So, switching gears now, we're going to go to axial stent deployment in our patient here who's got a large pseudocyst, and so we're going to have this patient set up. It's important to identify when you're looking at, you know, your pseudocysts or fluid collections, look within the stomach at it, you know, to see what's the most optimum area for puncture. You want to have an area that's clearly clear of any intervening veins or arteries. So that's, you know, problem number one. But then you also want to position it such that you'll be able to easily enter the cavity if you need to do necrosectomies or things like that. So you want to be cognizant of that. You want to have a stratoscope as possible. You want to avoid putting things at the GE junction or even within the esophagus as sometimes, you know, we can see fluid collections up to that point. You want to avoid those areas. And then you also want to, if you can, avoid going to the lesser sac because it can be associated with higher rates of complications. So Adje, it looks like you found a good spot here in the stomach. I think that's everything. And so it's important to ground the patient and our patient is grounded and it's plugged in and great. And the, the, the Irby setting, there's a hot Axio setting on the Irby generator and any other generators that you have, you may be able to set up, you know, an Axio, so I'm just going to attach this to heat. Oh, okay, Ellie, I'm not sure if it connects. Not connecting. So bear with us while we find a different cord. Actually, while we work on finding the right cord, you might want to talk about how you select the size of your Axio stents. So when Axio first came out, there were 10 millimeter stents, then 15 and now 20. So we started abandoning the 10s because they seem so small. So I would say generally you do 15 or 20 millimeter stents, but what I think might be useful with the 10s is the bile duct. So they've also developed ones for the bile duct, but they're really, really small. So I don't know if you guys have had experience with those and whether you like the six and But I find they're really hard to see on EOS and I've screwed up and mal-deployed them. So I think the 10s are good for the bile duct maybe, and otherwise I tend to do 15 or 20. 15 for, you know, a flu collection with no debris in it, and 20 if I'm going to have to go in and debride. What about you guys? Yeah, I feel similarly. I think we've used 10s for gallbladders. I think generally 15 is our go-to. If there's a lot of necrosis, we pick a two centimeter one so that we can easily, you know, get through with our scope to drive through there and clear out the necrosome. I do like the idea of the six and eights, especially for Colodoco Ds. But we don't have them at our institution yet. I think we're about to get the eight millimeter one. And I think that there's a rule. I was going to warn you on that is that we've used those and they're harder to see. And it's a little tricky with the bile duct because it's a different animal, just sort of like the GJ. It's a little different animal and you don't have the distance. You know, you're going to see, Ajay is going to put that way deep into the cyst to deploy the distal flange. It's harder to do depending upon your angle that you're in, in the bile duct. And then on top of that, I just find them very hard to see. So we stock them as well. And the first time I used a 10 because we didn't have the smaller, then I tried, I don't know if it's a six or an eight, and it got maldeployed and it was in the wall. And we ended up having to salvage with a wire and a fully covered metal biliary stem. Yeah, that can be tricky. Yeah. So that's the only thing I would warn against. Great. So getting back to our patient where we've got our cyst in view, Ajay's found his spot. He's going to do the steps, right? So the first step is going to be to unlock at the very bottom. And then his foot is going to be on the gas on the yellow pedal as he punctures the stent. And do you use a fluoroscopy when you're doing this or not at all? What is your approach to the fluoroscopy for these stents? I generally don't use fluoroscopy. If there's concern for the location of it, or I think that it may be challenging to deploy, then I'll put them on the fluoroscopy table. But when we first started, we were using fluoroscopy for all of them to confirm our position. But I think that as time has passed, when we become more comfortable placing these, we can get a really good EUS signature that kind of shows where we're at. What about you? Similarly. In the beginning, when I was starting my practice, I was like very, very risk-averse. So I wanted to always make sure that I'm well below the GE junction. So I would use one fluoroscope to make sure how far down from the GE junction. But I think that's too much caution. So here I have my site. I've ruled out any blood vessels. Normal practice, we would rely more on cautery than on the pressure, mechanical pressure to go through. But since it's an X-Plan models, we might have to rely both on that. So I start pressing onto my cautery before I go in. And you can see I'm into the collection here. I lock my catheter. I unlock my deployment setup. Step one is deploying the distal flange. I will deploy my distal flange into the catheter. It's going to be a little tricky in there, but you guys can see that it's locked again. So now I bring it back a little bit further to kind of get the football. It's the football that Shivangi was talking about earlier today. So how do you approach it? Do you deploy it within the... Yeah, I also deploy it within the catheter, within the scope, and then back my way out. I think initially when this first came out, they were teaching you to look at the black marking and discopically and all this stuff. And I think they had a lot of maldeployment. So I think they sort of changed the entire thing to say, you know what, just deploy it in the scope. And that way your scope's outside of the pseudocyst, right? Or the fluid collection. And then you just push it out. And especially trying to find the black spot. If you are in a tricky position, you can lose position. And sometimes there's a little bit of fluid coming out. So it becomes tricky. So I think this is easier. I tried to figure out how do I go to the endo view now? The endo, yeah, I can show you. Perfect. And that's when you kind of back up a little bit and push your catheter out. Yeah, perfect. And then next steps. So we'll typically stay in this position. Fluid is often draining at this point. And then the next step in this is going to be dilating to just about the size of the stent. So if this is a 10 millimeter, I will dilate to typically around 9. I don't dilate to 10 necessarily because I like the additional pressure to help prevent any kind of bleeding. So I tend to dilate to just lower than the diameter of the stent. And one thing which I realized some of the fellows, one of my fellows did not know was that there is a channel here for passage of our O35 wire at the top. Especially if you're doing in a tricky situation, sometimes you are not sure what if your position would be stable. You want to salvage the first end. It's not fully open into a cavity which is filled with necrosis. You can easily pass a wire through it and then have a safety backup plan as well. Yeah, that's a great tip. So Jen, when do you decide to do the dilate? I don't think I typically do not dilate. You know, I dilate all the time. Every time I dilate. Okay. One thing that Shivangi said in the earlier session today was a good point was if you have a lot of necrosis and you know you're going to be going in and out, it is a good idea if you have a choice to make sure you're putting your axios in a place that's not going to torture you to go in and out of a thousand times. So it is a good idea to think about it. I mean, sometimes you're stuck and you go where you can go. But if you have a choice, maybe good to look endoscopically briefly just to make sure that it's where you like it. Yeah, I really think that's an important point is your selection of the location for where you're going to place your axios is very important. And you really want to put it in a spot that's going to be easy to enter and exit as you're doing your necrosectomy. So we're just going to change over our equipment and shift gears to ERCP. So bear with us.

axial stent deployment

pseudocyst

puncture site selection

fluoroscopy

stent unlocking and deployment