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00:00:00
oh thank you very much it's really a great player for me to be here
00:00:05
as a we have a and longstanding an extensive fruitful cooperation with uh
00:00:12
the big bosses here in the first roll and i'm
00:00:16
really really pleased to be a hearing them
00:00:20
in uh i methodology student uh maybe seen so in a word
00:00:24
we see any type operation but we have a special
00:00:27
interest in uh only with disease and due to sound clinical
00:00:30
to sound and these is spending since about four years
00:00:34
and was started by my director prefers visible only an elisa but we got to draw in uh
00:00:41
our environment in our hospitals with multi number you need but uh the
00:00:45
something which is not specific our unit but is a a standard
00:00:49
or italy where most clinicians to perform with the sound and interventions
00:00:54
on the wrong and we have also a baby streak corporation
00:00:59
with the the radiologist that are in our same building so
00:01:02
we discuss the cases together we have meetings together
00:01:06
and uh since a year from now we'll start the about the ball
00:01:10
the boss will be with disease study group which is uh
00:01:13
cheered also by a professor the good to have the on an international basis but we discussed together
00:01:20
in a multi disciplinary by remember these difficult cases with the good but would be the surgeon
00:01:25
that indicated the radiologist peons all this for for protocol approaches
00:01:29
on the human toll does because often they have
00:01:32
on the levee underlying the with disease my talk today
00:01:35
will focus uh on imaging modalities with the uh
00:01:41
lot just part of the board to tool to sound because the this is something that you can perform
00:01:46
on your own personally and so i. e. uh to be time to sets many even this so that you can
00:01:54
uh collect them in our minds to maybe recall them when you see a uh cases but trying to
00:01:59
also apply this structure that we have when we approach
00:02:04
these patients so we'll touch base with the uh
00:02:11
shall i always better better show uh utilise the pointer or the mouse the
00:02:17
same for you okay if it works shouldn't where's the point about
00:02:20
so i would touch with a a very short big round about the frequency of composes
00:02:27
uh means heroes is because we have that onto roses and presupposes factors
00:02:32
and not to be over the portal windows big the beast it mainly to understand which techniques to apply
00:02:37
the detection extension of them was this shirt is racial portal been
00:02:41
from was and the assessment of the response to treatment
00:02:46
so the prevalence is a reported very valuable in different studies
00:02:52
and most importantly web all to always to keep in mind there
00:02:56
are two different types of what is called for moses
00:03:00
one is the uh caught and it's called also bland for for for more
00:03:04
just so when use here the word bland from was it means
00:03:08
this is not this is simply a the platelet opposition and the clocks
00:03:13
and the the best is can you stop but also because there there is an invasion from the two more
00:03:19
mainly observer 'cause you normal because this is the common is to to more which tends to invades
00:03:25
the the better brains but it can walk were also in panther punk about because you know my ah
00:03:32
and uh in a metal static a portal brain uh
00:03:36
two more invasion which uh whatever are quite rare
00:03:40
and uh we have to keep them in mind but they are not a very common
00:03:45
so just to have a an idea these was able to century study that was run
00:03:50
in a several units of internet maybe scene and propose bay that were national society
00:03:56
so all patient admitted to uh to these units was cleaned uh for having the uh
00:04:03
the portal vein thrombosis in c. forty patients and the overall prevalence was sixteen
00:04:10
point seven percent out of a nearly eight on the the patients
00:04:16
as you can see here this was the definition so the these clearly includes patient
00:04:21
who already have what the base imposes an uncanny again to the controls
00:04:26
as where a patient with the new a case of from poses as you can see here that portal basin trouble is is
00:04:32
in the study was suspected one solid and aluminium idea was detected
00:04:36
in the main franco the portal vein of these branches
00:04:39
by with the sound mean doppler examination so these are ready the clears which is usually the first
00:04:45
image modality uh to be uh utilise bases the prevalence so how many patients with zero these
00:04:53
coming into our lead have a portal been for moses and this is the incidence so how
00:04:59
many new cases they're up in patients who are not affected by from was before
00:05:05
this is a study run the my start study comparing
00:05:08
three man's that's just six months into about
00:05:12
for the assessment of the occurrence of it but also that 'cause you norma
00:05:16
but since the station received in emerging over the upper abdomen also all
00:05:21
they all chorus of portable for moses was recorded and a
00:05:26
again also in these cases the first technologies was made by with the sound
00:05:30
and conferred by contrast and has a city or i mean i
00:05:34
if you can see here the number where huge and partial obstruction was found in
00:05:39
eighty seven patients all cool really maybe six seven patients complete in seventeen
00:05:45
and it changes over time from partial to complete in a a
00:05:49
fourteen they also showed the the uh progression or not
00:05:55
of the only the disease and the compensation but what is
00:05:58
important is that overall the uh incidence was uh
00:06:02
five percent to one yeah eight percent that three years and ten percent of ideas
00:06:07
so these means is a quite common disease because out of five years
00:06:11
one of ten all our subtlety patient will develop a these
00:06:16
uh condition or a question is when it a lot
00:06:20
porter this imposes that's yours heroes he wasn't that the big compensate
00:06:25
and it you devalue can analysis there is a trend towards a
00:06:31
increase of leaving disease progression and the compensation so worsening of lot exams
00:06:37
or a over the compensation however these were not statistically significant it will
00:06:42
too but it analysis and in the end it is unclear whether
00:06:48
they portal they'd proposes a chorus wars and even
00:06:52
function or whatever that is a some
00:06:55
condition which wasn't even function and as a complication this
00:07:00
patient also develop a a portal the interim hoses
00:07:03
so there is actually no real situation where uh we can predict what
00:07:08
is going to happen at the time portal been to moses
00:07:11
accordance this is a prospective study and i would like to outline
00:07:16
uh that these were only tend to be in see patients
00:07:20
which are a as shown by these that that more often suffering by
00:07:25
a port of interim was you see that uh it two years
00:07:28
the rates of patients not receiving prophylactic uh and
00:07:33
the quiet ones because the study was aiming
00:07:35
it's showing the benefit that was the most slated of uh and the
00:07:39
quiet ones but the control group did not receive any profit axes
00:07:43
and as you can see the rate of development of a product that reported it from both these are
00:07:50
much bigger than intel eight pages because so variances applied usually instead a
00:07:56
patience and we've seen that it clears the rate is eighty percent
00:07:59
well he actually as is twenty seven percent because we're all prospective
00:08:03
studies so all that the weather core that does that
00:08:06
really so the data so if we have a patient with the lady instead
00:08:10
to be we have to be very careful looking for puerto vince importance
00:08:17
so that they come points of these big round is that a portal winter moses a
00:08:21
common find the is about impatience particularly if they have said b. or c.
