Shadowing Practice: Embolization of AV Malformations: Tips and Tricks - Learn English Speaking with Video

Hi.

I'd like to thank the organizers for inviting me here today.

So this is going to be a pretty quick review as well because it's kind of a complex topic.

So I'm going to focus mainly on the technical part of embolization procedures.

These are disclosures.

And so the AVM, as we all know,

are abnormal connections between arteries and veins.

Typically with the intervening nidus or collection of abnormal vessels with feeding arteries and draining veins.

They can be divided into different types,

the top being more fistulist-type connections,

which are a direct artery into a venous sac

and then going down to multiple arteries coming into a nidus and then an outflowing vein.

And these have been related to different genetic diseases,

such as hemorrhagic hereditary telangiectasia 1 and 2, capillary malformation AVM syndrome.

Then they—these do have genes associated with them,

but most AVMs are actually sporadic.

And then in, I am a neurointerventionalist,

so we divide our AVMs into many different types.

I'm not going to go over it very laboriously,

but depending on where it's located,

so in the cerebral matter itself,

peel malformations are ranging from nidal-type malformations to fistulas,

which occur mainly in pediatrics.

and galen malformations occur mainly in newborns.

And then there are malformations that are more fistulas

and acquired later in life that occur in the dura or lining of the brain.

And this can be found in the carotid cavernous region where you can also find direct fistulas from trauma.

And then there's a whole organization for spinal AVMs as well.

And so how, you know,

to get to the embolization part,

how do we close these malformations?

The focus and the goal really is to treat the nidus in the case of nidal aneurysms

and close this connection as well as in the fistula's connection,

the focus is really to get to the proximal part of the vein that's receiving the arteries and close that.

are sometimes used in these cases,

but actually less so because you really can only get to these medium-sized arteries or smaller,

even tinier arteries with coils,

so you can't really get good penetration into the nidus itself.

There have been use of sclerosing agents,

so taking a micro catheter sorry into a feeding artery injecting ethanol 100% ethanol to kind of burn the malformation

and and destroy it in that way but the more common uses liquid agents

and that can be there are really two

that are in use in the US right now there's NBC a which is a cyanoacrylate and then there's onyx

which is a polymer, and I'll go into those.

And then there's some neuroagents in development,

and these can be placed into the nidus or into the vein via a transarterial or a transvenous approach.

NBCA is closely related to crazy glue.

It's an adhesive, so it sticks to the arteries.

And the goals, as with any embolization of AVM,

is good penetration into the nidus.

And with NBCA, it is,

once it contacts the blood, it polymerizes very quickly.

And so you want to prevent proximal reflux along the catheter,

as prolonged contact with the catheter will cause adhesion to it.

And you can have a retained catheter or vessel injury when you try to pull it out.

Onyx was developed and approved by the FDA in the 1990s and actually in the mid-2000s.

And this is a copolymer of ethylene vinyl alcohol.

It's dissolved in a solvent, DMSO.

And then there's suspended micronized tantalum powder in it to achieve radio radio opacity,

so it needs to be shaken right before you inject it or else all the tantalum will settle out of it.

And then the traditional method of injecting onyx is to inject,

and it looks like this dark color because of the tantalum within it,

so you inject little bits along the tip of the microcatheter until you fill the proximal artery here,

refluxing a little bit along the catheter.

And then as soon as you create,

the goal of that is to create a plug within the proximal artery at the location of the tip of the catheter.

And then once you create that plug,

when you inject, it's going to go forward and penetrate into the nidus.

So like I said, a proximal plug is used,

and the catheter needs to be removed from the embolic cast at the end of the embolization.

So even though Onyx is not adhesive,

it can be, if you reflux too much along the catheter,

this can lead to a retained microcatheter as well,

just because of friction in trying to remove it.

And if you then pull too hard,

this can lead to rupture and hemorrhage.

