BackTable Vascular & Interventional: Recent Episodes
BackTable
The BackTable Podcast is a resource for interventional radiologists, vascular surgeons, interventional cardiologists, and other interventional and endovascular specialists to learn tips, techniques, and the ins and outs of the devices in their cabinets. Listen on BackTable.com or on the streaming platform of your choice. You can also visit www.BackTable.com to browse our open access, physician-catered knowledge center for all things vascular and interventional; now featuring practice tools, procedure walkthroughs, and expert guidance on more than 40 endovascular procedures.
In this episode, our host Michael Barazza interviews Dr. Jafar Golzarian, interventional radiologist at the University of Minnesota, about intra-arterial and percutaneous treatment of giant hepatic hemangiomas.
SHOW NOTES
We start this episode off by highlighting the Global Embolization Symposium and Technologies (GEST) initiative that Jafar co-founded in 2007. Over time, GEST has evolved into a highly acclaimed conference, drawing an international audience of thousands of participants for its webinars.
We then dive into cutting edge treatments of liver hemangiomas. Jafar discussed how he was introduced to a novel approach in 2014 when one of his friends, Dr. Shahram Akhlaghpoor, sent him a paper with his results from using transarterial bleomycin-lipiodol embolization (B/LE) to treat symptomatic giant hepatic hemangiomas. Another friend of Jafar’s shared an inventive approach in shifting perspectives to view hepatic hemangiomas as low-grade venous malformations and using percutaneous injections for treatment.
Then, Jafar discusses the specifics of his approach to hepatic hemangiomas and how he usually only treats hemangiomas that are large, cause pain and discomfort, or exert pressure on vital structures such as the portal vein or bile duct. Jafar notes that the patient demographic that presents with hemangiomas are typically women aged 30 to 50, and they can be self-referred or referred by hepatobiliary surgeons.
In regards to treatment, Jafar prefers either 30, 45, or 60 units of bleomycin, favoring the latter for hemangiomas exceeding 10 cm. He prefers percutaneous access if feasible, but he resorts to chemoembolization in cases when insurance coverage presents issues. Minor post-treatment symptoms post-treatment include abdominal pain and occasional nausea, with extremely rare compilations being pulmonary fibrosis or allergic reactions to the bleomycin. Jafar notes that imaging at 1, 3, and 6 months post-treatment guides assessment of treatment effectiveness of, with substantial change best evaluated at the 6-month mark.
Jafar’s treatment has garnered high patient satisfaction, with very few patients requiring return for further therapy after the 6 months. He notes that when surgeons are shown the before and after imaging of the treatment of hemangiomas, they become big advocates of these procedures.
RESOURCES
Transarterial Bleomycin–Lipiodol Embolization (B/LE) for Symptomatic Giant Hepatic Hemangioma: https://pubmed.ncbi.nlm.nih.gov/29922860/
En este episodio de BackTable, la Dra. Sara Lojo Lendoiro entrevista al Dr. Alberto Alonso, radiólogo intervencionista en la Clínica Universidad de Navarra, sobre la importancia del trabajo multidisciplinar e interdisciplinar en la Radiología intervencionista.
SHOW NOTES
El Dr. Alonso introduce el término de interdisciplinariedad, que ocurre cuando distintas especialidades trabajan de manera combinada para interconectarse y potenciar las ventajas de cada una, con un objetivo común. El Dr Alonso defiende que todas las disciplinas son finitas, y debido a ello, existen puntos ciegos y una ausencia de alternativas si se depende solamente de una especialidad. Fomentar el trabajo en equipo con otras especialidades es importante para los radiólogos intervencionistas porque puede ayudarles, no solo con los procedimientos técnicos, sino también con la parte clínica.
En este episodio, se enfatiza la importancia del análisis de los resultados de los procedimientos a corto y largo plazo. Para Alonso, ser autocrítico es importante y recomienda que se elimine la subjetividad en la medida de lo posible. Menciona que los errores y los malosentendidos entre las diferentes especialidades ocurren si no existe comunicación y confianza entre los distintos especialistas: es necesario que nos centremos en el factor humano, más que la reputación o el ego, para construir las relaciones personales, dejando atrás el narcisismo existente en la medicina.
Finalmente, se resumen algunos escenarios en los que la interdisciplinariedad puede mejorar el manejo de los pacientes, siendo especialmente importante en pacientes complejos como pacientes pediátricos y oncológicos. El Dr. Alonso termina el episodio animando a los oyentes a fomentar la comunicación con el resto de las especialidades, promover la autocrítica y evaluar los resultados obtenidos, así como impulsar el trabajo interdisciplinar en las diferentes unidades de radiología intervencionista.
In this episode, host Aaron Fritts is joined by Lake Odom and Chas Sanders. Lake is an IR technologist with over a decade of experience, and Chas is the founder and CEO of MARGIN, a company that handles supply chain and outpatient OBLs and ASCs. They focus on the vital role that techs play in maintaining the culture, workflow, and efficiency in an office-based lab (OBL).
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SHOW NOTES
The episode starts with a discussion on what a team lead should be looking for when hiring a IR or cath lab tech. Lake notes that experience and teamwork skills are essential. However, the willingness to learn can also make up for the lack of experience, especially because experience in one office does not always translate to another practice, since every practice has different needs and procedures.
Positive work culture and fair compensation are crucial to employee retention. While the physician plays a large role in defining the culture in a practice, it is also important that IR techs are trusted with the responsibility of maintaining the culture, as their roles are very patient-facing and key in practice efficiency. In the discussion of paying techs on a salary versus an hourly system, Lake notes how a salaried tech is more likely to feel like a part of the team and is more invested in the success of the practice.
As the discussion shifts to increasing the efficiency and profitability of a practice, Chas discusses how cost awareness is key. It is vital that the physician engages the techs in this conversation, since they are the ones who order tools. The guests wrap up the episode by emphasizing how putting trust in the techs is crucial to the efficiency and profitability of each practice, as they will be the biggest advocates of the practice to the patients.
In this episode, interventional nephrologist Dr. Neghae Mawla discusses with our host Dr. Christopher Beck about endovascular AV fistula creation.
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SHOW NOTES
We start off the episode by discussing Neghae’s current practice at Dallas Nephrology Associates, where most of his patient referrals come from his partners. Patients who come to see Neghae receive a standard vein mapping via ultrasound to determine whether they should receive an endovascular or a surgical procedure. If patients’ veins fit certain specifications, such as superficial location (cephalic, median cubital), large enough size (2-2.5 mm) and presence of large perforating veins (2 mm), then they are better candidates for an endovascular approach.
However, these rules do not perfectly predict fistula success. Neghae noticed that even if patients fit the above criteria, their fistulas don’t always mature correctly. With experience, he began to take into consideration the brachial vein size as well. While this is not part of the official vein mapping criteria, he has seen that if the brachial vein is significantly larger than the superficial veins, it could have a competitive outflow and hinder the maturation of the fistula.
The conversation then shifts to the types of devices used to create the anastomosis for the fistulas, WavelinQ and Ellipsys. Neghae notes that while most patients do well with either device, some patients do better with one over the other. Thus, he suggests that physicians are trained on both devices if possible, to guarantee the best outcomes. To end the episode, Neghae reflects on his previous decade of experience with endovascular AV fistulas and shares wisdom about failures and successes that he has learned from.
RESOURCES
ASDIN White Paper: Management of cephalic arch stenosis endorsed by the American Society of Diagnostic and Interventional Nephrology: https://cdn.ymaws.com/www.asdin.org/resource/resmgr/positionpaper/Cephalic_Arch.pdf
ASDIN White Paper: Patient selection, education, and cannulation of percutaneous arteriovenous fistulae: https://cdn.ymaws.com/www.asdin.org/resource/resmgr/positionpaper/ASDIN_EndoAVF.pdf
ASDIN Certification ink: https://www.asdin.org/page/pAVFCert
In this episode, co-hosts Dr. Aaron Fritts, Dr. Michael Barraza, and Dr. Eric J. Keller discuss social media ethics in medicine.
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SHOW NOTES
To kick-off the episode, the three IR physicians discuss “clot porn” and all the debate associated with posting case-related findings (clots, imaging, etc) on social media with device/company name visible. Dr. Keller, who has a strong background in medical ethics, shares his thoughts on the matter and underscores the 6 pitfalls of medical social media: patient privacy, patient dignity, information accuracy, conflict of interest, justice inequity, and interprofessional respect.
From Dr. Keller, we learn that the crux of the matter tends to circle back to two central issues– how the case is shared and intentions behind sharing. Additionally, Dr. Keller shares unique data on the relation between how often a medical device company is mentioned in social media posts, how often physicians are compensated for their public endorsements, and whether or not conflict of interests are disclosed.
