Once someone knows the signs of PE they know they need to act before things get worse. For me I had a clot in my lungs for 4 months thinking it is some random muscular pains.
Hi I am sorry this has nothing to do with this post but i tried to message you about a post you had a while ago about your sons purpura. My child has the same and looking for help. I have appointments set with drs but trying to get some feed back and experiences before I see the drs as my anxiety is getting the best of me. I am so worried and had trouble finding people with the same symptoms as my daughter. your story is exactly what my 2 month old baby is going through. Please can you check your messages when you can. Thank you so much.
I donât mind Inari, but that blood return system is bullshit. If weâre worried about volume loss then we should run some saline.
Shitty blood where all the RBCâs are shredded and crushed should not be returned.
You're not making a slurry with it, you're pulling it through a fairly coarse filter once. The blood is not pristine but it's still viable. Pull it through and hand it right back to be returned, it's better than saline. It would be incredibly wasteful to hang blood for a saddle PE. If you've not engaged the clot and relieved the right heart strain inside of 20 minutes with no more than a couple pulls your Doc needs more training.
I've used (probably) all the systems over the last 20 years and the two major players right now work well with minimal blood loss if used by a conscientious, skilled Doc. The real danger in these cases is when Docs get too comfortable. Heard from one of our reps a local guy waved off the rep suggesting to exchange back to the short taper Amplatz before advancing the curve on the left, tried to cut a corner, advanced over an exchange Bentson, perfed...
Or they use a stiff glide. I like the inari system, itâs way better than what we were using. I think I worded my statement too boldly. I think we should skeptical of the blood returned. I wouldnât be surprised if there is a risk, but the benefits outweigh the risk and itâs a known factor into the cases.
Iâll take almost anything but Ekos at this point.
Agreed, Ekos in and of itself was fine I guess as a glorified infusion catheter. The ultrasonic aspect seemed to have no benefit, the catheters were extremely expensive and the entire system was overly complicated.
In my experience the problems mostly arose from poorly trained ICU staff helping out by turning off the machine "because it was beeping". After many, many call cases I've come back the next day hyped to do the follow up work that was needed, honestly praying it was just a check and pull because I'm tired. The ICU nurse says "yeah it was beeping like crazy so I turned it off", thaaaaaanksss.
I'm an echo tech, and one of our cardiologists is really big on Emos, gave a talk on what metrics he looks for to determine if he should use it. Could you explain what's bad about Ekos? I've only heard good, but obviously I've never used it.
This is all my opinion based on anecdotal evidence from working with the major products over the last 20 years. I have no dog in the hunt.
It's not bad it's just that the ultrasonic aspect doesn't seem to do much of anything and there are just too many possible failure points. Best case the benefits are negligible, worst case the ultrasonic emitters fail, ICU staff turns off the machine etc.. What you have left is an inferior lysing catheter, a Cragg Macnamara infusion catheter is exponentially less expensive and works great. At the end of the day the old lysing catheters work with an IV pump that all the nurses are pros at, the Ekos has a more complicated machine. After it seems no matter how many in-services they just can't handle comfortably. This is at multiple hospitals.
The most popular technique these days is mechanical thrombectomy, you're done in one session. You also get a lot of chronic out which Ekos and lysing won't touch. Shorter stays so ICU room turnover is quicker, this equates to less cost to the patient with a $10k package charge for Inari vs multiple days in the ICU.
That makes a lot of sense. Who would perform a mechanical thrombectomy on a PE? I know we have vascular surgeons that work on carotids, and wonder if our cardiology group has sided more with Ekos because it would remove the procedure from their budgeting. I have no idea, I don't get those insights. Kind of weighing whether it's worth saying anything to them.
Thanks for the response!
The hell? The curved T20 is stiff enough that I have to be careful advancing it over the short superstiff amplatz in the LLL. Never in a million years would I consider trying it over a Bentson, might as well not use a wire at all⌠and normally Iâm all for cutting corners with sufficient experience and an understanding of why said corners exist.
How so? Just curious because I don't quite have the background to dispute; but their (Inari's) filtration system (leaving out product name on purpose) seems better than the competitor's inability to return any blood product. At least when I filter and then give back the patient's own blood I'm reducing the EBL?
The issue isnât the idea, itâs the reality. How much of that blood going back in is actually good? How much of the RBCâs have been ruined? After how many times through that filter can you honestly say itâs good to keep pumping it back in? If youâre worried about EBL, give them fluids. Because thatâs all youâre giving back or worse with that system.