00:08:27
and this should be kept in mind because that what patient you should undergo a
00:08:32
that is a variance in probably we out before being surveillance for these patients
00:08:37
therefore operators must be familiar with the findings imagine patents on port of interim
00:08:42
was is we have to keep in mind what is going to
00:08:45
the other but most importantly we must be actively impatiently search for the
00:08:52
nickel portable into more just because if if it goes undetected
00:08:56
any peas and treated you may progress doing been good about to the the next examination
00:09:02
and that it might become more longstanding more difficult to be resold it
00:09:08
so it is this is very important because uh as we will see part of
00:09:11
it imposes does not only cool in into the party portal vein branches
00:09:16
so we have to actively the look in the port is plenty
00:09:19
of blame to pay them isn't very contain important rank
00:09:24
as the older sum up later should we have an idea
00:09:28
whether some patients are at higher risk of uh
00:09:31
uh they're looking these finding apart from the the the dysfunction so if
00:09:37
the big background courses in nancy talking leave us we can call the
00:09:42
new normally that i plainly all conditions of local inflammation infection or
00:09:48
a trauma feel weak condition like milo probably for
00:09:51
the this or this hyper cognitive conditions
00:09:55
what is this effect less the situation is zero to patients because
00:10:00
you got the patient tend to have more local uh factors
00:10:05
that's a fair were the um occurrence of portal vein thrombosis
00:10:11
this is a another prospective study which uh excluded all patient with that with these
00:10:17
known causes of uh uh which favour portable from both zone operation with
00:10:24
cancer or uh other side all the the the most started this or there's no
00:10:29
previous pretty philbin stumbles this so after excluding all this patient with a
00:10:35
history of a high every scroll through moses the then started
00:10:39
and follow that for one yeah one hundred patients
00:10:43
out of this uh um the ultrasound was
00:10:47
performed every six man's as expected instead
00:10:49
of impatience the endpoint what the detection of puerto bins for moses and again
00:10:55
the technology was made by with a sound and doppler income for basically
00:11:01
and as you can see here after excluding patient who dropped from
00:11:04
the fall out because i that died or with transplanted
00:11:08
and they reportedly information whether that they had portal with remorse is but this could be the case
00:11:14
anyhow in the many patients sport of interim pauses according
00:11:18
a twelve out of thirteen so eighteen percent
00:11:22
in one yeah but is it relatively high percentage however as you
00:11:25
can see here fifty percent will sell to b. or
00:11:28
c. so it is consistent with the data or eighty can be less so this is the seems real data
00:11:35
and the the factors that were associated with the least
00:11:39
important ways from bodies where low platelet count
00:11:42
so this is important to keep in mind that that usually when you have
00:11:46
low platelet count we think only about three scroll the have mores
00:11:50
why the zeroes is low platelet count usually means higher portable pension and the uh high uh
00:11:57
hey more quite with the imbalance and this was associated with the occurrence of portal with through moses
00:12:03
abnormalities of from buffy factors and this was that
00:12:07
novel that of the study a slow
00:12:10
flow less than the portal vein flow velocity less than fifteen centimetres per second
00:12:15
i'm a bit proud of the study because i'm accustomed to doc okay i mean our centre
00:12:19
to learn when to summon doppler and when she went back she provided the study
00:12:25
so if we see a patient was low puerto from all we have to keep
00:12:28
in mind what he can so the next time to be sort valid for
00:12:32
uh an apple circus normal but is it diaries of portability moses
00:12:38
so this is the situation that we face and that when we use ultrasound we have to keep in mind
00:12:44
that that we had a very we are very good to uh investigate the internet patrick a basis
00:12:50
left puerto branch right proper brands segmented branches
00:12:55
and the dior and posted advances
00:12:58
fourth for and second segment dances the main portal thank is not
00:13:03
always very well visible sometimes that is intel pause i guess
00:13:07
uh from the gastrointestinal tract these one of the reason why we why the patient to four
00:13:12
be fasting for six eight hours because we want the store much to b. and b.
00:13:17
but even with empty storm uh sometimes the portal track is not very well visible so
00:13:22
we we can see doppler signals that is the bay might be difficult to detect
00:13:27
a tiny portions of a as for moses what as we must
00:13:32
re uh acknowledged that in the superior ms intelligent way apart from the distal track
00:13:38
in the infield missing page lane in the middle thought of this plainly bane
00:13:42
this is the t. v. deal with the sound is relatively port
00:13:45
x. spatially if we don't pay attention to explore these areas
00:13:49
so the easy to be kept in mind and if there is
00:13:52
any suspicion because maybe the patients become symptomatic we must
00:13:57
be aware that to the sound may not be enough alone and we have to resort to city or i mean i
00:14:06
so how and where to detect them was is uh it kinda
00:14:09
cool everywhere even is related so i mean that uh
00:14:13
uh in this planet vein thrombosis might oh cool regardless whether these from
00:14:19
was is even in the portal trunk or in been to partake
00:14:23
uh tracks or in the supreme isn't very being the commas place usually is here probably
00:14:30
because there is low vital items i cannot tell but this is the most common uh place so
00:14:38
we already mentioned that all the studies utilised ultrasound because this
00:14:42
is the tool that we utilised to investigate our patients
00:14:47
and fortunately with the sound is relatively actuate to
00:14:51
diagnose what exclude portal been for moses
00:14:54
at least as i mentioned when when exploring been to patty branches the
00:15:00
these that tract of the portal track as well because we can see then we
00:15:04
can seep through intercourse those can so avoiding been the pose a gas
00:15:10
well when we go to custody in some patients there is a lot of
00:15:14
gas and the some part of the portal tank might remain unix portable
00:15:19
what is a there's plenty plane is often what explore
00:15:23
the ball uh in it's the start part so
00:15:27
uh in front of the order that whereas in the middle part is the mansion
00:15:31
is not really a often visible and the sensitivity drops there so we
00:15:39
raise the suspicion of drum was when there is some it quite material within the portal been loon
00:15:45
the radical it should appeal black because bill's liquid so when there is a
00:15:49
a quite material we should think about uh from was i don't state
00:15:54
we diagnose long was because it quite materials might be happy fact from linda posing gas
00:15:59
so don't always want to see a collie is definitively from was
00:16:04
sometimes even very slow for all might be that cory so we have
00:16:09
to raise the suspicion and adopt other techniques to confirm that this is it from us
00:16:15
if the trial was is indeed in place the portal track can appear belated
00:16:21
usually when there is a complete occlusion but mainly when there is it to one
00:16:25
crumbles usually when there is a bland from was it occupies the little man
00:16:31
but does not expanded because usually it expands longitudinal d. after the
00:16:35
strongest and before the drums but it does not enlarge
00:16:39
they they still be on the the media that was present before the
00:16:43
thrombosis uh the cars in the city of the cloud is valuable
00:16:48
in the in the faces it is high point caloric then it tends to be
00:16:53
calm eyes though and then a hypothetical ache and over time each shootings
00:16:59
and we can see more and more high protocol can a
00:17:01
fibre optic however it is impossible to put a bait
00:17:06
in front of the drum was to tell whether these is the athens one day ten days
00:17:11
or one man's soul oh please refrain to date the strong
00:17:16
was based on that with the sound that bought them
00:17:20
colour doppler and spectral doppler flow battery improve sensitivity
00:17:25
inadequacy of baseline basically with the sound
00:17:29
but they do not always improve they might even sometimes overlook
00:17:33
uh the uh trauma was as i will show you because with the call
00:17:38
to be more sensibly we often put the game and so it might
00:17:43
extend over the throng was showing apparently the the scroll but before is the l.