Dr. Barraza and Dr. Keller then compare TikTok, Instagram, and Twitter’s roles and potentials in medicine. The trio discuss Twitter’s past, present, and future influences on medical research, networking, innovation, and education. They also consider the need for more clear, comprehensive social media posting guidelines issued by specialty societies and ideas for patient consent forms over social media posting.
To wrap up the episode, the doctors discuss interprofessionalism, dealing with social media trolls/negativity, and personal vs. professional accounts. Dr. Keller notes that 85% of the general public turns to social media networks to seek healthcare information, which highlights the online presence of physicians and how they are often held to a higher ethical standard on social media platforms.
For listeners wanting to learn more about social media ethics in medicine, the annual Western Angiographic Interventional Society (WAIS) in Palm Springs, California (October 7-11, 2023) will have dedicated medical social media ethics panels and discussions built into programming. Be sure to register and attend! Link to the WAIS webpage below.
RESOURCES
Western Angio Interventional Symposium 2023 Schedule: https://www.westernangio.org/
Western Angio Interventional Symposium 2023 Registration: https://www.westernangio.org/event-5048807
Link to Thomas Webb study: https://www.jvir.org/article/S1051-0443(22)01727-4/fulltext
CMS Sunshine Database: https://openpaymentsdata.cms.gov/
In this episode, host Dr. Sabeen Dhand interviews Dr. John Rundback about analysis of arterial calcifications using microCT.
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SHOW NOTES
Dr. Rundback starts by describing the basic differences between microCT and current imaging techniques. MicroCT is a non-destructive imaging method where the x-ray source is stationary but the subject is on a rotating stage. This method can create 3D imaging with a 3 to 5 micron resolution. On the other hand, in traditional CT imaging, the subject is stationary and the x-ray source rotates, which gives a 3 to 5 millimeter resolution.
Then, the episode shifts to a discussion on Dr. Rundback’s recent study, in which he used microCT to evaluate the treatment effect of medial arterial calcification in below knee interventions after Auryon laser atherectomy. For this study, arteries were dissected out of cadavers with cardiac risk factors. These artery segments were then subject to different energies from the Auryon laser. MicroCT was performed before and after the procedure to analyze the degree of calcification. These trials have shown that atherectomy using the Auryon laser could increase compliance of the treated arteries. MicroCT has also helped expand knowledge about different types of calcification and how atherectomy differentially impacts them.
RESOURCES
Treatment effect of medial arterial calcification in below-knee after Auryon laser atherectomy using micro-CT and histologic evaluation: https://pubmed.ncbi.nlm.nih.gov/37400346/
Auryon Atherectomy Device: https://www.angiodynamics.com/product/auryon/
In this episode, host Dr. Aaron Fritts interviews Dr. Junjian Huang & Dr. Sean Maratto on navigating early-career changes. Both Dr. Huang and Dr. Maratto touch on a range of their early-career experiences and offer their advice, insights, and realizations.
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SHOW NOTES
The trio begin by discussing the responsibilities of stepping up as new attendings and dive into all that goes into maintaining and building new service-lines. Both Dr. Huang and Dr. Maratto underscore the importance of being as available as possible, taking every brick and mortar case with enthusiasm and drive, and truly getting to know your referring physicians. These actions go a long way in successfully establishing and expanding IR service-lines.
Dr. Huang and Dr. Maratto also speak on the nuances of cultural awareness and sensitivity, as every region, hospital, and/or practice does not operate in the same fashion. Both early-career physicians convey the gravity of quickly adapting to the cultural norms of a new workplace and becoming comfortable in new environments. Dr. Maratto adds how conflict resolution is a mainstay throughout all career stages and highlights leadership and clear communication as vital qualities.
We then hear about the ins-and-outs of early-career mentorship from both physicians. Dr. Huang states how some of the most pivotal mentors can be from different fields, to always search for mentors, and to even make mentors through industry. Dr. Maratto shares how it is important to have mentors for both professional and emotional support and to always pay it forward to the next-generation of physicians and trainees.
Dr. Fritts, Dr. Huang, and Dr. Maratto share a real-time mentorship moment and have a conversation on how becoming an attending can be accompanied by extremely important life milestones such as getting married, starting a family, buying a house, and more.
We conclude the episode by discussing some challenges new attendings can face, such as navigating the business-side of medicine and becoming confident in marketing, insurance, and billing. Both early-career physicians agree how these tasks should not be delegated, as they are very worth knowing. Dr. Juang and Dr. Maratto leave us with important parting advice on what they wish they were told when they finished training and became attending physicians.
RESOURCES
Early Career Section (ECS) of SIR: https://www.sirweb.org/member-central/volunteer/early-career-section2/
In this episode, host Dr. Ally Baheti interviews interventional radiologist Dr. Saher Sabri and vascular surgeon Dr. Frank Arko about their perspectives on a July 2023 New York Times article about the ethics of peripheral arterial disease (PAD) treatment in outpatient based labs (OBLs) and ambulatory surgery centers (ASCs).
SHOW NOTES
Dr. Arko emphasizes the importance of approaching articles as an unbiased reader. He acknowledges that sensationalism in the news is common, and while bad actors do exist, he personally knows talented OBL/ASC practitioners. He also notes that the article fails to mention that the majority of these practitioners follow society guidelines to provide appropriate and effective treatment for their patients, rather than prioritizing financial gain. He believes that most non-surgical specialists have the clinical insight to know when patients would be better candidates for open bypasses as opposed to endovascular interventions. Dr. Arko describes the split response to the article within vascular surgeons on social media, based on their personal philosophies of open versus endovascular interventions for PAD.
Dr. Sabri believes that PAD and critical limb-threatening ischemia (CLTI) are not very well known by the general public, this article was a missed opportunity to bring attention to these conditions and disparities in treatments depending on patients’ geographic locations and ethnicities. The article may have the effect of scaring patients away from seeking treatment for PAD and CLTI, as well as receiving care at OBLs, which were originally founded to make interventions more efficient and patient-friendly. Additionally, the article could foster divisiveness between vascular surgeons, interventional radiologists, and interventional cardiologists and as a result, increase barriers to collaboration.
It is important to differentiate between PAD and CLTI and the stage at which patients present to medical care. Limb salvage rates and decisions to intervene and/or amputate are multifactorial and are not as straightforward as the article may imply. Both doctors agree that specialty societies share the responsibility of monitoring their members for overuse of interventions.
In terms of rebates and volume discounts from device companies, the doctors discuss the ethics of cost savings that benefit a hospital system versus savings that benefit a physician-owned OBL. Dr. Arko recognizes that financing an OBL with device company partnerships can be a smart business decision if devices are used appropriately and only when indicated. He speaks about the need for societies to support more randomized control trials that compare the effectiveness of each atherectomy device. We also discuss implications for insurance coverage of PAD/CLTI interventions. Dr. Sabri believes that it is unfortunate when insurance companies become the decision-maker of patient treatments.
RESOURCES
“They Lost Their Legs. Doctors and Health Giants Profited” (NY Times, July 2023 article): https://www.nytimes.com/2023/07/15/health/atherectomy-peripheral-artery-disease.html
BEST-CLI: https://www.bestcli.com/
“Blocked Artery in Your Leg? Here’s What You Should Know” (ProPublica, June 2023 article) https://www.propublica.org/article/what-to-know-about-peripheral-artery-disease
Outpatient Endovascular Interventional Society (OEIS): https://oeisweb.com/
Society of Vascular Surgery (SVS) Position Statement: https://vascular.org/news-advocacy/articles-press-releases/svs-response-new-york-times-article-overuse-interventions
In this episode, host Dr. Michael Barraza interviews Dr. Zola N’Dandu, an interventional cardiologist at Ochsner Medical Center in Louisiana, about building a successful critical limb ischemia (CLI) program.
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SHOW NOTES
Dr. N’Dandu’s current practice is about 65% peripheral artery disease, with a focus on critical limb ischemia. He discusses how he developed his current CLI focus by traveling and attending conferences, after his formal training. It was during one of these conferences that Dr. N’Dandu was inspired to further get involved with the patients in the wound care center at Ochsner. This interest led to the start of his CLI team.
The episode then shifts towards Dr. N’Dandu’s process of building his CLI team. His commitment to this endeavor helped bring more like-minded people to his team. Having a centralized and committed team has helped Dr. N’Dandu streamline his patient visits, reduce the number of appointments needed for each patient, and greatly decrease the burden on the patients.
Dr. N’Dandu then discusses the evolution of CLI in the last decade and how there are now more medications, therapies, and data available to support patient care. Procedural advancements have also been immensely helpful. Things like radial-to-pedal, 3rd and 4th generation stents, proliferative therapy with stents, drug-coated balloons, and bio-absorbable stents are all advancements in CLI treatment. Additionally, obtaining more data on each therapy will help refine the treatment algorithm for CLI.
