PTC - As it is - LGM method

​

bsaically use US or use fluoro

or use bof

​

L side is nice for US

​

R side is better for fluoro

​

typcal target is R inferio-post ducts however, ductal systems are extremely varied

​

you kinda go in the mid ax line and then advance the needle in the plane of the ducts

then tilt the tube and see how you did - just like LGM

​

its a mind twister but you gotta figure out if you in front or in back of the ducts

adjust your needle and try try again

​

evetulally you get really good

​

you can make tons of needle passes

​

ala KK (HK)

do it like the matrix 

​

make tons of passes till the wire passes

always watch under 3 mag of fluoro

​

"fluoro it" - LGM

​

--

​

using tube rotation to tell where you are

​

if on the AP you are in line with the duct

​

and you rotate the towards the head (II towards head)

if your in front of the duct- will project below

​

if behind duct - will project above

​

if you go RAO- if needle in front will project to left

if go LAO, if needle in front will project right

​

guaranteed ill forget this in the case

​

--

​

re. biliary stenting

​

can perform biliary stenting with 10 mm viabil stent when life expect is approx 6-12 mths

​

can extend stents into R and L sided ducts using bare metal self exp stents such as protege, with CG placed drug eluting Zilvers (PTX) in the bile ducts

​

if the pt returns with jaundice, can consider doing percutaneous balloon sweeping of the stents

​

consider placing anchor in the bile access prior to dc'ing after placing indwelling stent.  This is an amplatz anchor placing in a peripheral duct

​

​

​

​

​