00:17:48
by any does not be alec specially when the combos is body it out
00:17:52
is only the wall of the vessel and it does not all by the entire a
00:17:56
human however it is practically non that thirty to integrate the conventional grey scale
00:18:04
well the sound was call or and uh with a spectral
00:18:08
doctors so usually all these techniques are used in combination
00:18:13
these are some examples you see here there is equality material is the luminous
00:18:17
blake however as you can see apart from the dissolution of the images
00:18:22
even the the the the basis of not completely black where there is no uh flow
00:18:29
so this is why we need additional technique to confirm especially depends also on
00:18:35
the quality of the keep and if you have a point okay uh
00:18:39
but sound although some scan that often the best of them are completely back even when they're completely patent
00:18:46
differently in high end the scandalous usually they are more able to uh
00:18:50
polish to clear the image and to make black the spot that
00:18:55
doppler can comfort that there is no floor however to provide a very good and accurate
00:19:02
doppler examination probably is more difficult than you
00:19:05
to utilise qantas announce ultrasound because uh
00:19:10
in comparison to baseline grey scale to sound doppler
00:19:14
wallpaper sensitive uh you must uh um
00:19:18
said many different buttons curled up again frequency too
00:19:23
so the fifties the the provision frequency
00:19:25
and go obvious a nation all these things are not very relevant for grey scale
00:19:30
so before i use it for you had to help yourself
00:19:35
but if you're not they've experienced uh please consider i've been calling first whatever the
00:19:41
uh technique you will tell lies i the city or deny but uh uh
00:19:47
dublin is extremely useful but needs a bit
00:19:49
more expert uh operators than conventional ultrasound
00:19:54
so you scenes mm these examples that it's yeah but clearly there is a
00:19:58
drum was but the the strong most is partially they can allies
00:20:02
so it means that it is crossed by some for all and when
00:20:06
you add the doppler the flow tended to all the light
00:20:10
the the more images so you need some experience because if you
00:20:14
raise too high the gain here probably you will feel entirely the vessel any if you
00:20:20
rely on your the colour pattern you can state the these doctrine most here
00:20:26
clearly even in this case you see that that i have to fax these
00:20:30
are uh not this is noise it related to the movement so is
00:20:34
not always easy to define exactly the extension of the drum was small but you
00:20:39
know that with doppler you needed installation angle which should not be ninety degrees
00:20:44
so when you go all close to ninety degrees like in this case here
00:20:49
it is not an meg to all others is awful because there is
00:20:53
null for all these these absence of signal but probably the flow
00:20:57
is they out but simply this is it ninety degrees
00:21:01
be uh in summation angle the intonation beam and the the
00:21:05
axes of the vessel so you need more uh experience
00:21:11
he does for instance another example where the ninety degrees
00:21:15
effect might leave it to the possibility to detect
00:21:18
tiny um from by so you know the to work
00:21:22
and this imitation just uh some practical recommendation
00:21:26
to be as sensitive as possible lower the pull this week the petition frequency basically a
00:21:32
stylised think about that makes the doppler ball sensitive increases the doppler call again
00:21:38
never all the information and also try in the area of your interest like to
00:21:44
uh created the narrow waist angle between the vessel and your information be in
00:21:50
try with probably doppler and inject contests that can be utilised even to increase the signals
00:21:56
from doppler saw if you are a key pen is not a a key that
00:22:01
with qantas not with the sound in some situation if it is very
00:22:04
important you can add contest pages just to improve the doppler signal
00:22:11
so as you can see here the gain is high and you say that there is a quite material but it is
00:22:18
quite difficult to assess they a real the
00:22:22
exact extension of these uh uh material
00:22:25
and when you add doppler inexperience eyes you can see here the problem was
00:22:31
but uh at the this is on the it world for moses any bad
00:22:35
be overlooked if ya on how we understand the patient very quickly so
00:22:40
uh we must pay attention to our to our patient to
00:22:43
detect these tiny drum by because this can easily be
00:22:47
uh this all the that we've uh and the calculation before they become a bigger
00:22:53
and uh it if the thomas is partial clearly you
00:22:57
have it to serve the a portable a flow
00:23:02
this is a case of a recent trauma was because the
00:23:05
patient was the only fact the the disease without
00:23:09
a a and c. roses and a patient add count
00:23:13
to the hospital because she suddenly became symptomatic
00:23:17
so as you can see in this case they uh i'm
00:23:21
from was is quite high put caloric and you might
00:23:26
ms technology it for the patent portal bane unless you are the doppler which clearly
00:23:31
shows that there is no fuel in the in the basis and that these
00:23:36
tiny basis out at the high that topic up very compensating
00:23:41
the lack of the portable and this is not
00:23:44
a cat and mouse does formation this is important because
00:23:48
you differentiate the complete obstruction of the portal fuel
00:23:52
uh compared to where we can is a show which does not
00:23:55
resolve the portable pension but might improve the uh interpret profusion
00:24:01
so this is the appearance at the all the sound of uh
00:24:06
the trauma was how does it look at the city
00:24:10
if you start as it always is the case with non
00:24:14
enhance said se t. usually you don't see this roles
00:24:18
so because it is eyes advanced to the addition soft issue
00:24:23
only in the any phase it might be hyper bands if uh there is
00:24:28
the eh uh still him applauding inside so before female as completely
00:24:33
uh i said they are and there was a leases of the bible says
00:24:39
but based happens only in case of symptomatic complete occlusion by the patient can directly
00:24:44
to be off people because of the pain usually or buy whiskey yeah
00:24:48
so in this case you performed basically in the first hours or days after the occurrence of the
00:24:54
i'm from all these other why usually you don't see these hyper dance
00:24:59
and appearance these means that that city without contrast is unable
00:25:04
to loud to moses so you cannot rule out
00:25:08
and these also is relevant because this means that a a
00:25:12
sickly is useless if you think about the ball
00:25:15
this if the patient cannot receive contest because of late
00:25:18
as insufficient see allergy hyper fatter the isn't it
00:25:22
so you know the situation uh we master the sort to other
00:25:26
techniques like doppler a and c. use or i mean i
00:25:31
so this is needed please keep in mind that uh often if that is the uh um
00:25:37
from both these which is especially into popular the inflow might be slow where
00:25:43
and so if you take the acquisitions too heavily
00:25:48
uh the same time but it is usually taken before the port
00:25:52
of roll which is slow down might not ever arrived yet
00:25:56
and so you might all that estimate with room was is simply because the portal bases have not be
00:26:02
he led by the contrast uh can mean through this planting supply consistent so the recommendation is to
00:26:09
i carry out these uh askance about eight ten seconds later then
00:26:13
usually which usually is about forty forty five seconds so
00:26:17
it is important that when you make the request to the the others is to outline
00:26:21
and whether you have a suspicion of puerto vein as from bosses
00:26:26
uh clearly after you inject the contrast the appearance is that
00:26:30
of a the fact of enhancement in the portal bases
00:26:34
so this is in a hanson lever and the uh this is uh from
00:26:39
the amount of sleep that i enjoyed reading it be recently published by
00:26:44
and then these uh and the crossover but they got it was a big daddy
00:26:49
and the you can see that the the appeal best as adam has saying
00:26:55
the putting camera isn't has seen but there is no enhancement in the portal
00:26:58
phase within the portal being the woman so this is a a complete
00:27:04
uh from was is this is a tiny a portal to moses you can see this
00:27:10
is divide portal vein and without conscious you are unable to recognise any thrombosis
00:27:15
whereas after that congress is actually that they'll face you see the all that is filled
00:27:21
with contrast the party cavities filled in contrast again we are not able to recognise
00:27:27
any trauma zia whereas these tiny thrombosis appears in the portal face
00:27:33
so it is important it all was it we we should we master got that
00:27:39
this situation a bit differently from public so that it's normal when we look for about the selectors to norma to
00:27:46
screen patient follicles circus animal that master relevant phase is yeah
00:27:50
pale face to detect hyper announcement when we look
00:27:53
for the port of interim was clearly the port of interface become the most uh relevant
00:27:59
these are uh other uh image this uh not from my centre but uh uh the uh they
00:28:05
were very nice so i prefer to to them this is a a panic attack this
00:28:10
complicated by explain it away in a tremble this you see here these no enhancement
00:28:16
and what you can see here is that there is also into patting strum was is of these segmented dances
00:28:22
and there's a compensatory effect you have a basic idea of
00:28:27
the lever which is confused only by the happy
00:28:31