So the tips and tricks,

I'm really just going to talk about a few newer techniques that we're using in the last few years.

And one of them is,

and it has to do with newer technology that's coming out.

So one is the use of the detachable tip microcatheter,

which is called the Apollo microcatheter.

And it's a single lumen catheter.

It has a tip that's actually held into a shaft here by pressure, by friction.

And this allows for a force being required to actually separate the two.

So it's less than a third of the force that you would need to actually break any other part of the catheter.

So it's thought that it's a more gentle force of retrieving the catheter.

And you basically just pull slowly and stretch and stretch until it detaches or the whole thing pulls out of the onyx.

And this catheter comes with two tips.

So this is the distal tip,

the proximal marker here is where the detachment zone is.

So you can't, if you're injecting and you reflux all the way to this point,

you have to stop because you're going to then glue that detachment zone in place.

And this is an example of a vertebral peel fistula.

So this is an AP view and a lateral view,

the vertebral artery in the neck,

and this fistula's connection to posterior fossa vein.

And this is a navigation of the Apollo catheter to the fistula.

You could see it in place,

100

the distal marker and the proximal marker.

101

And there you see an injection of NBCA.

102

So this catheter can be used with both NBCA and ONIX.

103

And in this case, it looks like the catheter was completely removed without detaching.

104

So then in a second injection,

105

another Apollo catheter was brought up to a second fistula site.

106

And there's some injection of contrast showing the direct connection to the vein.

107

And this is a video here.

108

And this is high concentration of NBCA.

109

So this really, if you were using any standard microcatheter,

110

you would not keep it there that long because you'd be afraid of actually polymerizing and gluing the catheter in place.

111

But because now that we have the detachable tip,

112

we're more comfortable trying to get good penetration with NBCA.

113

And so that's the injection.

114

You can see more NBCA filling into the venous side of the fistula,

115

and then pull and out.

116

And then you can see kind of tiny here,

117

but that's the distal tip, and that's the catheter.

118

So it's actually detached, and the distal tip of it is left in place.

119

So the advantages with Onyx,

120

you make reflux purposefully to create a plug,

121

so you know how much you can reflux.

122

And with the NBCA, you have a controlled injection instead of trying to inject quickly and then pull it out.

123

So this allows for better penetration.

124

And then it requires less pressure to remove the catheter,

125

so less chance of injuring.

126

The disadvantage, it is a bit stiffer at the detachment zone,

127

so the connection between the tip and the proximal microcatheter

128

compared with the rest of the microcatheter and with some other softer microcatheters that we may use.

129

And then we've had now two cases where on navigating the catheter without attempting to detach the tip,

130

it's inadvertently detached in a proximal artery.

131

So that's something that that if you're navigating in torturous anatomy, it can happen.

132

And that's the tip.

133

So the other thing that's come about is the development of DMSO compatible balloon microcatheters.

134

So these are the SEPTR balloons.

135

And it's just, it's a dual lumen catheter.

136

So you have a lumen that you can inject onyx or glue or coils,

137

whatever you want, whatever you're doing,

138

and then a second port to inflate this balloon.

139

And then this is a case,

140

so this really allows for a really good penetration without having to worry about reflux or make a plug.

141

So So this is a case of a maxillary arteriovenous malformation.

142

This is the internal maxillary, the patient's maxilla.

143

And you see this abnormal AVM, capillary-type AVM right here.

144

And then this is the balloon catheter in place.

145

So it's in this branch here.

146

And this is the inflation of the balloon.

147

So you create a plug just by inflating the balloon.

148

It's very quick.

149

And then you can achieve great penetration into the entire AVM.

150

This required injection into a couple different feeders,

151

but by using this technique,

152

I was able to completely treat.

153

And at the end of this treatment,

154

there was no remaining shunting.

155

The important thing when you're using Onyx is you have to be able to recognize abnormal and normal and know your,

156

especially in the head and neck,

157

you have to know where you're located.