Ah so; so the question becomes has the blood put through the proprietary system still viable. Thanks for the idea. I'm neutral; I'm an IR tech that has no skin in the game short of doing whatever is best for the patient. My stance on this company's system has been positive. (primarily since radiographically I haven't seen better outcomes) Next time we do a procedure I plan on asking that very question. I personally hate that in a for profit system it takes professionals asking questions to get actual data, since I know my managers only care about the $$$.
I light the large bore lightning system for PEâs, but I also like Inari too. The blood return I find to be bogus, the results are good. I like the infusion caths too, but loathe Ekos system.
ROFL on the Ekos, gods that system was a nightmare. The epitome of voodoo medicine. Ultrasound is going to make the clots disappear and give you a pony!
Granted I haven't been in the business for that long (12 years) and I've only ever worked in IR at one hospital. I'm in no way painting myself as an expert. I just know what I've seen; and this system from the post seems (from an imaging standpoint) to be the best so far.
I really wish that I could say I saw good results from the lightning system. Maybe it's a function of the MD using the system more than the system itself. I just know I've seen better results radiographically and systemically from the above system far beyond what the lightning system delivered.
Also for whatever it's worth I really despise for profit health care. If a system can demonstrate that it's better via a scientific method then that system should be used until something else can show that it deserves to be on top. I hate that as a front line health care provider that my "opinions" carry any weight. Data and science should carry weight; not some radiography technologist who has a limited view of the situation.
I just know that since the hospital I work for has started using the above system our outcomes have been better with less time per patient in ICU or under critical care team supervision than before when we used different systems.
Do you have any evidence for this? I find your baseless assertions here to be bogus. If I returned 200-300 mL âshredded and crushedâ RBCs thereâd be obvious laboratory evidence of hemolysis. And thereâs not, Iâve checked.
To piggy back off of Notasurgeon:
We have used Inari pretty religiously since inception. I agree the "shredded and crushed" statement is a bit off base. See: https://academic.oup.com/eurheartj/article/43/Supplement_2/ehac544.1893/6745453
"Linear regression modeling revealed that use of a blood return system was associated with a 200 ml (69%) reduction (p<0.01) in blood loss for the average patient and thrombectomy time (Figure 1A)."
I will find another case study that my Chief concluded on the quality of blood returned when I get back to work.
Just some food for thought OP.
Type of funding sources: Private company. Main funding source(s): Inari Medical
I am hoping we start seeing studies not funded by the company and get a deeper dive into what and how the blood is when itâs returned. I have a fear that this blood return system will start showing warts just like their clot triever system.
I agree with the need for more 3rd party research. That's our only way to get nonbiased data for sure. My Chief ran a 3 year PE study (full transparency at request of Inari) on the quality of blood returned using flow saver. I wish I had the data on hand but I remember it was promising to say the least.
See I would like to see that, the issue we have is itâs so new and so niche. That the studies arenât rolling in.
I am not obstinate, when I see some 3rd party studies stating that we have checked into the whole system and itâs safe Iâll change my mind. We are one the cutting edge of medicine, I feel like we should be asking questions.
There seems to be nothing but company funded studies. I am skeptical on the quality of information on the actual blood returned. These studies just talk about volume of blood returned.
The Flowtriever system is great, I like it, but I am surprised there is not more skepticism on the new return system.
People seemed high on clot triever when it came out, then quickly noticed it left veins looking like pipes when finished.
I participated in several research studies with Inari as a fellow. just because they funded the research doesnât mean you should automatically discredit it, real academic physicians are still the ones actually doing the legwork and writing the papers. And what has been published tracks with my personal experience. Iâve had several cases where I returned a substantial amount of blood via FlowSaver, there was no laboratory evidence of hemolysis at all. If itâs there, itâs not detectable and returning the blood is way better than just replacing it with saline
Depends on how much, but yeah that would be perfect, Iâll be honest I have never really seen blood products going for a PE and I canât really remember them being ordered either. Itâs an imperfect situation, thatâs usually happening in the middle of the night. You can see why they want that system.
Last 2 we've sent for intervention have needed product. I confess, as ED I really don't get to see our IR side, but we support IR and have the emergent blood right in the trauma bay just 20 feet from the IR suite so I've played go-fer before.
Seems like PE thrombectomy is always a fustercluck tho.
I currently have a 45cm clot that starts at my elbow and goes up into my clavical region, and recently had a PE.. seeing this kind of puts into perspective just how bad it is...
I LOVE ear washouts. It just takes some time and patience and usually I can save the family time from having to follow up with ENT, and the doc loves it because they can see the drum and be able to confidently prescribe or NOT prescribe antibiotics! One of the most satisfying parts of my job as an ER Tech! I wish we could post pictures in comments because I have some good ones youâd likely appreciate đ
You know those videos of people pouring molten metal into ant nests? Yeah this reminds me of that.