As the conversation shifts towards aspects that still need to evolve in CLI treatment, Dr. N’Dandu emphasizes that our treatment of no-option-CLI patients needs to change. One of the treatments that he uses for these patients is deep vein arterialization, a technique that was first discovered in 1912 but still has more potential for growth. DVA involves shunting arterial blood to the veins, which works for CLI, as studies show that it increases angiogenesis and perfusion of the tissue. As Dr. N’Dandu discusses the specifics of his DVA technique, he emphasizes that new advancements are being made every day, so it is crucial to have a cohesive team that can follow up with patients.
In this episode, we delve into the career of Dr. Thomas Sos, a renowned figure in the field of Interventional Radiology (IR), and the triumphs and challenges he faced in the formative years of interventional radiology.
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SHOW NOTES
The episode starts with an introduction to Dr. Sos, who’s accomplishments include serving as SIR president from 1986-1987, SIR gold medalist in 2009, author of 140 publications and 60+ book chapters, as well as a winner of the SIR foundations in leadership and innovation award this past year.
Dr. Sos reflects on his educational journey, starting with his medical degree from Harvard and continuing with a three-year radiology training followed by an IR fellowship at Cornell. As one of Cornell's first IR fellows, he discusses the intensity of his early training and his reasons for choosing this specialty. His fellowship years coincided with the formation of SIR and the rapid evolution of the IR field, offering him a chance to be part of its groundbreaking developments. He then traces his professional path, highlighting his work at Cornell and Brigham, his role as the youngest professor of IR at Cornell, and his position as the divisional chief of Cardiovascular IR.
An important turning point in his career was the coronary angioplasty course in Zurich, Switzerland, which led to his collaboration with Cardiothoracic surgeons and Cardiologists. He also notes his active participation in major conferences to share knowledge about angioplasty.
The conversation turns towards his shift into peripheral vascular disease. Dr. Sos points out that as his work in IR began to draw attention, other surgeons started acknowledging the growing influence of IR in medicine. This shift resulted in more surgeons learning about angioplasty and a collaboration between SIR and the Society for Vascular Surgery (SVS).
In this episode, co-hosts Drs. Ally Baheti and Mike Barraza interview Dr. Ted Wen of Texas Radiology Associates and Dhruv Chopra of Collaborative Imaging about perspectives and helpful technology when managing an independent radiology practice.
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SHOW NOTES
Dr. Wen shares reasons why he and his colleagues chose to keep their practice independent. The fast-growing group spent eight years doing due diligence about private equity (PE) to decide if that was the right model for them. Dr. Wen met with PE firms around the country to explore the process of transitioning into PE practice ownership and its implications for current colleagues and future physician hires. Selling to PE would disproportionately benefit senior partners, who were ready to be bought out, over junior partners who would not qualify for the same deal. Additionally PE management could have the power to raise minimum RVU requirements and enforce highly restrictive noncompetes. Texas Radiology Associates ultimately decided that in order to compete in the radiology marketplace as an independent practice, they needed to make significant investments in technology to better serve their patients. They started to connect with Collaborative Imaging to pursue this mission.
Dhruv notes that PE has the potential to bring in financial support, strategic relationships, and pathways to growth, but he also warns the audience that not all PE contracts are transparent nor designed to benefit physicians. Workflow, staffing, and collaboration with referring doctors can be extremely difficult when firms value cost savings and RVUs over patient care. All of these stressors have negatively impacted the radiology burnout rate. Dhruv describes the start of Collaborative Imaging, in 2018, as an attempt to integrate a revenue cycle management (RCM) system with radiology workflow at Texas Radiology Associates. This provided a cost-efficient solution that frees up funds to invest in other areas of the practice. Collaborative Imaging is currently working on an AI-driven system to notify patients of actionable findings that come up in their imaging. They are also exploring technology that will adapt the style of radiology reports to different referrers’ preferences.
Both guests discuss the common inefficiencies that independent radiology practices face, including RCM, clarification over patients’ payment plans, and office wait times. Collaborative Imaging is working with practices around the country to build solutions. Radiology groups can contribute a percentage of their revenue into Collaborative Imaging and receive dividends, or they can license the RCM solution.
RESOURCES
Ep. 277- Private Equity and the Radiology Job Environment with Dr. Ben White: https://www.backtable.com/shows/vi/podcasts/277/private-equity-the-radiology-job-environment
Texas Radiology Associates: https://texasradiology.com/
Collaborative Imaging: https://collaborativeimaging.com/
In this episode, Dr. Michael Baraza interviews Dr. Justin Guan, an interventional radiologist at the Cleveland Clinic, about the SIR Global IR training network.
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SHOW NOTES
Dr. Guan first discusses the IR program at the Cleveland Clinic and how they have a large case volume, which enables their trainees to get their pick about what types of cases they want to do.
Guan then mentions his recent trip to Seol, Korea for the Asia Pacific IR conference and discusses how Korea is doing some new IR techniques that haven't made their way to the mainstream yet. Guan also discusses the SIR Global training network, and how it was created due to a need for an entity that can spread IR education globally. Guan talks about how there are overall insufficient training opportunities worldwide, and in the countries that do have these opportunities, there is a huge variation in IR training. Thus, Guan discusses how the SIR’s Global training network’s objective is to expand IR’s footprint globally.
Guan then moves on to talk about initiatives that the SIR Global training network is trying to implement. First, Guan talks about the current challenges that these initiatives are trying to address. These challenges include : 1. Insufficient IR services worldwide, 2. A lack of public awareness about IR and its procedures, and 3. A lack of data about what countries have IR training and what countries don't. The initiatives aimed to address these challenges include the Global IR juniors summits, which recently got approval to be held at the SIR conference. Guan talks about how at this summit, IRs from around the world discuss what their IR society is doing and the new progress they have made. Guan also discusses how they are working on the Global Training Network currently, a database of different IR physicians to provide opportunities for observership, mentorship and serve as a hub for a clinical exchange of IR knowledge worldwide.
RESOURCES
Public Awareness of Interventional Radiology: Population-Based Analysis of the Current State of and Pathways for Improvement: https://www.jvir.org/article/S1051-0443(23)00122-7/fulltext
Global Assessment of the Status of Interventional Radiology: https://www.surveymonkey.com/r/ZBVFXQ8
In this episode, host Dr. Sabeen Dhand interviews vascular surgeon Dr. Rami Tadros about advantages and indications for radial access in PAD treatment and the current selection of radial access devices.
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SHOW NOTES
Dr. Rami Tadros is a vascular surgeon and Site Director of Endovascular Aortic Surgery at Mount Sinai Hospital. Dr. Tadros begins by discussing how often he uses radial access in his practice, how current wire and catheter technology limits the potential of radial access, and how evolution of these devices (such as increased length and improved sizing for transradial tools) is on the horizon.
Dr. Tadros also discusses the indications and specific advantages for radial access. He describes his device preferences, workflow, and workarounds for radial access. The doctors then take a deeper dive into lengths and sizing of the tools that are currently on the market. They offer some insight on maximizing distance while still maintaining pushability and taking into account the variety of patient anatomy. There is also a brief discussion on pedal access, risks associated with it, and closure complications.
Dr. Tadros covers specific clinical vignettes for treating PAD with radial access. There are limitations of the currently available devices, so it is important to plan for distal embolization and bailout stents.
We conclude the episode with some guidance for radial access. We review the required tools, the importance of confirming patency of the palmar arch, and the Barbeau test to inform radial access. Dr. Tadros also highlights the use of verapamil, heparin, and nitroglycerin to minimize the risk of vessel spasm.
RESOURCES
Dr. Rami Tadros Twitter: https://twitter.com/VascMD
In this episode, host Dr. Aparna Baheti interviews Dr. Kuldeep Singh who breaks down the three stages of lymphedema, their respective medical and surgical treatment options, all while sharing key insights he has developed through years of experience in treating and caring for patients with lymphedema at a high level throughout the episode.
In this episode, host Dr. Jacob Fleming interviews one of his attendings Dr. Bhavya Shah about the remarkable features of focused ultrasound technology and its applications. They discuss its dynamic nature, allowing for a wide range of applications.
SHOW NOTES
Dr. Bhavya Shah is a neuroradiologist at UT Southwestern in Dallas, TX and the director of their transcranial-focused ultrasound lab. While in residency at Boston MIT, he studied the radiology applications for nerve regeneration and expanded his scope of practice during his fellowship at Stanford. Dr. Bhavya Shah explains the use of low intensity focused ultrasound (LIFU) and high intensity focused ultrasound (HIFU), particularly in the context of movement disorders including essential tremor and Parkinson’s disease. LIFU is used to identify the appropriate targets in the brain in relation to the disease and may be used to alter how neurons behave. In contrast, high intensity focused ultrasound (HIFU) is utilized to ablate and destroy tissues typically after the localization of the intended treatment area.