because the portal vein is uh please be no clue is a cruel that now in this segment
00:28:36
so in the these uh uh time of a a position which is not delay time
00:28:42
these high paid enhancements here because this part of the lever will announce it beep
00:28:48
uh later when there is a full arrival of the contest uh there you can see from the clean is this is uh
00:28:55
and now the latent they'll phase and is not is not yet eh reported phase
00:29:00
this is not the example of our uh how when you will
00:29:04
have a extensive portal been from both the you have also
00:29:08
severance is can express a a severance of them is intake uh and i'm about would buttons
00:29:15
with a man i again you need contrast enhancement at
00:29:19
least with conventional and ice cannons because uh
00:29:23
and i have said that the one in teach away the sequences i'm not very good
00:29:28
with conventional scanners that uh uh do not work with the speed up already
00:29:33
gating and the they're not able to that
00:29:37
was properly tiny portion of thrombosis
00:29:41
what is the uh there are innovation in that place but
00:29:44
these are not present in a four centres yet
00:29:49
and with this new sick once it is claimed that
00:29:51
uh even this takes longer to be quiet because
00:29:56
but is it a speedup body gating but uh it it can uh the tech to be
00:30:03
peyton see all the rest of the longest in a good way this is not a logical
00:30:08
because clearly liquid material is very well depicted by him and i for instance east
00:30:15
what human dorm ah are easily and very precisely detected by
00:30:21
and then i so it means that a vessel which is filled with liquid should be
00:30:27
highly intense in some faces the problem is that uh to uh acquire the basis you need the
00:30:33
uh dating with the speed of body movements because it takes longer so probably in the future
00:30:40
even these big down but with the improvement of the technique will have this information
00:30:45
when want to select lies whether it ramos is made of the tool
00:30:49
more or a is made of a um fabian clots uh
00:30:54
uh we can assault also to the diffusion uh
00:30:57
water uh analysis because the water molecules
00:31:02
uh when i'm back in two more they move less and they created different signals in
00:31:07
this is being established to make it back knowledge is all about the circus norma
00:31:11
but when we have when you have it to what invasion i got this email about that also in the brain
00:31:17
uh in in the portal vein so these are uh the two different
00:31:22
uh uh acquisitions with the calculus they shut to with the
00:31:26
uh i'm an ally analyses of the pack them and this is the
00:31:31
y. and b. is the uh diffusion coefficient the a map
00:31:36
and they clearly show that in this case the a drum
00:31:40
was is made of packed cells on is uh
00:31:43
um malignant so this is invalid p. that can be utilised before
00:31:49
the stock into the contrast injection which is the weather today
00:31:53
no not really in the mm conventional m. n. i. scandals
00:31:58
so without the weeds conventional to sound adding doppler we have a says that
00:32:03
we have uh i represented how city and and then i work
00:32:08
as i mentioned m. at i. s. u. p. two date a quite
00:32:11
a contrast c. p. would require contest even in the future
00:32:15
in it i maybe but clearly needs more cooperation with the
00:32:19
patient while uh uh although somewhat in real time
00:32:24
so similarly to see the end and then i also to sound improves it that is accuracy
00:32:30
by using a qantas finance ultrasound these are some examples
00:32:36
when there is very slow for all it might be difficult to a state whether this is the
00:32:42
completely from was or not
00:32:46
okay
00:32:48
this is a quite a a lawful p. l. f. for hand that
00:32:52
had for those of you with allies doctrinal that is probably
00:32:56
is the mini mall mean email valued the installation angle is the street so there is not
00:33:02
much more that we can do to assess whether there is partial to moses some out
00:33:08
this is how how it looks so and the so even said it best of
00:33:15
the doppler capabilities it is impossible to state whether there is some partial
00:33:20
from both this if we add instead contest to see the ulterior phase
00:33:26
the still the void the portal system allies some seconds later stalls fill the void of contrast this means
00:33:31
that there is a very slow in for all these patients as it means a lot to patient
00:33:37
and you can see that the that arise from here so probably they visited there so for all these area
00:33:44
in this explains also why there is such a slow for all of them tends to feel entirely
00:33:53
you can see here that if you wait some more time it is entirely
00:33:56
field and if you break the bubbles and let them be field again
00:34:00
it is very clear that there is no all i'm drawn by and this
00:34:05
is the main frank and it is basically less sensible that that
00:34:09
uh what we have seen in the previous images is uh
00:34:13
just loaf role in not portal been from all this
00:34:17
and the thing that these images highlight the quality of the real time modality
00:34:21
even for a glass of port of interim was this c. uses very useful because the the peaks
00:34:26
much more precisely the extension of the drum most part but it is
00:34:32
not the fused in case the bland portal been for moses
00:34:36
you can see here by doppler by of optimising doppler
00:34:40
we can measure this thickness of drum was
00:34:44
maybe its extension we can guess it even on be more even just
00:34:49
but this is much much clearer on a c. use emerges
00:34:55
this is the case i showed you the portal tantrum was is this is this
00:34:59
planning when from bosses you see these the the display make about because
00:35:04
but because i've been a ever gone last so there are a collateral
00:35:08
circulation at this planning hiram and we don't see uh the bases
00:35:13
if they come was is is longstanding over months of yeah
00:35:17
but it might be can classified like in this case
00:35:21
and the the technical suffocation uh i that's c. e. or
00:35:26
with the sound are a best that they work better then uh um and then i
00:35:34
in this situation uh although the long long time when you have chronic
00:35:38
portal interim was is that this past analogy can allies than
00:35:42
you can see that when you are doppler it tends to
00:35:45
call over these uh parts of the drum was because
00:35:49
there is some fuel event in between uh the drum was so
00:35:54
if you up to my is the game to be sensitive to stroll you might call over these images
00:36:01
and the again in this situation they uh when using c. use made things much easier
00:36:07
so this is why i was stating that a given base safety although contest analysis
00:36:12
with the sound because basically they save countless days as you don't even require
00:36:17
no need to look at the lab exams because there is no problem with the other insufficiently anything
00:36:24
the only requirement that even page annie's if we're
00:36:27
still really legit so yes several allergies
00:36:30
i would prefer to give steroids but for instance patient while
00:36:34
allergic to identity because the contras they'd enforce it p.
00:36:38
in our centre they receive a micro bubbles for seals without any pain medication so busy we
00:36:44
found it very safe where that for more than a ten thousand the examination so
00:36:52
as you can see here hopefully
00:36:57
it is easily easy is the visible and this is important if you want
00:37:02
to manage out over time the changes induced by a anti calculation
00:37:09
these images have to show that you can detect
00:37:12
even tiny fee in portions of a um
00:37:19
one of them was is that go undetected by conventional grey scale images these clearly of
00:37:24
not the convention like the scale because below men is filled with contrast which generates
00:37:29
he has even conventionally more so don't don't refer to these left hand images
00:37:36
but this is to show that even for instance cross sectional images which
00:37:41
doppler does not walk because this is it ninety degrees estimation
00:37:45
seals works a very well so this is really a
00:37:48
useful just if you want example this is there
00:37:53
patient with a non dilated portal they in this was about to ten millimetres
00:37:58
but if you are doppler you immediately see that this is a vessel for all
00:38:02
and when you put a put a doppler you see that it
00:38:06
tend to have a physique um but then uh likely
00:38:12
representing the annotator phase so we go all in the right lobe in in the last two all
00:38:18
in the light all these other vets of puerto floor but we have to be at the base
00:38:22
and putting the float here we see that uh this is the most likely
00:38:28
a pity for the feast a lot because you have their data flow
00:38:31
and that they then as fuel is that a vested but
00:38:34
with the physique updated appearance and finally we detected the
00:38:38
feasibility of so there is no night low level so full which goals outcome believe that in the portal thank
00:38:45
then moving to the left logo we were unable heaving using low p. i have
00:38:51
and uh a good insulation angles to take whether this was completely crumbles or not
00:39:01
i wanted to show it again now okay so here
00:39:05
clearly the something moving so the idea the spatial
00:39:09
was the fed with the backing all this base on be more of a portal they come moses
00:39:16
but in the this could be a fresh
00:39:20
from was but as i mentioned city uh sorry
00:39:25
seals might be useful this is to show the appeal phase button
00:39:30
ram of these computers probably is not be yes strong enough
00:39:34
but this is the representative emails so you can see that in their late
00:39:38
at the interface that is only partial profusion so if we stop here
00:39:43