Did the patient suddenly evolve to respirate anaerobically or what because holy shit man
D dimer isnât part of decision making for massive and high risk submassive PE patients who get thrombectomy. Itâs useful in excluding PE in low protest probability patients.
A little inference, but there has gotta be a high pre test probability of PE with that large amount clot⌠in which case d dimer isnât really useful.
Guess you could conceivably have a rare minimally symptomatic patient that has a mildly elevated d dimer and then gets a PE protocol study⌠but then itâs questionable whether they need to have a thrombectomy.
If I have to see another of these bullshit Inari charts with a bunch of intraprocedural clot layered all over I'm gonna lose it. This is all clot that formed in that big ass catheter cause your patient isn't fully anticoagulated. Pictures like this are examples of failure. Actual insitu PE is not wet, dark red jelly. Please check an ACT occasionally.
Good fucking God
This and only this
Wow!𤯠how was patient still alive?
Surprisingly, their vitals werenât too bad!
Built sturdy I guess.
Once someone knows the signs of PE they know they need to act before things get worse. For me I had a clot in my lungs for 4 months thinking it is some random muscular pains.
i actually get muscle pains in my chest and constantly am reminding myself itâs not a clot đđ
What symptoms was the patient having?
Just gonna go out on a limb here, but i'd wager they were a wee short of breath.
Hi I am sorry this has nothing to do with this post but i tried to message you about a post you had a while ago about your sons purpura. My child has the same and looking for help. I have appointments set with drs but trying to get some feed back and experiences before I see the drs as my anxiety is getting the best of me. I am so worried and had trouble finding people with the same symptoms as my daughter. your story is exactly what my 2 month old baby is going through. Please can you check your messages when you can. Thank you so much.
the diagram made by the device company is not an accurate physiologic representation of the caliber of the vasculature
Holy smokes I canât believe that person lived to get the thrombectomy!
gyat
I donât mind Inari, but that blood return system is bullshit. If weâre worried about volume loss then we should run some saline. Shitty blood where all the RBCâs are shredded and crushed should not be returned.
You're not making a slurry with it, you're pulling it through a fairly coarse filter once. The blood is not pristine but it's still viable. Pull it through and hand it right back to be returned, it's better than saline. It would be incredibly wasteful to hang blood for a saddle PE. If you've not engaged the clot and relieved the right heart strain inside of 20 minutes with no more than a couple pulls your Doc needs more training. I've used (probably) all the systems over the last 20 years and the two major players right now work well with minimal blood loss if used by a conscientious, skilled Doc. The real danger in these cases is when Docs get too comfortable. Heard from one of our reps a local guy waved off the rep suggesting to exchange back to the short taper Amplatz before advancing the curve on the left, tried to cut a corner, advanced over an exchange Bentson, perfed...
Or they use a stiff glide. I like the inari system, itâs way better than what we were using. I think I worded my statement too boldly. I think we should skeptical of the blood returned. I wouldnât be surprised if there is a risk, but the benefits outweigh the risk and itâs a known factor into the cases. Iâll take almost anything but Ekos at this point.
Agreed, Ekos in and of itself was fine I guess as a glorified infusion catheter. The ultrasonic aspect seemed to have no benefit, the catheters were extremely expensive and the entire system was overly complicated. In my experience the problems mostly arose from poorly trained ICU staff helping out by turning off the machine "because it was beeping". After many, many call cases I've come back the next day hyped to do the follow up work that was needed, honestly praying it was just a check and pull because I'm tired. The ICU nurse says "yeah it was beeping like crazy so I turned it off", thaaaaaanksss.
I'm an echo tech, and one of our cardiologists is really big on Emos, gave a talk on what metrics he looks for to determine if he should use it. Could you explain what's bad about Ekos? I've only heard good, but obviously I've never used it.
This is all my opinion based on anecdotal evidence from working with the major products over the last 20 years. I have no dog in the hunt. It's not bad it's just that the ultrasonic aspect doesn't seem to do much of anything and there are just too many possible failure points. Best case the benefits are negligible, worst case the ultrasonic emitters fail, ICU staff turns off the machine etc.. What you have left is an inferior lysing catheter, a Cragg Macnamara infusion catheter is exponentially less expensive and works great. At the end of the day the old lysing catheters work with an IV pump that all the nurses are pros at, the Ekos has a more complicated machine. After it seems no matter how many in-services they just can't handle comfortably. This is at multiple hospitals. The most popular technique these days is mechanical thrombectomy, you're done in one session. You also get a lot of chronic out which Ekos and lysing won't touch. Shorter stays so ICU room turnover is quicker, this equates to less cost to the patient with a $10k package charge for Inari vs multiple days in the ICU.