Dr. Shah developed a way to identify targets in the brain for treatment with focused ultrasound with the use of four-tract tractography in cadavers. Using this technology, the brain can be thinly sliced into sections which could then be registered off an MRI back to the path using block face photography, allowing the identification of white matter tracts that enter and leave the thalamus. With these tracts identified, neuroradiologists can first stimulate the localized area with LIFU to confirm the location, then ablate using HIFU. The procedure lasts approximately 30-45 minutes as the patient remains awake. Remarkably, patients with essential tremor usually experience benefit immediately following the procedure as patients with Parkinson’s have symptom improvement within days to weeks. After two hours of observation, patients are discharged assuming no side effects. Side effects are uncommon but can include numbness and tingling around the mouth or fingertips as well as muscle weakness.
Beyond its use for movement disorders, the adaptable nature of focused ultrasound technology shows promise for a broad range of applications, particularly for the use of neuropsychiatric conditions. Dr. Shah offers the potential for the use of HIFU as a wearable device that delivers constant stimulation modulated by biofeedback, potentially eliminating the need for MRI for the procedure. Dr. Shah and Dr. Fleming end the discussion with how radiology has evolved over the years and the importance of keeping an open mind working in a multidisciplinary team. They emphasize the gravity of patient engagement and the central goal of medicine and improving the standard of care should always be aimed at benefiting the patient.
RESOURCES
MRI–Guided Focused Ultrasound Thalamotomy for Essential Tremor: https://thejns.org/view/journals/j-neurosurg/138/4/article-p1028.xml
Trial of Globus Pallidus Focused Ultrasound Ablation in Parkinson’s Disease: https://www.nejm.org/doi/10.1056/NEJMoa2202721
Long-term effects of bilateral subthalamic nucleus deep brain stimulation on gait disorders in Parkinson's disease: a clinical-instrumental study https://pubmed.ncbi.nlm.nih.gov/37208527/
Magnetic Resonance Image Guided Focused Ultrasound Thalamotomy. A Single Center Experience With 160 Procedures: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8894664/
In this episode, host Dr. Aaron Fritts interviews Dr. Peter Soukas taking a deep dive into novel balloon technologies, appropriate uses below the knee, and how these new balloons are highly effective in treating patients with critical limb ischemia (CLI). Dr. Soukas explains how these new balloon technologies can minimize the risk of dissections (therefore decreasing the need for bailout stents), create effective lumen gain in concentric and eccentric calcified lesions with minimal recoil, and keep pressures low compared to legacy products.
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SHOW NOTES
Dr. Soukas is an Interventional Cardiologist who is the Founder and Director of the Brown Vascular and Endovascular Medicine Fellowship program, serves as the Director of the Interventional PV Lab at the Lifespan Cardiovascular Institute of Brown, and an Associate Professor of Medicine at the Warren Alpert School of Medicine. We begin by discussing the treatment of CLI, particularly with new below the knee balloon angioplasty devices like the Cagent Serranator and how balloon tech has evolved over time.
These new technologies allow for 1000x more force than previous balloon models through unique serration technology at significantly lesser pressures, minimizing the risk of barotrauma and iatrogenic lumen dissections, while allowing for effective luminal gain, and showing success in treating CLI even when calcified lesions are present. What’s more is that there is now a variety of serration balloon lengths available, which was definitely a huge shortcoming in prior scoring balloons with limited sizing. While IVL is the preferred option in terms of treating concentric (360°) calcified lesions, new serration balloons are cheaper and show success in treating both concentric and eccentric calcified lesions with minimal recoil.
Dr. Soukas and Dr. Fritts also go on to discuss how using IVUS is critical in visualizing the size, shape, and depth of possible calcifications but also important in picking the correctly sized serration-balloon to get the job done. Dr. Soukas also explains how the serration balloon technology is easily deployable, tracks very well within vasculature, and can even be used below the ankle if needed (with some pre-dilation of the lumen) stating that if the IVUS can fit, usually so can the serration balloon.
To wrap up the episode we underscore how important it is to have the right tools in our toolbox to treat patients with CLI, getting as much “red gold” down to the foot as possible to avoid loss of the limb, and a few papers our listeners can check out to learn more about serration balloons (find linked in Resources below).
RESOURCES
CagentVascular.com
Prospective Study of Serration Angioplasty in the Infrapopliteal Arteries Using the Serranator Device: PRELUDE BTK Study DOI: 10.1177/15266028211059917
Standard Balloon Angioplasty Versus Serranator Serration Balloon Angioplasty for the Treatment of Below-the-Knee Artery Occlusive Disease: A Single-Center Subanalysis From the PRELUDE-BTK Prospective Study DOI: 10.1177/15266028221134891
PRELUDE Prospective Study of the Serranator Device in the Treatment of Atherosclerotic Lesions in the Superficial Femoral and Popliteal Arteries DOI: 10.1177/1526602818820787
In this episode, host Dr. Bryan Hartley interviews Rishi Nayyar, co-founder and CEO of PocketHealth, the first patient-centered medical image exchange platform.
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SHOW NOTES
PocketHealth is a subscription-based image sharing service that allows patients to store, access, and share their medical imaging with providers across different health systems. Rishi and his brother Harsh developed the idea for this service after realizing how antiquated and frustrating it was for patients to physically carry their CDs to different physician offices. Additionally, with the sheer volume of medical images ordered today and the cost of data storage, hospitals usually delete images after a certain period of time. First, the Nayyar brothers conducted their own market research by calling hundreds of local hospitals and clinics and asking them about their image exchange process. This process confirmed that the status quo of image exchange was a burdensome process for patients and inspired them to configure a patient-centered service.
The second stage of their entrepreneurial pursuit was to figure out how the service would be paid for. The founders realized that patients were willing to pay a small subscription fee (instead of paying for CDs) to safely indefinitely store and virtually send their own and their family members’ images to healthcare providers using a link or QR code. Overtime, insurance companies have become willing to reimburse this subscription fee. This payment model allows hospitals and clinics to participate in image exchange at no cost, and has been a key factor in encouraging widespread adoption as well as enabling the growth of their enterprise image sharing business.
Rishi highlights the fact that he had the advantage of being an outsider to healthcare when he first started the company, which helped him recognize issues with the current system instead of just accepting the standard processes. He shared the same perspectives as patients who were interacting with the system as non-health experts. PocketHealth’s success in the last eight years has propelled it to take on new challenges, such as patient education within radiology reports.
Finally, Rishi gives advice to budding entrepreneurs. He encourages them to pick a problem that they don’t mind grinding at, since there is a large initial time and effort requirement needed to convince people to adopt their product. Additionally, the innovation journey is long, so to manage one’s psyche, it is wise to set short term achievable benchmarks and reflect on day-to-day progress.
RESOURCES
PocketHealth: https://www.pockethealth.com/
In this episode, host Dr. Aparna Baheti interviews Dr. Bill Julien about the evolution of the outpatient based lab (OBL), its role in expanding patient access to IR care, and its relationship with other IR practice models around the country.
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SHOW NOTES
Dr. Julien is one of the initial OBL founders in the United States. In 2001, he started his current practice, South Florida Vascular Associates in an effort to practice independent IR. At this time, he struggled to get hospital privileges due to exclusive diagnostic radiology contracts, so he placed a C-arm in his office out of necessity. Eventually, he built a formal angio suite. As a result, patients enjoyed the efficiency and comfort of office based procedures, and he enjoyed physician autonomy and freedom from hospital politics. Dr. Julien notes that overtime, CMS has recognized the value of an office-based intervention and saw that IRs could practice high-quality care at a lower price point with higher patient satisfaction, leading to improved Medicare reimbursements.
Since the conception of his OBL, Dr. Julien has seen practice structures change, especially with the influence of venture capital firms and the pressure to generate RVUs. Additionally, though some voices have pushed for more IR involvement in the clinical sphere, there has not been much progress made in advocating for IR hospital privileges. This is a significant barrier to independent IR practices, since some states require that an IR has hospital privileges before opening an OBL. Dr. Julien says that this dilemma is unique to IR, since other specialties, such as vascular surgery and cardiology, are not affected by exclusive contracts to the same extent. He believes that IR societies and leading voices should actively challenge the legal basis of these contracts and support interventionalists who want to stay independent. We highlight recent SIR and ACR position statements on this topic.
Finally, Dr. Julien offers advice to IRs who are seeking to enter the OBL setting. He encourages them to perform and learn from as many procedures as possible, find ways to develop and maintain clinical skills, identify mentors, and ensure that their restrictive covenants are not too stringent.
RESOURCES
South Florida Vascular Associates: https://www.southfloridavascular.com/
Outpatient Endovascular and Interventional Society (OEIS): https://oeisweb.com/
SIR Position Statement on Exclusive Contracts: https://www.sirweb.org/globalassets/aasociety-of-interventional-radiology-home-page/practice-resources/standards_pdfs/exclusive_contracts_policy_final_approved_9-21-15.pdf
ACR Position Statement on Exclusive Contracts: https://www.acr.org/-/media/ACR/Files/About-ACR/2022-2023-Digest-of-Council-Actions.pdf
Line Monkey MD- “The IR Startup:” https://linemonkeymd.com/the-ir-startup/
Line Monkey MD- “Pseudoexclusive Radiology Contracts:” https://linemonkeymd.com/pseudoexclusive-radiology-contracts-our-downfall/#comment-2087
In this episode, host Dr. Michael Barraza interviews interventional radiologist Dr. David Johnson about practice building in an IR/DR group, including factors that make a good job, and how he formed one of the largest PAE practices in the Southeast.
