedation. Let's just double-check our spot. It hasn't moved, so we are planning on treating this. This will be the left, and we'll start treatment. We're going to see if this is okay. Sounds good. I've got some more meds coming your way. Try to keep those arms to your side. Okay, so I think we're pretty much done with this particular superior artery. I love where that is. We're going to move on to the next, so I think we're going to either go to the middle or the inferior range. I want you to advance your wire here. I'm going to get 150. Great. Thank you. Out there? Yep. Different artery right there. All right, that's the middle range. That's the middle one, yeah. I'm going to advance the spiral over this wire. Can you put some counter on this if you don't mind? Nice, okay. Is this full? Yeah, it's not full. Okay, four. Excellent. All right, so we are in the middle branch, and I do think that we're probably five millimeters away from the ostium or the one that goes inferior, so I'm willing to take all four of these with the one caveat that we are going to have to pull back our wire just a little bit more here from electrode four. Perfect. Nice. So we're in a tree. So one of the things here is that as you pull back on your spiral catheter, you may want to utilize the helical shapes to point downwards so that you can then engage the inferior branch. Excellent. I'm going to kind of try and turn your catheter down here. Right there. Pull back your wire. See if the wire advances now. Nice. Keep going with your wire, please. And that's fine. You can take that J. Okay. Keep advancing. Nice. Keep going. So that was a nice example of utilizing the spiral catheter shape to be able to engage some of these arteries here that have tortuous bends. Why don't you advance your spiral catheter now? Okay. You can go a little further. And put a little forward tension on the spiral catheter as you pull back on your wire here. Okay. Go ahead. Nice. Okay. Pull back a little more with your wire. A little more forward tension with your spiral catheter. Okay. It appears to be pretty far out there, but I think that that's okay for this particular shot. So in this particular shot, it does look like electrode 1 does look like it's pretty far out there. But electrodes 2, 3, and 4 appear to be in good position. So what we're going to do here is we're going to turn electrode 1 off. Okay. And we're going to go ahead and treat. Yeah, although the last one was disruptive because everything you wanted to do was out. Perfect. All right. So why don't you pull the catheter backwards? Mm-hmm. Mm-hmm. So bring 1 to where 4 was. The tall order. Just a little more there. That's nice. About there? Yeah, I think so because I think you've got an approximate portion, so then remember that when you pull the wire back, it's going to pull back a little bit. Pull back. So why don't you pull the wire and see how the catheter then acts. We're going to confirm placement here. Mm-hmm. Okay. See where that is. Okay. So electrode 4 is right at the osteum and the branch point of the more higher distal renal artery that we've already treated. And so electrode 3 and electrode 2 appear to be in nice position. I think electrode 1 overlaps with where electrode 4 was on the previous burn. So we're just going to do electrodes 2 and 3. Mm-hmm. Mm-hmm. And then we just have to do the main. We're done with this side. Okay. Pull the catheter back. Yep. Okay. Yeah, so this is a great example, again, just to show that each electrode is being monitored by the generator. And when the generator finds a problem with one particular electrode, it has an algorithm to either shut everything off or to shut off the energy that's delivered to one electrode. So in this particular case, the generator has picked up that the electrode may have moved. That may be based off of temperature drops or impedance drops or changes, rather. And it has shut off any sort of electricity to the third electrode. You could see that electrodes 1, 2, and 4 are performing normally, and they've completed their treatment. And so in this particular case, what we'll do is we'll adjust the position of the catheter by just putting a half-turn o'clock on to the catheter to ensure that the patient's arteries are nicely opposed. Furthermore, we're going to assess for the level of sedation. In this particular case, the patient is very well sedated. So we're going to attempt this one more time with just the isolated number 3 electrode to treat. Beautiful. All right. Beautiful. Everything looks great.

radiofrequency renal denervation

ultrasound arterial access

digital subtraction angiography

Medtronic Thunder Wire

spiral catheter

patient sedation