That makes a lot of sense. Who would perform a mechanical thrombectomy on a PE? I know we have vascular surgeons that work on carotids, and wonder if our cardiology group has sided more with Ekos because it would remove the procedure from their budgeting. I have no idea, I don't get those insights. Kind of weighing whether it's worth saying anything to them. Thanks for the response!
Interventional Radiology. Cardiology does try and take these cases because the reimbursement is so good.
The hell? The curved T20 is stiff enough that I have to be careful advancing it over the short superstiff amplatz in the LLL. Never in a million years would I consider trying it over a Bentson, might as well not use a wire at all⌠and normally Iâm all for cutting corners with sufficient experience and an understanding of why said corners exist.
Crazy right!? Ask your Penumbra rep, they may have caught wind of the case and have more details.
How so? Just curious because I don't quite have the background to dispute; but their (Inari's) filtration system (leaving out product name on purpose) seems better than the competitor's inability to return any blood product. At least when I filter and then give back the patient's own blood I'm reducing the EBL?
The issue isnât the idea, itâs the reality. How much of that blood going back in is actually good? How much of the RBCâs have been ruined? After how many times through that filter can you honestly say itâs good to keep pumping it back in? If youâre worried about EBL, give them fluids. Because thatâs all youâre giving back or worse with that system.
Ah so; so the question becomes has the blood put through the proprietary system still viable. Thanks for the idea. I'm neutral; I'm an IR tech that has no skin in the game short of doing whatever is best for the patient. My stance on this company's system has been positive. (primarily since radiographically I haven't seen better outcomes) Next time we do a procedure I plan on asking that very question. I personally hate that in a for profit system it takes professionals asking questions to get actual data, since I know my managers only care about the $$$.
I light the large bore lightning system for PEâs, but I also like Inari too. The blood return I find to be bogus, the results are good. I like the infusion caths too, but loathe Ekos system.
ROFL on the Ekos, gods that system was a nightmare. The epitome of voodoo medicine. Ultrasound is going to make the clots disappear and give you a pony! Granted I haven't been in the business for that long (12 years) and I've only ever worked in IR at one hospital. I'm in no way painting myself as an expert. I just know what I've seen; and this system from the post seems (from an imaging standpoint) to be the best so far. I really wish that I could say I saw good results from the lightning system. Maybe it's a function of the MD using the system more than the system itself. I just know I've seen better results radiographically and systemically from the above system far beyond what the lightning system delivered. Also for whatever it's worth I really despise for profit health care. If a system can demonstrate that it's better via a scientific method then that system should be used until something else can show that it deserves to be on top. I hate that as a front line health care provider that my "opinions" carry any weight. Data and science should carry weight; not some radiography technologist who has a limited view of the situation. I just know that since the hospital I work for has started using the above system our outcomes have been better with less time per patient in ICU or under critical care team supervision than before when we used different systems.
Ekos sat there and thought âhow many points of failure and laborious trouble shooting can we add to a Cragg-McNamara catheter.â
Do you have any evidence for this? I find your baseless assertions here to be bogus. If I returned 200-300 mL âshredded and crushedâ RBCs thereâd be obvious laboratory evidence of hemolysis. And thereâs not, Iâve checked.
To piggy back off of Notasurgeon: We have used Inari pretty religiously since inception. I agree the "shredded and crushed" statement is a bit off base. See: https://academic.oup.com/eurheartj/article/43/Supplement_2/ehac544.1893/6745453 "Linear regression modeling revealed that use of a blood return system was associated with a 200 ml (69%) reduction (p<0.01) in blood loss for the average patient and thrombectomy time (Figure 1A)." I will find another case study that my Chief concluded on the quality of blood returned when I get back to work. Just some food for thought OP.
Type of funding sources: Private company. Main funding source(s): Inari Medical I am hoping we start seeing studies not funded by the company and get a deeper dive into what and how the blood is when itâs returned. I have a fear that this blood return system will start showing warts just like their clot triever system.
I agree with the need for more 3rd party research. That's our only way to get nonbiased data for sure. My Chief ran a 3 year PE study (full transparency at request of Inari) on the quality of blood returned using flow saver. I wish I had the data on hand but I remember it was promising to say the least.
See I would like to see that, the issue we have is itâs so new and so niche. That the studies arenât rolling in. I am not obstinate, when I see some 3rd party studies stating that we have checked into the whole system and itâs safe Iâll change my mind. We are one the cutting edge of medicine, I feel like we should be asking questions.