In this crossover episode between BackTable VI and BackTable Innovation, Dr. Chris Beck interviews Dr. Riad Salem (Chief of Interventional Radiology at Northwestern University) and Peter Pattison (President of Interventional Oncology at Boston Scientific) about how TheraSpheres for Y90 radioembolization became a mainstay in the IR toolkit for HCC and where the technology is heading next.
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In this next installment of our Back to the Basics series, Drs. Aaron Fritts and Chris Beck discuss their techniques, considerations, and tips for ensuring safe and high quality renal biopsies.
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SHOW NOTES
First, the doctors discuss indications and contraindications for biopsy. In the outpatient setting, the doctors have noticed that proteinuria is the most common reason for referral, followed by lupus nephritis. For inpatients, acute unexplained kidney failure is an additional indication. It is important to talk with nephrologists to weigh the risks and benefits of renal biopsy, especially if the patient has a coagulopathy, is experiencing uncontrolled hypertension, or is too unstable to lay prone on the table. The SIR Guidelines app is a useful tool to risk stratify patients.
In terms of imaging, CT or ultrasound can be used, although they each have unique advantages. Ultrasound allows for real-time guidance and the ability to use the probe to hold pressure on the kidney to prevent bleeding. On the other hand, CT allows for better imaging in patients with larger body habitus and allows the patients to lay prone. Dr. Fritts emphasizes that the best imaging modality is the one that the operator is most comfortable with, since this will ensure maximal safety for the patient. One helpful tip when planning a biopsy is to avoid needle entry into the paraspinal muscles, since this could change the trajectory of the needle and cause pain.
Both doctors prefer to use moderate sedation if the patient can tolerate it. This sedation usually has the added benefit of facilitating an intra-procedural blood pressure dip, which protects against bleeding when biopsying hypertensive patients. Since sedation can alter breathing patterns, starting sedation early (before scanning the patient) can be helpful in establishing a steady breathing pattern before the procedure starts. Dr. Beck also recommends checking blood pressure while the patient is in pre-operative care, in order to predict whether or not they might require additional intra-procedural antihypertensive medications such as hydralazine, labetalol, or clonidine. Since blood pressure control is a cornerstone of a safe procedure, each doctor has their own safety threshold for blood pressure.
Then, the doctors discuss different types and sizes of biopsy needles. While a 16G needle can obtain better diagnostic samples, the 18G needle might have a lower risk of bleeding complications. The doctors also share their preferred brands of needles.
The episode concludes with tips for surveilling patients in the post-procedural period and dealing with bleeding complications. Dr. Beck describes his protocol for re-scanning patients to check for large hematomas and keeping them under observation for at least three hours. If there is a large hematoma, emergency embolization must be performed.
RESOURCES
SIR Guidelines App: https://apps.apple.com/us/app/sir-guidelines/id1552455529
SIR Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions: https://www.jvir.org/article/S1051-0443(19)30407-5/fulltext
18G BioPince Biopsy Needle: https://www.argonmedical.com/products/biopince-full-core-biopsy-instrument
Bard Mission Biopsy Needle: https://www.bd.com/en-us/products-and-solutions/products/product-families/mission-disposable-core-biopsy-instrument
Temno Biopsy Needle: https://www.merit.com/peripheral-intervention/biopsy/soft-tissue-biopsy/temno-evolution-biopsy-device/
On this episode, BackTable VI host Dr. Christopher Beck shares the mic with two Maternal Fetal Medicine (MFM) specialists, Drs. Roxane Rampersad at Washington University and Tony Shanks at Indiana University, to discuss cross-specialty management of postpartum hemorrhage (PPH) between OBGYN and interventional radiology (IR).
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In this episode, host Dr. Aaron Fritts interviews interventional cardiologist Dr. Rohit Amin about his private practice PE response team, including his treatment algorithm, follow-up protocol, and how he believes AI can contribute to PE care.
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SHOW NOTES
Dr. Amin trained at Ochsner Clinic in New Orleans, and now works in private practice in Pensacola, Florida. He and a partner decided to start a PE response team (PERT) to better serve patients in the area and expand their practice. It took a lot of groundwork. They had to pitch it to administration and raise awareness, which they did by hosting CME such as grand rounds. They struggled to get a pulmonologist on board in 2013 when there was less clinical data and guidelines.
Next, we discuss how the PERT algorithm functions in his private practice. An ER doctor or hospitalist evaluates the patient first. If the CT shows proximal thrombus, the PERT is notified. If it is a massive PE or submassive with clinical severity, he does thrombectomy promptly. If there is no elevated troponin and normal hemodynamics, the patient gets admitted and evaluated with a stat echo and venous doppler. Dr. Amin’s practice prefers an echo with PE protocol to risk stratify RV dysfunction - i.e. RV size, tricuspid annular plane systolic excursion (TAPSE). He also evaluates pulmonary artery (PA) pressure, PA saturation, and cardiac index which are important clinical factors that determine the optimal route of intervention. For patients with submassive PE who get admitted overnight, he gives all patients a heparinoid, preferably lovenox over heparin. He sees the patient in the morning and if the clot is submassive or proximal, he does a thrombectomy that day.
Lastly, we cover the importance of treating PE and how Dr. Amin approaches longitudinal follow up. Dr. Amin refers to the ICOPER trial that showed that the 30 day mortality for submassive PE is 15%, higher than that of NSTEMIs. If a PE is left untreated or if treatment is significantly delayed, a patient can develop post-PE syndrome or chronic thromboembolic pulmonary hypertension (CTEPH), which significantly worsen morbidity and mortality. Dr. Amin treats his PE / DVT patients with one week of lovenox before transitioning to a direct oral anticoagulant (DOAC). He sees them in the office in one month and gets an echo at 3 months. He then sees patients semi-annually or annually for 3-5 years.
RESOURCES
BackTable Episode 196: https://www.backtable.com/shows/vi/podcasts/196/building-a-pe-response-team
PERT Consortium: https://pertconsortium.org
ICOPER Trial: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(98)07534-5/fulltext
In this episode, host Dr. Ally Baheti interviews interventional radiologist Dr. Luke Wilkins about his approach to the subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) technique for crossing challenging chronic total occlusions (CTO) in critical limb ischemia (CLI) patients.
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SHOW NOTES
Dr. WIlkins gives us the basic indication for the procedure, which is when the lesion is unable to be crossed from a purely antegrade approach and other re-entry devices have failed. Dr. Wilkins will always attempt to use an Outback wire and an Enteer balloon before performing the SAFARI technique. There are multiple factors that influence the decision to use SAFARI, such as lesion location, level of calcification, and size of the true lumen at the re-entry point.
Next, Dr. Wilkins walks us through a typical SAFARI. He normally establishes retrograde access in the dorsalis pedis or posterior tibial artery using a 4 cm micropuncture needle and an exchange length Nitrex wire. He uses telescoping catheters from the antegrade direction. When the antegrade and retrograde approaches enter the same subintimal plane, the 2 devices can connect and the lesion can be crossed. If it is challenging to achieve the same intimal plane for both devices, the gunsight approach of overlapping snares can be utilized. After the lesion is crossed, normal angioplasty and stenting can occur.
Dr. Wilkins gives advice on how to make the procedure efficient. In occlusions that are longer than 1 cm, he always makes sure that the foot is prepped before the case starts. He also emphasizes the importance of knowing when to try a different technique and notes that this intuition comes from experience.
Finally, we discuss patency rates for SAFARI patients, which have been relatively high. This technique has made a large impact on limb salvage in a patient population that previously had no other non-surgical options.
RESOURCES
Rotarex Atherectomy System: https://www.bd.com/en-us/products-and-solutions/products/product-families/rotarex-rotational-excisional-atherectomy-system
Outback Re-Entry Catheter: https://cordis.com/na/products/cross/endovascular/outback-elite-re-entry-catheter
Enteer Re-Entry Catheter/Balloon: https://www.medtronic.com/us-en/healthcare-professionals/products/cardiovascular/chronic-total-occlusion-devices/enteer/indications-safety-warnings.html
Nitrex Wire: https://www.medtronic.com/us-en/healthcare-professionals/products/cardiovascular/guidewires/nitrex.html
CXI Catheter: https://www.cookmedical.com/products/di_cxi_webds/
Outcome and Distal Access Patency in Subintimal Arterial Flossing with Antegrade-Retrograde Intervention for Chronic Total Occlusions in Lower Extremity Critical Limb Ischemia: https://www.jvir.org/article/S1051-0443(19)31033-4/fulltext
In this episode, host Dr. Michael Barraza interviews interventional radiologist Dr. Doug Hidlay about how he has built a solo IR practice in rural Virginia, including how he got equipment, employees and referrals to build a busy and diverse practice.