158

Avoid any abnormal connections to the internal carotid circulation

159

or any normal connections that you might not see

160

but you know are there because the onyx with this technique can penetrate into small collaterals that are otherwise closed.

161

And then just as This is a last example.

162

This is a 42-year-old man with headaches and tinnitus,

163

and he got this MRA,

164

which shows this markedly abnormal enlarged vessels on the left side of his head from external and as well internal circulation,

165

and all going into the left transverse sinus.

166

This is a typical dural arteriovenous fistula, and usually acquired.

167

This is the MRA showing that fistula.

168

You see some external carotid artery,

169

occipital branches, middle meningeal branches,

170

and then on angiography marked dilatation of these branches.

171

And really on the CAT scan,

172

we can see that they really all come down to this connection right here into the transverse sinus,

173

or so we thought.

174

However, when we closed that off,

175

we realized that the fistulas were coming to multiple locations along that sinus.

176

And this is one disadvantage of ONIX.

177

So after you have to close such a complex malformation with multiple vessels,

178

you're left with this sort of picture in which you can't really see anything afterwards.

179

So that leads to my last point,

180

which is the development of this new liquid embolic called Phil,

181

which is currently approved in Europe.

182

And this is going to be,

183

it's going to have iodine attached to the copolymer.

184

And so therefore that should absorb and it will be less radio-opaque when you come back for later treatments.

185

And that's it.

186

Thank you for your attention.

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Woordenschat en spreektips bij deze les

Deze spreekles op niveau C2 is gebaseerd op de video “Embolization of AV Malformations: Tips and Tricks”. Deze woorden komen het vaakst terug: catheter, tip, fistula, connection, Avm. Deze video bevat 186 zinnen en 1881 woorden om na te spreken. Het gesproken deel duurt 14:09. De spreker praat in een gelijkmatig tempo van ongeveer 133 woorden per minuut, prettig om te shadowen. Slechts 76% van de woorden hoort bij de 3.000 meest gebruikte Engelse woorden, dus de woordenschat is pittig.

Belangrijke woorden in deze video

De 15 moeilijkste woorden uit de video, met uitspraak en betekenis:

Woord	Uitspraak	Betekenis
catheter zelfstandig naamwoord	/ˈkæθɪtɚ/	katheter
artery zelfstandig naamwoord	/ˈɑɹ.təɹ.i/	slagader, arterie
fistula zelfstandig naamwoord	/ˈfɪs.tjə.lə/	fistel
inject werkwoord	/ɪnˈd͡ʒɛkt/	injecteren, inspuiten
onyx zelfstandig naamwoord	/ˈɒnɪks/	onyx
vein zelfstandig naamwoord	/veɪn/	ader
abnormal bijvoeglijk naamwoord	/ˌæbˈnɔɹ.ml̩/	abnormaal
balloon zelfstandig naamwoord	/bəˈlun/	ballon
injection zelfstandig naamwoord	/ɪnˈd͡ʒɛk.ʃən/	inspuiting
distal bijvoeglijk naamwoord	/ˈdɪs.təl/	distaal
glue zelfstandig naamwoord	/ɡlu/	lijm
carotid zelfstandig naamwoord	/kəˈɹɑt.ɪd/	halsslagader
detachment zelfstandig naamwoord	/dɪˈtæt͡ʃmənt/	scheiding, losraking
tantalum zelfstandig naamwoord	/ˈtæntələm/	tantaal, tantalium
adhesive bijvoeglijk naamwoord	/ədˈhiː.sɪv/	adhesief

Phrasal verbs die je zult horen

Woord	Uitspraak	Betekenis
come out werkwoord	/ˌkʌm ˈaʊt/	uitkomen

Grammatica in deze video

De structuren die de spreker het meest gebruikt, met de exacte woorden uit de video:

Structuur	In de video
Lijdende vorm be + voltooid deelwoord — het gaat om wat er gebeurt, niet om wie het doet	can be divided · have been related · can be found
Present perfect have/has + voltooid deelwoord — iets uit het verleden dat nu nog telt	have been related · have been

Uitspraak om op te letten

De spreker gebruikt 19 samentrekkingen en verkorte vormen, zoals you're, can't, I'm. Spreek ze kort uit, zoals je ze hoort.