clearly he is seeing that i portal part part this is feel but we have to think that this patient as
00:39:50
a feast allow so clearly does not unexpected that here we have a feel for the main tank
00:39:58
but to explain the back then we uh but from seals
00:40:03
and i think these shows very clearly the advantage of the ideal time modality
00:40:07
because we understand that this is only the the the the scroll scroll
00:40:12
you see how slow is the fuel in the left
00:40:15
portal system not just keeping patiently observing the patient
00:40:21
uh we could the mustard whether these the traumas of not and as you can see here this is
00:40:28
the the fuel is extremely slow nearly standing but
00:40:32
it is completely patent because he feels entirely
00:40:36
the looming of the best and so this is the benefit of the uh on sales because you
00:40:43
could avoid the city was before because she uh was a fair to us and uh
00:40:50
clearly seals in this situation can immediately uh
00:40:54
clarify the a complete patton c. of
00:40:57
the situation would indeed can be shown even in the portal phase where
00:41:03
i'm sorry one that to show
00:41:10
oh the the the one part of the of the vessel is less field with contest
00:41:19
so this is an overview or how we can use the different technologies to
00:41:25
assess the presence of portal been from was is all too loud
00:41:31
both of islam bosses
00:41:33
once they to moses is longstanding always mm longstanding is not correct
00:41:39
is uh in places yes at least a few days
00:41:42
you might have what is called the cover most over cover models transformation
00:41:48
which is selected eyes by the code and so small totals basis with about a bit of role in the
00:41:53
side or around that is out portal track affected by that on the base is a way to bypass
00:41:59
the abstract that track starts radially between six and twenty days
00:42:04
after nick to onset of them all these all complete symbols is clearly parts of them was is
00:42:09
wars and portable pension but does not generate the collateral circulation
00:42:15
and one is the patient have uh the cavernous transformation that are
00:42:21
gonna get that as having and the the crone stage
00:42:24
uh since some of these uh portal they must option might be
00:42:30
stand in the l. c. is the time of infancy uh these uh terminology is being applied
00:42:37
for patient that dustin without zero this with the
00:42:40
longstanding s. that patti porter the abstraction
00:42:44
and this is uh the definition and over time
00:42:47
this might use also changes in the better
00:42:51
these are some examples you see this is a cover number two transformation
00:42:55
you see the portal puerto collateral seen big outlet there was
00:43:00
uh please take care not to define these is inflamed got that that because sometimes is
00:43:06
seen the thickening of the down rather watch which is related to portable pension
00:43:11
with the blood vessels inside so to to be eh i should call this
00:43:15
is tied this this is only report that it opens in condition
00:43:19
and the u. v. c. they profusion these are all uh then as vessels
00:43:25
this is the cover normal clothes transformation of the troubles right portal
00:43:30
vein in the courses can this is more fully can allies
00:43:36
in other location these another situation but i've seen technologies of a a
00:43:40
is the pancreatic uh e. p. and and tried to defuse because if you don't have
00:43:46
the doppler you can see that many sees any be patient as not several this
00:43:51
i remember it is one patient it well the fact that was for pancreatic disease
00:43:56
and the the portal they long spending part of infirm pauses as being overlooked
00:44:01
but if you had the doppler you clearly see the these analyses
00:44:04
on a collateral bases so it is very important that you either doppler whenever
00:44:09
you find an equality uh lesions so what happens here is that uh
00:44:15
as collateral us there is a a enlargement of these that tiny basis
00:44:21
it equally local vendors lexus and the particle it all goes a bit inspectors
00:44:27
uh all of the long term the labs meant of these vessels tend to compress the bile ducts
00:44:34
and the is is they unfortunately a complication which is call the puerto below but the
00:44:41
because inclusive behaviour changes it'll distract obstruction of that by that's
00:44:47
due to the compression of the the elated portal collateral it's
00:44:52
at the uh patty hi loom clearly even for you have any
00:44:57
can alleviation with the government was transformation this does not
00:45:02
completely restore the normal portal pleasures so the patient over
00:45:06
time they block all the conditions of portable pension
00:45:10
which means puerto collapse else including batteries but um
00:45:14
but i says i'm split omega lee
00:45:18
and potentially hyper topic changes of the of databases to compensate
00:45:23
they interrupt but floor and the enlargement of the uh spleen
00:45:29
clearly if you have a suspicion of the situation this
00:45:33
might be tricky because you see many an equality
00:45:37
things at the high low sam might be but that's and some might be collateral so
00:45:44
this is situation with is very very important to perform very good doppler examination
00:45:50
because if you have a suspicion this some of these anechoic
00:45:53
lesions and not basis but are violated but that's
00:45:58
you have to ask what a and then i uh i call runs open photography
00:46:04
to the most late like in this case busy they indentation due to the
00:46:08
but that's that cause you to stop shown the parcels trash on
00:46:12
in the the elation of the inter party but that's
00:46:17
this has been classified into two three different
00:46:21
uh seventy degree of severity delayed one
00:46:26
smile delegation great shoe in grade three with the most of the the
00:46:31
location and abstraction due to the compression of the uh but that's
00:46:37
please note that seem tom's you to call it stays is our core only in grade three powerful
00:46:44
or they can be delayed three uh cases of portable uh uh colours up at the
00:46:50
this is a quite important busted that that underlies the portal columns up at the
00:46:58
con sequel to portal with moses saw how we should approach by emerging
00:47:03
so clearly the recommendation is to proceed with him and i columns of the three
00:47:08
the weather number of patients with acute part of it from pauses at the time
00:47:12
of first detections so symptomatic and sam had chronic portal been for moses
00:47:18
and clearly acute port of interim was it at the shot the
00:47:22
time from technologies to uh from um accordance to technologies
00:47:27
so less than one yeah that and you can see the moss it and all puerto colour job but the
00:47:33
whereas when legal longstanding chronic portal vein thrombosis
00:47:39
meantime for black ball this about a a five yes
00:47:43
you can see that half of the patient had a lady grade three
00:47:47
so these clearly shows that columns up but we of course over time and we must not
00:47:52
forget this patient even when they have a baby with a look at the moment because
00:47:58
apart from the portal it'd bessie complications unfortunately this patient might even they're up
00:48:04
other complication which uh which are the by that's in this is the portal uh columns up but it's so
00:48:11
uh this is a proposal of the um how how to follow up this patient is is not
00:48:16
being and also the fully by everybody so i deportees dust uh uh as a proposal
00:48:22
but uh it in case you have a primary complete reprimand visitation after that you don't
00:48:27
said there is no need for a a an eye colours of the fee
00:48:32
whereas in case that you have a better band all covered norma or there is a chronic portal of interim bosses
00:48:38
there is a need to put for an ally not with contrast specifically with contest for the
00:48:45
sorry for the portal with proposes but it was as the by that's uh
00:48:50
uh and to assess whether they had ballet to them out just where standpoint
00:48:54
to compare with future acquisitions and they recommend to perform
00:48:59
in use can in the second yep to confer
00:49:02
the lack of probation really that there is not enough information on how well fed to perform it
00:49:08
amanda commendation would be to that that would astound is enough for these patients
00:49:15
so we have detected part of it for moses we have the tech
00:49:18
the complications we know that by the coding several uh locations
00:49:23
so one recommendation is how to classify a this page and
00:49:29
this is something i discussed also with the with about
00:49:31
that because i think this could be relevant now that we're starting more beauty lies and the choir glance
00:49:37
to to assess how we declare that there is any improvement and not an improvement from
00:49:42
maybe on the you will tell us uh later how to says this but
00:49:46
you might you this is not been enough um standardised so we must report the location
00:49:54
the degree of occlusion the presence of a cam cover most transformations in the
00:49:59
science of puerto little attention portal of protests in colour job but the
00:50:03
and possible signs about whisky name cases of extensive oh prudential
00:50:08
all this information should be present in the report
00:50:11
and therefore should stay also in the classification this at all anatomical finding
00:50:17
so there are the all this can be bought all this information
00:50:21
but probably they are not enough because it is important also to mull the symptom
00:50:25
of the patient this is why their ideology on his alone is not enough
00:50:31
the initial sorry not the ninja but one of the most adopted classification was this one
00:50:37
it was proposed to classify patients candidate for the there's been page on this is that yeah bill classification
00:50:44
you can see it is a non complete um