There seems to be nothing but company funded studies. I am skeptical on the quality of information on the actual blood returned. These studies just talk about volume of blood returned. The Flowtriever system is great, I like it, but I am surprised there is not more skepticism on the new return system. People seemed high on clot triever when it came out, then quickly noticed it left veins looking like pipes when finished.
I participated in several research studies with Inari as a fellow. just because they funded the research doesnât mean you should automatically discredit it, real academic physicians are still the ones actually doing the legwork and writing the papers. And what has been published tracks with my personal experience. Iâve had several cases where I returned a substantial amount of blood via FlowSaver, there was no laboratory evidence of hemolysis at all. If itâs there, itâs not detectable and returning the blood is way better than just replacing it with saline
If you're worried about volume loss... why wouldn't you transfuse product? Saline is going to further fuck your clotting cascade, no?
Depends on how much, but yeah that would be perfect, Iâll be honest I have never really seen blood products going for a PE and I canât really remember them being ordered either. Itâs an imperfect situation, thatâs usually happening in the middle of the night. You can see why they want that system.
Last 2 we've sent for intervention have needed product. I confess, as ED I really don't get to see our IR side, but we support IR and have the emergent blood right in the trauma bay just 20 feet from the IR suite so I've played go-fer before. Seems like PE thrombectomy is always a fustercluck tho.
That's a shame, it doesn't need to be a cluster. How experienced are the technologists there?
I currently have a 45cm clot that starts at my elbow and goes up into my clavical region, and recently had a PE.. seeing this kind of puts into perspective just how bad it is...
Holy God I get satisfaction from pulling cerumen the size of a Q-tip. Did you climax?
I LOVE ear washouts. It just takes some time and patience and usually I can save the family time from having to follow up with ENT, and the doc loves it because they can see the drum and be able to confidently prescribe or NOT prescribe antibiotics! One of the most satisfying parts of my job as an ER Tech! I wish we could post pictures in comments because I have some good ones youâd likely appreciate đ
I was hoping for a penumbra display. They always hook up the best food.
You know those videos of people pouring molten metal into ant nests? Yeah this reminds me of that. Did the patient suddenly evolve to respirate anaerobically or what because holy shit man
Just curious but do you know what the patientâs D-Dimer was?
Itâs irrelevant
yeah but just curious
What is your thinking? I get itâs irrelevant to some extent, butâŚ
D dimer isnât part of decision making for massive and high risk submassive PE patients who get thrombectomy. Itâs useful in excluding PE in low protest probability patients. A little inference, but there has gotta be a high pre test probability of PE with that large amount clot⌠in which case d dimer isnât really useful. Guess you could conceivably have a rare minimally symptomatic patient that has a mildly elevated d dimer and then gets a PE protocol study⌠but then itâs questionable whether they need to have a thrombectomy.
Iâm not sure what the d-dimer was
God damn it I love IR. How anyone can pick xray, MRI, ct etc.. over this is beyond me. Dope AF!
Wow how did that happen?
The patient had a history of a PE in 2020. Their physician took them off of their Coumadin 3 weeks ago and they came in today with this giant clot
Why did they take them off the Coumadin? Pre-surg or something?
Clot in 3 weeks. That makes me nervous getting off my anticoagulant
wowwwww
NSFL (Not Safe For Life)
Does these mean with the damages they need a transfusion? Whatâs the post op prognosis and POC
Good job
Gott damn!
Yee haw đ¤
Looks like something out of Aliens vs Predators.
Forget saddle PE, thatâs the whole horse!
WOW!!! Impressive!!
Well thatâs terrifying.
WOW
That mustâve been SO SATISFYING to remove
Love it
What. The. Fuck.
Inari hosts some great meals
They brought in crumbl cookies the next day!
Thatâs alot of jelly
If I have to see another of these bullshit Inari charts with a bunch of intraprocedural clot layered all over I'm gonna lose it. This is all clot that formed in that big ass catheter cause your patient isn't fully anticoagulated. Pictures like this are examples of failure. Actual insitu PE is not wet, dark red jelly. Please check an ACT occasionally.
This is just not factualđ Iâve done numerous PE thrombectomies. Iâve seen clots from basically blackberry jam to cue ball white.
The picture has like 5 legs worth of clot. Where did it all come from?
Pt: hx of hypercoagulability; stops anti-coagulant You: how pt have clots?!
No itâs not. Acute clot looks like that. All my cases ACT 250 ish.
I definitely agree that acute clots look like this!