De “th”-klanken: catheter /ˈkæθɪtɚ/, ethanol /ˈɛθ.ə.nɑl/, ethylene /ˈɛθɪˌliːn/
De klanken “sh” en “zh”: penetration /pɛ.nəˈtɹeɪ.ʃən/, injection /ɪnˈd͡ʒɛk.ʃən/, friction /ˈfɹɪkʃən/, circulation /ˌsɝkjʊˈleɪʃən/, adhesion /ˌædˈhiː.ʒən/
Lange woorden — let op de klemtoon: penetration /pɛ.nəˈtɹeɪ.ʃən/, capillary /ˈkæpəˌlɛri/, maxillary /ˈmæk.səˌlɛɹ.i/, polymerize /pəˈlɪ.mə.ɹaɪz/, disadvantage /ˌdɪsədˈvæntɪd͡ʒ/

Klanken die Nederlandstaligen lastig vinden:

Stemhebbende eindmedeklinker — /b/, /d/, /g/, /z/, /v/ niet verscherpen: carotid /kəˈɹɑt.ɪd/, adhesive /ədˈhiː.sɪv/, polymerize /pəˈlɪ.mə.ɹaɪz/, disadvantage /ˌdɪsədˈvæntɪd͡ʒ/, approve /əˈpɹuːv/
/æ/ — opener dan de Nederlandse “e”: catheter /ˈkæθɪtɚ/, abnormal /ˌæbˈnɔɹ.ml̩/, detach /dɪˈtæt͡ʃ/, detachment /dɪˈtæt͡ʃmənt/, tantalum /ˈtæntələm/
/g/ — een harde plofklank, geen Nederlandse “g”: glue /ɡlu/, navigate /ˈnæv.ɪ.ɡeɪt/, angiography /ˌæn.d͡ʒiˈɑ.ɡɹə.fi/, organizer /ˈɔɹɡənaɪzɚ/, navigation /nævɪˈɡeɪʃən/

Zo oefen je met deze video

Luister de hele video één keer zonder te spreken en noteer de woorden die je niet kent.
Spreek zin voor zin na op normale snelheid en herhaal elke zin tot je ritme gelijk is aan dat van de spreker.
Neem jezelf op en vergelijk met het origineel; let daarbij op woorden als catheter, artery, fistula.

Wat is de Shadowing-techniek?

Shadowing is een wetenschappelijk onderbouwde taalleermethode die oorspronkelijk is ontwikkeld voor professionele tolkentraining en gepopulariseerd door polyglot Dr. Alexander Arguelles. De methode is eenvoudig maar krachtig: je luistert naar native Engelse audio en herhaalt het onmiddellijk hardop — als een schaduw die de spreker volgt met slechts 1–2 seconden vertraging. In tegenstelling tot passief luisteren of grammaticadrills, dwingt shadowing je hersenen en mondspieren om echte spraakpatronen tegelijkertijd te verwerken en te reproduceren. Onderzoek toont aan dat het de uitspraaknauwkeurigheid, intonatie, ritme, verbonden spraak, luisterbegrip en spreekvaardigheid aanzienlijk verbetert — waardoor het een van de meest effectieve methoden is voor IELTS Speaking-voorbereiding en echte Engelse communicatie.

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Woordenschat en spreektips bij deze les

Belangrijke woorden in deze video

Phrasal verbs die je zult horen

Grammatica in deze video

Uitspraak om op te letten

Zo oefen je met deze video

Wat is de Shadowing-techniek?