00:50:48
portal they important black hole displayed one complete um or
00:50:55
more than fifty percent of the portal been planned
00:50:58
then process now supreme is intelligent main issue the involvement of
00:51:02
this opinion isn't bathing is very relevant really because basing
00:51:05
use in terms of buy whisky you know so it's very important to applebee's is probably the the main
00:51:11
paid for all the all the sound which is not very good
00:51:14
to assess disappeared um isn't very rainy especially the bees objects
00:51:18
you realise that this is quite good but in uh besides it is not very good how well this
00:51:23
is only anatomically this is mainly the van was
00:51:27
sees this article choices so from is not
00:51:31
uh optimal i like maybe more much more this classification which is a
00:51:37
adopted from that but the anal propose above in a six a
00:51:41
and the slightly about that there was a report to the by the uh um your by the band group
00:51:47
as i mentioned so this is anatomical the location an extension of the
00:51:53
a tomboy this only the portal been flank or only the branches one
00:51:57
or two branches into party dances or whether it involves both conditions
00:52:04
backward you have here a point for spanish brain as intelligent being or both so put into guys that
00:52:10
point one point four you have a very thorough
00:52:13
uh at analysis of the extension through moses
00:52:17
whether the thrombosis is completely all cruise your martin this is the
00:52:22
recommended the crowning all clues eve what normal cruise if
00:52:25
the duration whether this can be always assess so that not
00:52:29
is uh not easy but what what can be easily
00:52:33
essays is whether these governments as formation in in this case
00:52:37
clearly we must be clear is is chronic and
00:52:40
it has also functional presentation whether it is symptomatic or of symptomatic
00:52:46
so this is important especially in a time now without the calculation is counting
00:52:51
if you want to compare the fantasy it is from different centres
00:52:55
we have to have a standardisation of a patient to assess whether they
00:52:59
patiently tennis centre ah are compatible with one that are compatible to patient incentive be
00:53:05
with a different and so i think that that is absolutely a need
00:53:09
for these uh classification to be standardised and adopted a worldwide
00:53:16
one of the that probably the last point because these would be only three slides but this is a very relevant one
00:53:21
what does it mean to tell lies as i mentioned we have too much invasion and the uh brown trouble is is
00:53:29
when they believe they can so the data go goals in the main cities quite easy but sometimes
00:53:35
it is only the danes any this situation it might
00:53:38
be the key to distinguish blanton was this from
00:53:42
two more a presence i would say the other that infiltration
00:53:46
and it is highly relevant because clearly no plastic pot of interim bosses mean sport problem all this
00:53:52
in very limited on call logical treatment possibilities only systemic that's already been decision
00:53:59
while any few cases says it but these the availability needed when on the plastic bottle bit of houses he's
00:54:05
not so relevant on the outcome and some bible and can be completely the call that so it is
00:54:11
very important to this thing with this whole situation because they require completely different ads
00:54:18
and that the presence of two well they invasion is present
00:54:22
in all to most asian system diseases japanese one this
00:54:26
is one does what not it is not the it is still kept but it was propose many years ago
00:54:33
and you see that this is one of the three main factors and also
00:54:37
in the uh western counties the present of puerto they've invasion a long
00:54:43
means advances days where that if ever blunder was this
00:54:47
you can belong to any of these condition
00:54:51
so all it is a completely different situation and it is very important to direct advice probably
00:54:57
properly the patient this is particularly that banned in the stepping all
00:55:02
leave it has been patient because uh now at least in volunteer with aspen patients
00:55:08
more than half of the patient at least in front of the silicon sonoma
00:55:12
they have zero this and we've seen that in basically don't zero this the incidence of portal
00:55:18
been from was is is between eighteen twenty percent so the patient weight one yeah but
00:55:23
even those with a purpose other cancer norma one out of five with el portal with both so it is
00:55:29
eyes is too worried invasion based band from those is can the patient remain on
00:55:33
the list or market in in in the so this is a very
00:55:36
talk question any in the past we prospectively assesses the situation in uh uh the study
00:55:43
and that we defined arbitrarily this pattern as
00:55:48
associated with two what of invasion
00:55:50
so the throng most as a mass for me aspect this is quite
00:55:55
subjective is related to experience of the paper but it is
00:56:01
might be relevant this adoption of the portal was this is a very valid well it
00:56:06
can be seen only by with the sound because the c. p. and that i
00:56:10
i'm not very good too because they have not enough uh
00:56:13
additional specialist solution to see the uh puerto vessels
00:56:20
when they don't want to almost stick the locate the close to that of the circus norman
00:56:25
these are all signs these particularly basis what specific for the big
00:56:31
noses to one of the invasion this is only suggested
00:56:35
while doppler low impedance elevator cygnus yes and the throng was
00:56:39
enhancements of the troubles both indicate disease activity issue
00:56:44
because blanton was this does not have appeal lessons inside it might
00:56:48
have been a signals because that is they can isolation
00:56:52
but not appear signals when all these lack
00:56:56
then we messages this is in on a plastic drum was and also
00:57:00
when there is longstanding cannot cover models transformation every can isolation
00:57:05
clearly these out signs of a bland from was so just to show images
00:57:11
so this is the mass forming you see that the vessel here is lab
00:57:15
that then yeah you see that the vessel wall he's is interrupted
00:57:21
he's as well so mass forming and is an option of the vessel was and this can be seen only by with the sound
00:57:28
this is the tool or this is the portal vein branch these they are thirty when it this is next
00:57:35
this is also highly suggestive this is it previously treated the too well
00:57:40
you see expanding drum was because the messages lab that here they need
00:57:47
you know you need cross the part that i think you should be can now where a narrow uh as
00:57:53
long as big all the study so this is the mail so that mass forming
00:57:58
this option of the vessel was because here it is very
00:58:02
clear the vessel wall when he added this goes last
00:58:07
and after injection or contest it is enhancing already and get paid a phase
00:58:13
while it washout the late face so you can see more of a very well
00:58:18
that this is the previously the the tool more which is exactly crawls
00:58:24
to these portable and so this was a patient on the waiting list and
00:58:28
when we see these appearance clearly he was immediately removed from the list
00:58:34
updated cygnus inside the trauma was see this is again this adoption of the so was
00:58:41
bit mass forming aspect but this is not so clear mass forming
00:58:46
but importantly if you go to pick up with puts a
00:58:50
doctor the signals you see updated floor was low impedance
00:58:54
these are different from normal uh i've seen other licensees high impedance
00:58:58
and what duty lies in the past to make it back noses away to see by doppler
00:59:03
while here probably because the out for all those immediately the bane of low impedance
00:59:09
so please don't make the mistake that easy low impedance mean means
00:59:14
benign leisure no this is it to whatever drum was
00:59:18
you see you see the of the helpful inside the
00:59:22
the traumas itself this is from was portable
00:59:25
does this for and so was the patient with hepatitis b. and there can be no surveillance
00:59:30
and he's on several counts that was only inside the a
00:59:34
portal they system so there was no all focal lesion
00:59:39
and they clearly when you see the spot that does is it too much to want promos
00:59:45
well the sound in the in the patent and this is very sensitive because the
00:59:49
the text even tiny lesions this is if you millimetre lesion drum was
00:59:55
go with contrast eighteen seconds twenty two seconds you see that it is diffuse mass before the
01:00:03
profusion of the portal brain so this is not a refusal of the portal woman
01:00:08
but is at they'll profusion of it issue and now even the portal vein
01:00:12
is feel was qantas thirty four seconds we don't see any more thrombosis
01:00:18
because the thrombosis diffuse by the out pretty and the luminous feet was contrast of
01:00:23
the patent portal brain also this patient wasn't with at least an was removed
01:00:28
this was another patient uh it's seventy eight yes
01:00:32
all but still very fit should winced was
01:00:35
maybe often something she cooks so we are happy to people have very well and that
01:00:42
and when she came to their usual control we detected these tiny uh
01:00:48
thomas here
01:00:50
so this is not clearly mass forming it seems that is it is
01:00:55
it optional the vessels so this can be seen only by ultrasound
01:01:00
it is not only a partial to moses not complete room was is so it's uh
01:01:06
not soul mass for mean also expensive and they have a fit
01:01:10
approaching was normal soul by this once a long it
01:01:13
is not enough to the clear the this is it to what the issue also very suspicious this is the button