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SHOW NOTES
Dr. Hidlay begins by discussing how he was recruited out of fellowship into a medical group in Virginia. They offered him the opportunity to build an entire IR practice and do the kinds of procedures that he wanted to bring with whatever skills he had from his residency at Brown and fellowship at the University of Washington. He is employed by a hospital group where he does about 30% diagnostic radiology, runs his own clinic and sees consults. He was hired to prioritize IR, and feels very supported by his diagnostic colleagues to do so.
We discuss what he learned through this process, and what he wished he would have known. He says the biggest surprises were from his own naivete, having gone straight into this position out of fellowship. The administration was up front with him and told him to expect to have to build this practice from scratch. When he started, he had 6 FTEs including himself, a scheduler, 3 techs and 3 nurses. He started off doing about 10 paracenteses, a couple lung biopsies and some thyroid biopsies per week. He attributes his success to showing up consistently. He asked for time to talk at every local practice and grand rounds. He met with surgeons, hospitalists, and primary care doctors to tell them what he could do, with the idea that even if they didn’t remember, they would have his number and could reach him at any time. What he didn’t realize was how much of a need there was. He soon became overwhelmed by the demand, and realized he was in over his head, doing 12-18 cases daily with the same support staff.
As for acquiring equipment to do procedures, Dr. Hidlay feels he was fortunate to have administration who were willing to believe him when he said he needed certain equipment. When it came to training staff, he often worked with them at the backtable and taught them how to use the image intensifier (II) controls to help them ‘learn by doing’. He started out on call 24/7, while his 3 techs and nurses were on call every 3 days. He slowly adjusted this as it was unsustainable for all, and has more staff now. By volume, he still mostly does light IR and feels that if he didn’t accept these cases he would never have built trust and made connections to referring providers. He also has a kyphoplasty service, a venous thromboembolism (VTE) service, and also does a sizeable volume of renal ablations, chemoembolizations, and emergent bleeds. He is hoping to bring on two more IRs to round out his practice and meet the community demand.
RESOURCES
BackTable Episode 221: Building a Musculoskeletal Interventional Oncology Service with Dr. Alan Sag https://www.backtable.com/shows/vi/podcasts/221/building-a-musculoskeletal-interventional-oncology-service
Doug Hidlay Twitter: @DHidlayVIR
In this episode, host Dr. Aaron Fritts interviews Dr. Marc Sapoval about practicing IR in France, the origins of the Global Embolization Oncology Symposium Technologies (GEST) Conference, and an upcoming conference in MSK embolization.
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SHOW NOTES
First, Dr. Sapoval gives an overview of the French IR landscape. He outlines the training pathway, which is a four year radiology program with an additional two years of IR specialization. He also describes his role at an academic hospital. Dr. Sapoval says that in his country, collaboration with other endovascular specialists depends on both interpersonal relationships and business incentives.
For the remainder of the interview, we talk about how GEST began and where it is today. In 2007, Drs. Marc Sapoval, Jafar Golzarian, and Ziv Haskal started the first GEST conference in Barcelona, after they realized the need for a specific meeting geared towards embolization. This inaugural meeting turned out to be a success, with attendance reaching much higher numbers than they had originally anticipated. Since then, GEST annual meetings have taken place throughout Europe and the United States. In recent years, it has found a permanent home in New York City.
Dr. Sapoval introduces a new smaller conference series called GEST Hot Topics. An upcoming conference in this series focuses on MSK interventions, and it will be held in Paris on January 20-21, 2023. He emphasizes that it is an incredible opportunity to be part of a new field of IR. He highlights speakers who currently lead research efforts in MSK embolization and encourages all listeners to register and attend GEST Hot Topics: MSK Embolization.
RESOURCES
GEST Hot Topic: MSK Embolization: https://thegestgroup.com/gest-msk-2023-paris/
GEST Annual Conference 2023: https://annual.thegestgroup.com/GEST23/Public/mainhall.aspx
In this episode, Dr. Chris Beck interviews Interventional Radiologist Dr. Josh Kuban about his liver tumor ablation practice at MD Anderson Cancer Center, including how it's evolved over time with newer technologies. They also discuss patient workup for liver tumors, treatment with microwave ablation, and post-procedure follow up. Dr. Kuban shares why he uses microwave ablation technology, and the advantages of ablation confirmation software for these procedures.
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SHOW NOTES
We begin by discussing how Dr. Kuban started to get involved in interventional oncology and tumor ablation. He started off doing a broad base of vascular procedures. When he came to MD Anderson, he began building close relationships with oncologists which led him to become focused on ablation, primarily of liver and lung lesions.
For liver tumors, Dr. Kuban primarily uses microwave ablation, while in the lung, he does cryoablation. The benefits of microwave ablation are the efficiency of the procedure compared to the time it takes to perform cryoablation. He generally does multiprobe ablations, which allows him to treat the tumor more aggressively from the beginning. He is able to do this confidently by taking advantage of ablation confirmation (AC) software. He always starts with a pre-procedure CT which he uploads to the AC software. He then compares his pre-image to his probe image which helps target the lesion intraoperatively. After ablating, he does another scan that has arterial and venous phases to look for bleeding. The AC software then takes the pre-scan and post-scan and merges them to show the ablation zone.
Lastly, we discuss the impact that AC software has had on Dr. Kuban’s practice. When Dr. Kuban approaches a liver ablation case, his goal is to get the entire tumor in a single procedure, and he believes that he has to be able to see the margins in order to effectively ablate them. The software allows him to see the treatment effect in real time and provide more complete treatment the first time. After using this software, his recurrence rates have been very low, and he is confident that if a recurrence does happen, it is not due to incomplete ablation. He also emphasizes the effects that AC software has had on practice building. Because of this software, he is able to show images of cases to referring providers.
DISCLAIMER
Dr. Josh Kuban is presenting on behalf of Ethicon. The presentation reflects the opinions of the individual presenter, and the steps described may not encompass the complete steps of the procedure. Additionally, other surgeons may prefer different techniques, approaches, etc., as individual surgeon experience in his/her clinical practice, as well as patient needs, may dictate variation in procedure steps. Accordingly, results from any case studies reported in this presentation may not be predictive of results in other cases.
Before using any medical device, review all labeling, including without limitation; the Instructions For Use (IFU), and relevant package inserts with particular attention to indications, contradindications, warnings and precautions, and steps for use of the device(s).
Dr. Josh Kuban is compensated by and presenting on behalf of Ethicon and must present information in accordance with applicable regulatory requirements.
The NeuWave™ Ablation System and Accessories are indicated for the ablation (coagulation) of soft tissue in percutaneous, open surgical and in conjunction with laparoscopic surgical settings, including the partial or complete ablation of non-resectable liver tumors. The NeuWave™ Microwave Ablation System and Accessories are not indicated for use in cardiac procedures. The system is designed for facility use and should only be used under the orders of a clinician.
In this episode, guest host Dr. Nicholas Fidelman interviews Dr. Michael Solen, a key player in the development and widespread adoption of transarterial chemoembolization (TACE). The doctors discuss how TACE became a major therapeutic option for liver tumors, his preferred method of TACE dosage and management, and exciting new frontiers in chemoembolization.
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SHOW NOTES
Dr. Soulen recalls his first ever TACE patient, who was a patient self-referring for a rare neuroendocrine tumor. As an IR fellow at the University of Pennsylvania, Dr. Soulen recognized the opportunity to incorporate clinic time into his IR practice. His push for clinical management of IR patients resulted in successful medical and financial outcomes, which also led his hospital to establishing an interventional oncology clinic. He emphasizes that a clinic presence is crucial to participating in tumor boards and being able to accept outside referrals.
Next, we delve into the history of the CAM (cisplatin, adriamycin, mitomycin) conventional TACE cocktail, which Dr. Soulen developed alongside medical oncologists and pharmacists. These chemotherapeutics, combined with lipiodol and followed by particle embolics, make up the most widely used TACE protocol in the United States. Dr. Soulen reviews his preferred ratios and mixing method for maximal efficacy. He discusses his current RETNET trial that directly compares treatment of neuroendocrine tumors with conventional TACE versus bland embolization in terms of progression free survival, toxic side effects, and patient quality of life.
Additionally, we address the high prevalence of post-embolization syndrome and SIR consensus guidelines for its management. Since chemoembolization is a highly emetogenic therapy, Dr. Soulen uses an oncology evidence-based combination of Benadryl, Zofran, and Decadron. He administers PRN pain medication on an individual patient basis. Furthermore, we discuss post-TACE management, specifically length of hospital stay. While all patients used to be admitted for overnight monitoring, this has shifted to mostly same-day discharges. This change has allowed the hospital to conserve resources and decrease costs.