01:01:21
because as i mentioned this but then i highly suggestive uh
01:01:25
whereas outfit the protein is not so relevant so we
01:01:28
have to put more than one of the spartan together so what was lacking is the and hasn't bought them
01:01:35
and when you see here didn't get pale face it feels before the
01:01:39
contrast allies in the portal buses so this is a fatally enhancing
01:01:45
and it was is out you see that there is now less enhancements
01:01:50
then the the budding time uh and clearly less than in
01:01:54
the portal branches but most importantly it is a portion
01:01:58
all the uh from was which is diffuse so that out micro
01:02:01
bubbles inside inside the drum was you see here very well
01:02:06
so the spatial was fortunately this is the sickly appearance you see india pale face
01:02:13
um later they'll face these enhancing any washes out in the portal face
01:02:20
so the station was the take the very end is so she could go all undergo all successfully about improvisation
01:02:26
so this is signal up back there potentially mass forming no there's an option unless it was not signals
01:02:33
but clearly there is no i'll signal it all inside so if you see this patient if
01:02:38
this page in is on the waiting list especially would be kept on the waiting list
01:02:42
because this is that non uh plastic drum was all you see how relevant it is the addition of contrast agents
01:02:48
if there is any doubt don't forget that we can take by steel
01:02:53
drum some sorry for the uh the solution but we had to
01:02:57
uh so we because of the clip you see the needle here coming down
01:03:04
at that time we were still working freehand with a biopsy
01:03:11
and that that is not clearly there are some risk of uh creating a belated fees to learn
01:03:17
but if you for the spatial was very important to be kept on the list to the most it really was not it tomorrow crumbles
01:03:23
so you can perform the biopsy even in tiny
01:03:27
promises is fine need those not so difficult
01:03:31
this is a basic ways to agency dissipation still alive on the waiting list
01:03:36
any developed is is part of the study from most of this part
01:03:41
i'll say the was outgoing but you see there was devoid of any signal
01:03:45
and uh uh clearly that there might be some active like this is not come basically about the
01:03:51
uh in area time in this image of it is not working
01:03:55
uh there was no mike about what's equating was kept on
01:03:58
the least and finally at the x. plant analysis is the strongest was bland from was is it not too well they
01:04:05
uh sometimes we need to take by so that almost even
01:04:08
to do a rotation the trials or if if they
01:04:12
almost is eve the vessel is drum was then there is also all the weather is completely because there are there
01:04:18
is an awful so you can put the needle inside the throng balls and a tape there and the biopsy
01:04:27
see when distracting the scan through all the the throngs
01:04:32
okay this is uh just some more and last example
01:04:37
says yeah again when the strong by i. p. it is difficult to state whether they are no
01:04:42
plastic or not because they look mass forming they have a a collie a difficult to say
01:04:51
and the in the situation see use is really extremely extremely useful because it
01:04:56
it working real time you see the mike about will seek liquidating
01:04:59
even with c. t. is not so easy sometimes to spell whether thrombosis diffuse them off
01:05:05
well here you clearly the most laid the that is null see quality meant about was
01:05:09
this was what signals that would present before the conference injections so this is
01:05:14
clearly not they'll announce interim was not portal vein phase and
01:05:19
as interim was and this is the plan for moses
01:05:23
so in this study that showed we're loaded forty patiently stuffer presentation
01:05:29
with a button selects norma n. we stumbled is i that new one set
01:05:34
well they can all this concurrently of two more and a cancer
01:05:39
we've clues sam because they uh some dropped out from that is eight with a school that because we fought
01:05:45
that this was an a plus it almost but fifteen what kept on the least because we
01:05:50
we're confident that that this patient had a bland for moses and
01:05:54
in all of them with the criteria that they showed you
01:05:58
uh which included the combination of ultrasound and i the city or i mean i see use
01:06:05
plus i that's it the other omitted or emmett i to be most as most
01:06:10
confident as possible all of them at bland portables importance so the
01:06:14
pause it the predictive value to state visit down through bosses
01:06:18
is extremely high demonstrated on the expand analysis
01:06:23
does that i've been also conferred by uh uh other studies that a cane previously
01:06:29
in which uh they uh these also these italian although two
01:06:33
different groups perform biopsy of troubles as it showed you
01:06:37
and they could even the most so they they the seals is more sensitive than net
01:06:43
city for tiny segment adventures in this is not strange
01:06:47
because the city and i'm alive the patient base
01:06:51
might be suboptimal lot position while you can repeat uh seals
01:06:56
but most importantly some of these to work almost every out of me causes or jazz components of
01:07:02
clocks so if you put the needle where the disney closes you don't find one says
01:07:07
so it's use is also useful when you want to perform a biopsy of the crown was
01:07:12
to show where to put the needle so combining all this situation these both these studies show that
01:07:19
so use is at least as articulate as it the as an ally
01:07:24
to check that i support of interim board this but when you speak
01:07:27
about in the button benches it is even more a sensitive
01:07:32
okay this one one example but that would go through very quickly is already did enough
01:07:39
uh they very good characterisation capability is not only for part
01:07:45
of interim was is in c. topic leave it
01:07:47
this was a patient always a single bypasses this but when she came
01:07:52
she had also portal vein from all these with some weekend visitation
01:07:57
this was the part then uh all the throng was in the late phase this was many years ago with initially
01:08:03
keep and so it's difficult to say whether this is devoid of signal out the facts or a confusion
01:08:09
what is important is is then it passes is you see hyper announcing that their face and washout
01:08:15
the same pattern of course also in the trouble so this means that the type of
01:08:19
the issue is the same here in the bay passes and in that from those
01:08:24
so it is important if you want to select the lies
01:08:27
the trauma was was says also they uh appear phase
01:08:32
so if you want to see the extension we look at the portal face if you
01:08:37
want to select the lies we have to pay attention also at that period phase
01:08:42
so these spends two also for me to static a
01:08:46
thrombosis okay go through quickly this is somewhat examples
01:08:53
okay so they take compliance going to the conclusion is there to to sound blast
01:08:58
doppler usually is the first imaging modality to detect the portal vein thrombosis
01:09:04
unless the patients can symptomatic because these are more huge in cases and is better to
01:09:09
go directly to c. d. or m. n. i. because in this equation more often
01:09:13
the supreme isn't very can they all be in film isn't very good may not involve any with ultrasound we're not sensitive enough
01:09:20
the additional seals helps to select that i supported him to moses distinguish
01:09:25
to work from non to waltz into the ten min is expand
01:09:30
if the findings adding come close if you we might also to buy i've seen all including all
01:09:36
into patty uh to moses not of x. the bathroom with these these it would be dangerous
01:09:42
because this is particularly important if we need to decide whether the patient can stay on the waiting list or not
01:09:48
city is recommended to us as part of an extension and the uh
01:09:53
yeah but because usually is more easily uh utilise the ball
01:09:58
and then i school but needs more corporation of the patients so if the patient is as paid off and is
01:10:03
unable to hold is bad so sleepy is better in this situation unless it is a a contra indicated
01:10:10
just a few slides to conclude how we do that's emerging to assess as possible treatment
01:10:16
uh and the combination is beneficial i hope these must it would be a set that we were able
01:10:21
to the most lately no respect to say this that and the glacial even improve survival instead occupations
01:10:27
so in the future because to make very still did it a
01:10:30
beta was discussing with um daily shake uh and he called
01:10:34
because of the study that the proposed he's it but always say how long we'll take your baby without
01:10:40
the population in the answer i don't it at glacier these vendors for our patients in the states
01:10:45
so clearly these the most ladies still not clear whether they have to be treated or not
01:10:51
hopefully in the future all this page you will be treated but given these big
01:10:55
around with them all for how long how strongly clunky cool aid them so
01:11:00
my in my view probably we need to monitor this patient basically because
01:11:05
maybe we'll start with the full article glacier only the patients vices
01:11:09
but if it does not improve in fifteen days probably have to go
01:11:13
to four and a little asian visit only speculations i don't know
01:11:17
but clearly does it not the situation was to perform c. p. so
01:11:20
often because of the has that so valuation high level conversations
01:11:25
so in my view there is a need in the monitoring of
01:11:28
different techniques city alumni for initial assessment and then probably
01:11:34
uh well the sound based techniques because we needed more strict uh