Finally, Dr. Soulen shares his perspective on new developments in interventional oncology. He highlights a need to identify TACE drugs that specifically target intratumoral hypoxic response mechanisms. He also compares transarterial radioembolization (TARE) to TACE, noting that the former has not shown superiority to systemic therapy in research trials. However, there are possibilities that TARE or TACE could be useful to slow tumor progression in radiation lobectomy or as immunostimulants for combination therapy with immune checkpoint inhibitors and CAR-T cell therapy.
RESOURCES
RETNET Trial: https://clinicaltrials.gov/ct2/show/NCT02724540
Transcatheter oily chemoembolization of hepatocellular carcinoma: https://pubmed.ncbi.nlm.nih.gov/2536946/
Prospective Randomized Study of Doxorubicin-Eluting-Bead Embolization in the Treatment of Hepatocellular Carcinoma: Results of the PRECISION V Study: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2816794/
Randomised controlled trial of doxorubicin-eluting beads vs conventional chemoembolisation for hepatocellular carcinoma: https://pubmed.ncbi.nlm.nih.gov/24937669/
Treatment of Liver Tumors with Lipiodol TACE: Technical Recommendations from Experts Opinion: https://pubmed.ncbi.nlm.nih.gov/26390875/
Outpatient Transarterial Chemoembolization of Hepatocellular Carcinoma: Review of a Same-Day Discharge Strategy: https://pubmed.ncbi.nlm.nih.gov/29478795/
Phase I Trial on Arterial Embolization with Hypoxia Activated Tirapazamine for Unresectable Hepatocellular Carcinoma: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8139681/
In this episode, guest host Dr. Steven Raman interviews a founding father of percutaneous tumor ablation, Dr. Luigi Solbiati about the development of this revolutionary treatment, new therapies that have stemmed from it, and his vision for the future of interventional oncology.
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SHOW NOTES
Dr. Solbiati was a radiologist at the General Hospital of Busto Arsizio when he developed an interest in cancer in the 1980s. He traveled to the UK to learn about CT and ultrasound imaging. Upon his return to Italy, he combined this knowledge with his hospital’s department of pathology to obtain the first liver and abdominal ultrasound-guided biopsies for non-palpable lesions. Dr. Solbiati notes that in most of the world, ultrasound is personally performed by medical doctors, and it is an important skill to have.
Next, we discover how Dr. Solbiati came to treat the first parathyroid adenoma using percutaneous ethanol injection. After Dr. Solbiati had performed a parathyroid tumor biopsy, the treatment team realized that her serum PTH levels had completely normalized due to compression of the overactive parenchyma. Inspired by this result, Dr. Solbiati researched past literature and saw the success of ethanol injection to cause sclerosis of liver and renal cysts. Since the patient was not a surgical candidate, she was willing to undergo ethanol injection, which was eventually successful. Dr. Solbiati explains that parathyroid tumors are hypervasculated and encapsulated, so they are able to contain ethanol and prevent diffusion. Additionally, the use of ultrasound made it possible for operators to visualize the amount of liquid ethanol entering a solid tumor.
Overtime, Dr. Solbiati began to work with Dr. Tito Livraghi to inject ethanol and chemotherapeutics for hepatocellular carcinoma lesions. The outcomes from their initial studies are still used as benchmarks for locoregional therapies today. Their research gained publicity from scientific and non-scientific media, which came with both positive and negative reactions. Dr. Solbiati emphasizes the importance of collaboration with surgeons and other interventionalists to combine surgical, intravascular, and percutaneous therapies. Additionally, he also played a key role in the testing of cool-tip radiofrequency ablation.
Dr. Solbiati highlights the significance of percutaneous ablation in advancing health equity. Ethanol and radiofrequency ablation are relatively cost-efficient and safe, which allows for higher quality of cancer treatment in resource-limited settings. He looks toward the future of interventional oncology as the “fourth pillar” of cancer care (in addition to medical, surgical, and radiation oncological treatments), the growing use of augmented reality for percutaneous procedures, and the increasing rate of combination therapy with immunologic agents.
RESOURCES
Percutaneous ethanol injection of parathyroid tumors under US guidance: treatment for secondary hyperparathyroidism (Radiology, 1985): https://pubmed.ncbi.nlm.nih.gov/3889999/
Hepatic metastases: percutaneous radio-frequency ablation with cooled-tip electrodes (RSNA, 1997): https://pubs.rsna.org/doi/10.1148/radiology.205.2.9356616
In this episode, guest host Dr. Sean Tutton interviews Dr. Bill Rilling and Dr. Sarah White about the history of the Society of Interventional Oncology (SIO), their current research and volunteer involvement, and future directions of the society.
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SHOW NOTES
We begin by discussing how the Society of Interventional Oncology (SIO) began. It started as the World Conference of Interventional Oncology (WCIO), but was formed into an official society with the goal to become the fourth pillar of oncology care, in addition to surgical oncology, medical oncology and radiation oncology. At the time of its inception, the group asked themselves whether interventional oncology would be bettered by the addition of a professional membership society, and there was a thoughtful and unified decision that it would be.
Next, we discuss what goes into forming a society? When asking people to become members, pay money and give their time, they will expect some return on their investment. It's important to have a formal society, as it greatly advances the field forward. The ability to focus resources and effort completely on what you're passionate about is what having SIO allows. At SIO, we want people to be members of both SIR and SIO, it should be both, not one or the other.
Finally, we talk about some of the current research funded by SIO. SIO fulfills the research aspect of the society by creating data, currently via the Ablation with Confirmation of Colorectal Liver Metastasis (ACCLAIM) Trial. This trial uses software to determine post-treatment margins in percutaneous microwave ablation for colorectal metastasis of the liver. With this trial, they hope to prove that this procedure results in high rates of clear margins, which will make it a minimally invasive alternative to surgical resection. Future research efforts will likely focus on coupling locoregional therapy with targeted immunotherapy. They aim to start treating new cancers, develop further partnerships with industry and pharma, and continue to produce quality data on response rates to promote interventional oncology as the well respected and accepted fourth pillar of oncology.
RESOURCES
SIO: www.sio-central.org
ACCLAIM Trial: www.sio-central.org/p/cm/ld/fid=809
In this back to the basics episode, Dr. Christopher Beck interviews Dr. Aaron Fritts about his standard procedure for nephrostomy tube placement, preferred tools, and troubleshooting tips.
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Dr. Fritts says that most of his referrals come from urology, and patients need treatment for hydronephrosis, kidney stones, and pre-operative access for lithotripsy. He goes over his workup, which can be expedited in emergency cases. He checks for normal coagulation tests and anticoagulation medications, since bleeding is the most common and dangerous complication of the procedure. Both doctors prefer to use CT imaging to map out the procedure, identify stone burden, and decide which calyx to access. It is important to use CT to make note of and avoid the colon (lateral) and paraspinal muscles (medial) when choosing an access site. Dr. Fritts also marks the access site before the patient gets prepped for the procedure, in order to ensure that the correct area is cleaned. Patients are usually under moderate sedation with versed and fentanyl.
Then the doctors walk through a typical nephrostomy tube placement under ultrasound guidance. They emphasize that lidocaine needs to be injected all the way down to the cortex to maximize patient comfort and decrease the likelihood of patient movement during the procedure. Then, the needle is inserted into a calyx. While it is standard to access the lower pole to minimize bleeding risk, Dr. Beck sometimes prefers mid-pole access since this provides a shorter distance from skin to target and a more favorable angle to enter the ureter from the renal pelvis. The upper pole is generally avoided due to risk of diaphragmatic puncture, but it can be accessed if a stone is present there. Dr. Beck shares a tip about injecting saline to plump up the calyces and allow for better access.
Dr. Fritts describes the two-stick technique that was primarily used before ultrasound access was available. He also recommends communicating with urologists in lithotripsy patients to identify optimal access sites for each patient’s lithotripsy. If the wire is placed directly on top of the stone and you have difficulty maneuvering the wire around the stone, you can inject saline to dilate the system and obtain a better angle for the wire.
Finally, the doctors talk about drain selection, which is usually an 8Fr or 10Fr. The drain is secured with stitches, and possibly a bumper stitch. Pyonephrosis patients are usually kept inpatient, while other patients can get discharged after two hours. It is important to watch for hematuria and distinguish between mildly red venous blood from minor procedural trauma (which will subside) and bright red blood from arterial damage.
RESOURCES
SIR Now: https://sirnow.sirweb.org/
Ep. 97- Nephrostomy Tube Placement with Dr. David Feld: https://www.backtable.com/shows/vi/podcasts/97/nephrostomy-tube-placement-basic-to-advanced
Diuretic agent and normal saline infusion technique for ultrasound-guided percutaneous nephrostomies in nondilated pelvicaliceal systems: https://pubmed.ncbi.nlm.nih.gov/22893420/
Bumper Stitch for Drainage Tube Securement: https://www.jvir.org/article/S1051-0443(11)01353-4/pdf
In this episode, Dr. Aaron Fritts interviews Dr. Christopher Beck about gastrostomy tubes, including the evolution of his method, tips for patients who pull their tubes out, and why g-tubes are such a controversial topic in IR.