01:11:40
monitoring as short time interval and this is uh i conclude with these
01:11:45
events that i think is a taken from the man has it
01:11:49
been a seventy four because it illustrates very well the benefits and
01:11:52
the disadvantages of the big fat and techniques that they already
01:11:57
um mention to you and if you'd like to download these i think this is a really good overview
01:12:03
on the situation and the advantages and disadvantages of the different techniques that realise that
01:12:09
and all the fee is very really utilise only for diagnostic propose you could utilise when you need to
01:12:15
proceed with some to the political measures thank you very much for your
01:12:19
attention thank you very much for your presentation any questions or comments
01:12:34
you mentioned justification which which which function is to you when
01:12:39
images but what easy one for patients isa him
01:12:45
he sleeps functions not compete actually human
01:12:49
dynamic consultants he's almost to see
01:12:53
is a complete absorption what keys for you in terms
01:12:57
of even she completed function it must be completely
01:13:03
i would actually reasons smooth can oh of let's say ten percent
01:13:08
according to the was was real easy yeah in in our retrospective study we
01:13:14
did find that uh ninety percent of the rest of the need that
01:13:18
involved but strong was was held as a complete obstruction because in the end
01:13:23
i it's similar to what to say but there is no all
01:13:26
homage enters the finnish and this is uh what is clear is that once we have some degree of them was is
01:13:33
you want it to be skull portable pension regardless of whether
01:13:36
this is a limited or more expensive so that is
01:13:41
puerto letter bridge and then we have to keep in mind all the possible consequences supported attention
01:13:46
whether there is a certain degree percentage which creates a more c. news
01:13:52
uh the compensation difficulty then because like in the canopy yeah pretty you might have seventy
01:13:57
percent but if your cannot that that is lab that then what remains is enough
01:14:02
so clearly is difficult to state which part of the little man
01:14:06
is to be included to have them all see the other
01:14:10
ah complication so i don't have the answer if you have one place
01:14:15
ninety percent was seems to be the more just commenting on the committee now makes i
01:14:21
think yeah two situations when is this to look dictation um below that also take
01:14:26
a human and then we can be a significant huh just to know seasonal show closed an acceleration of blood flow
01:14:34
that possibly you can detected by the open and this will lead you
01:14:37
to the images of significant human a manic obstruction each these
01:14:43
knocks original but both to the the the idea of the ponytail
01:14:47
troubles probably is not significant from any point of view
01:14:51
and when you can she was use and establish prototype attention
01:14:56
to convert from goes in one place to another sometimes mitch makes very little difference because
01:15:03
you have already collectibles the composing the system and probably because of that
01:15:08
the significance of portability embassies insurers is easily match the beat it and then the data
01:15:14
uh showing that probably it can matters and the to showing that he
01:15:19
doesn't matter so it's it it depends on on on that
01:15:24
but even though i think that you should coming
01:15:28
on whether easy these acceleration through distances
01:15:33
because these ease by the finishing what defines
01:15:37
a significant distances causing portable station
01:15:41
and probably but in the say in the vendor system is more difficult to assess the acceleration
01:15:47
because the in the health care system you have more or less the same pressure
01:15:51
in the portal system uh you might not have a significant celebration because
01:15:55
you have not enough pressure and uh it is uh the asian
01:16:03
with the you know i wanted to me i think the question because it
01:16:10
it has nothing to do with this i think really at the moment
01:16:13
one of the major problems we open is really to differentiate between huh
01:16:18
plan to movie and an invasion from a two more impatient than in the waiting
01:16:22
list for the the transplantation and it is it's really a relevant topic
01:16:28
so the question is you showed us and we use it in the compacted that's use
01:16:32
is extremely sensitive we're assessing whether that's that's two more or or to who's
01:16:40
however there are cases in which is maybe i speak he
01:16:44
pizzas mulder movies close to an an opening my which
01:16:47
is the fruit of your difficult patients not you really always straight from youth maybe so the question is
01:16:55
when do you perform by you see so do you have click here mismatch between
01:16:59
emerging can or you just really trust on to some and that's all
01:17:05
because in that case we should never prefer mine to the little trouble is that uh usually if
01:17:10
uh with the sound can assess these it isn't very well really gives you a proper answer
01:17:18
the trouble is you mention is that when it is very deep but these
01:17:21
are also difficult location for biopsy so this guy was a situation
01:17:26
so basically should we try to stress other part like an i. part that um the why
01:17:32
uh i clearly you can perform live c. but usually a difficult location if
01:17:36
it is a limited portion of does not extend in the yeah
01:17:40
ideally this is this might be difficult even so this is really not a very common
01:17:45
but sometimes you can take bribes even over a a limited the portion but
01:17:51
are being c. t. m. n. i. n. c. use it is and yes we had to resort to biopsy less often then you pass
01:17:57
fifteen years ago the acquisition time over and then i was very long
01:18:00
so it was very difficult to to have a good images of
01:18:05
only need to portland maine uh combine not now it's better but uh in some
01:18:11
situation if you have no all and so what we do is the x.
01:18:15
you wanted was we give and take out loans and we see what happens
01:18:18
if you get the souls it was not too well if it progresses
01:18:22
we we remove the patient from the least maybe it's not it's not cool whatever but uh we remove the vision from this
01:18:30
oh yes which we just we close the questions
01:18:36
it was rather naive question about the points again in my wish by one point six week lesions inside
01:18:43
the problem of the very low of the little not there no negative predictive value so if we
01:18:48
have indicated by so we don't know if it's actually sampling error or if it's not consumer
01:18:52
and i will ask if you're going to see from those things you
01:18:55
do get problems material into bikes are you confident that it
01:19:02
would you still be quick system with that you relative ms do you
01:19:05
go to force the mikes your remarks mister he can coexist
01:19:09
as i mentioned in some of the studies there was the table
01:19:13
janice appearance and so they tried to but from the biopsy
01:19:17
not in our study but in the study by seventy no they perform the by c. in there
01:19:22
areas and more enhancing and be a
01:19:27
doubtful but enhancing its use
01:19:30
usually if you take material and most importantly if you're confident that the needle wasn't gonna
01:19:36
take place so they open it or the pain you know usually when you
01:19:40
i'm not sure you you already when you take the biopsy if uh you have completely targeted delusion or you
01:19:46
are on the border so or even for their from by you know whether you crossed the chromosome all
01:19:54
it is sometimes they don't you don't get any material because it especially with aspiration needles
01:19:59
if the drum was not completely might has played the blah then you
01:20:03
lose b. and markham so it's uh these could be you know
01:20:10
right but then if you we we do not perform any by c. but that is a also that
01:20:17
performer are conceived and things considered cruel obvious and greater
01:20:21
competition was uh what is important is that
01:20:25
you all need all only when you are incident from was because usually you
01:20:31
can cross even the best as if we need to the scrolls
01:20:35
uh it does not them as when you really reflect the needle it close if you cross with the open needle
01:20:42
the the vessels and the bad that's then you can create the fees colour so
01:20:46
it is important that you open the needle only within the from those
01:20:51
usually we use the mindy
01:20:53
but you can use even we because it basically my impression the goal was movements
01:20:58
i believe that when is the two cat uh i've me for perusal
01:21:07
insisting eek huh vince composes u. k. and the user decide to just the time it's
01:21:14
you mentioned steffi to as a complement of like news is do we use the diamonds
01:21:20
spanking operators and this is part of the proposal eternally the for the prospective study
01:21:27
no usually not because the diamonds other very often elevated in
01:21:31
even in beijing without remorse is whether these are
01:21:35
related to the the school that opens it for that it was a nobody knows i don't know maybe so
01:21:40
maybe you know if you have more experience than myself but so far uh uh we don't know it
01:21:48
any other questions or
01:21:51
uh_huh

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Conference program

Imaging modalities to assess splanchnic vein thrombosis
Prof. Fabio Piscaglia, University of Bologna, Italy
21 June 2018 · 6 p.m.
Anticoagulation treatment for portal vein thrombosis in patients with cirrhosis: DOACs – are we still far from using them?
Prof. Dr. med. Andrea De Gottardi, Hepatology, Inselspital, University Hospital Bern
21 June 2018 · 7:30 p.m.

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