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SHOW NOTES
We begin by discussing indications and contraindications for gastrostomy tubes. Frequent indications are stroke patients, head and neck cancer patients, and trauma patients. Contraindications include uncorrectable coagulopathy, ascites, peritoneal carcinomatosis, or something interposed between the abdominal wall and the stomach, such as liver or bowel. Dr. Beck prefers having imaging to review, which most patients have. If no prior imaging is available, he will get a non-contrast CT abdomen the day of the procedure. He likes all his patients to drink barium for visualization of bowel during the procedure, but will not cancel the procedure if they didn’t drink it, as the insufflation should move bowel out of the way and there should be enough bowel gas to identify and avoid the bowel.
Next, Dr. Beck reviews the details of his method. He likes to use monitored anesthesia care (MAC), because frequently he has patients with bad Mallampati scores. Additionally, anesthesia is very helpful with NG placement. Furthermore, it makes the procedure much more comfortable for the patient. He always checks liver margins with ultrasound prior to starting the procedure. He always gives 1 mg glucagon before insufflation and antibiotics per the SIR Guidelines App. As for equipment, he uses t-fasteners from Avanos, a dilator set, and a 20Fr G-tube. He used to start with 16Fr but found he frequently had to size up to a 20Fr. He uses a 24Fr peel away sheath. For the procedure, he insufflates, marks his entry point with a hemostat, and then numbs in all 3 spots where he will place his gastropexies. He uses 1/2 syringe of contrast for his gastropexy placement. He uses 2 t-tags, and prefers the C-arm in RAO rather than AP during this step. For G-tube placement, he aims 20 degrees toward the pylorus, and always makes sure he sees wire touching two walls of the stomach to ensure he is intraluminal. He uses sterile water to inflate the balloon rather than saline or contrast. Lastly, he always makes sure to get a good final image to confirm placement in the stomach.
For post-care, on inpatients he rounds the next morning, checking that the tube flushes and then clears it for use. For outpatients, he recommends no feeding (via G or NG) for three hours and a consult with a dietician before discharge. After this, the patient can receive nutrition via NG. If the patient has no peritoneal signs, the G-tube can be used the next day. For tube management, he exchanges the tube every 6 months or sooner if there is an issue, such as the tube being pulled out or becoming clogged beyond the point of a bedside fix.
RESOURCES
BackTable YouTube Gastrostomy Tube Demo: https://www.youtube.com/watch?v=17ep0AEkKqs
Early Initiation of Enteral Feeding: https://pubmed.ncbi.nlm.nih.gov/24674218/
SIR Guidelines App: https://apps.apple.com/us/app/sir-guidelines/id1552455529
In this episode, Dr. Ally Baheti interviews interventional radiologist Dr. Judy Gichoya about her recent paper on artificial intelligence (AI) and the use of a deep learning model to recognize patients’ self-described racial identity, based on radiology images.
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Dr. Gichoya had started by tackling the original problem of bias in diagnoses for chest X-rays, since it has always been difficult to tell whether something is a real diagnosis, or simply just a finding. Her team built a deep learning model; however, they saw that it did not work well for black patients. With further investigation, they discovered that their model had learned signals that correlated with self-identified race.
Intrigued by this finding, Dr. Gichoya and her team sought to identify the factors that the model used when making its race determination. Because AI is black box in nature, the methods by which the algorithm learns remains largely unknown. When tested in other imaging modalities (mammogram, chest CT, spine imaging), the model still showed high accuracy. Additionally, the model retained accuracy when different information was eliminated from the images (ex. age, disease distributions, bone densities). The model was also able to predict race in healthy patients, showing that it did not rely on patterns of disease prevalence in specific ethnic groups.
Next, we spoke about the implications of this research in developing risk scores. Deep learning models are able to look at factors that humans are not trained or able to see. Dr. Gichoya highlights the model’s potential effectiveness in predicting osteoarthritis risk in black patients. We also look at applications in opportunistic screening and information about social determinants of health. For example, most patients presenting with chest pain often get chest CTs. Dr. Gichoya thinks that these images can be used by the model to learn about patients’ environmental exposures, like pollution.
We finish the episode with a discussion on the changing landscape of IR and how AI can be used as an assistive technology. Interventional cardiologists are already using AI to dictate their procedural reports in real-time. In the interventional oncology space, AI could help integrate imaging and pathology findings to determine personalized treatment courses. All of these applications depend on researchers’ ability to market their findings to peers and the public, Dr. Gichoya gives tips on how to do this.
RESOURCES
AI recognition of patient race in medical imaging: a modelling study: https://www.thelancet.com/journals/landig/article/PIIS2589-7500(22)00063-2/fulltext
In this episode, Dr. Vishal Kumar interviews Dr. Mark Wilson, vice chair and professor of radiology and biomedical imaging at UCSF, and chief of diagnostic and interventional radiology at the Zuckerberg San Francisco General Hospital and Trauma Center about the evolution of trauma care in interventional radiology, translational research, and the impact of mentorship and student outreach.
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We begin by discussing how Dr. Wilson discovered radiology, and how he has come to be a leader in IR. He started out with an interest in psychiatry, and became involved in research on psychiatric brain imaging. As he delved deeper into biomedical imaging, his fascination grew. With help from his mentor, he began publishing, which motivated him to further pursue his passion for research. He learned about IR, and then got into UCSF for his radiology residency.
Being at the frontier of innovations, Dr. Wilson has been involved in research on MR guided interventions, remote navigation, and percutaneous venous chemo filters. He says these projects have reinforced that radiology and research isn’t done in a vacuum. He depends on his collaborators in material science, chemistry, and other fields to successfully innovate. One thing he loves about the research lab is the student involvement, and getting to see high school and college students get their name on a paper. This is one area of student outreach that has an incredible impact and shapes future leaders in radiology and medicine.
Finally, we discuss how Dr. Wilson spearheaded the role of radiology within the hospital infrastructure when they created the new SF General Hospital, the Zuckerberg San Francisco General Hospital and Trauma Center. He collaborated with hospital leadership and architects, as well as emergency medicine, surgery, anesthesia and nursing to build a state of the art trauma care center to serve the people of San Francisco. It fulfills its goal of bringing the services to the patient to deliver better and more efficient care. From CT scanners in the ED, to a hybrid trauma OR, this new center is one of the leading IR and trauma centers in the world.
RESOURCES
The History of the Zuckerberg San Francisco General Hospital and Trauma Center: https://zuckerbergsanfranciscogeneral.org/about-us/our-history/
In this episode, BackTable is on location in Barcelona for CIRSE 2022! Dr. Aaron Fritts conducts a live video interview with interventional radiologist Dr. Lorenzo Patrone. They discuss their experiences with balancing clinical, academic, and family responsibilities, as well as differences in the American and European physician work environments and the use of social media in medicine.
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Dr. Patrone recounts his entry into the European IR speaking circuit. Through networking, he continues to meet speakers, learn from their experiences, and gain effective communication and presentation skills. He speaks about normalizing the feeling of imposter syndrome, especially when being invited to speak among IR founders and luminaries. He emphasizes personal growth and identifying where your passion and talent overlaps with lecture content.
Dr. Patrone highlights the fact that the field of IR revolves around three different aspects: First, the pioneering phase to innovate new procedures, then the research/evidence phase to demonstrate reproducible results, and finally, the education phase to disseminate knowledge and inspire new generations of IRs. It is common for IRs to feel overwhelmed when trying to commit to all of these fields. Instead of trying to master all aspects of the job, Dr. Patrone recommends that clinicians find different angles of their jobs and hone in the aspects that make them enthusiastic to come to work. Personally, he prioritizes clinical care and teaching. We discuss how time is the ultimate luxury, and how to avoid over-commitment and burnout. We also consider societal gender roles and talk about unjust extra pressures faced by female physicians.
Then, we look at some key differences between a physician career in the US, versus one in Europe. Dr. Patrone comments on the pay gap, training pathway, and overall philosophy of the Italian and British healthcare systems.
Finally, we discuss benefits and misuses of social media within the medical community. Dr. Patrone emphasizes that social media should be used as a tool to teach and inspire, rather than a platform to criticize individuals or specialties. Regarding case-based posts and feedback, he highlights the point that every clinician could have a different but valid approach to each case, based on the practice setting and operator skill. He also encourages other posters to talk about case complications, which can provide enormous educational value for learners.
In this episode, Dr. Aaron Fritts interviews Dr. Peder Horner about the impact of staff culture on patient care, how to manage bad players, and how to maintain an active role in shaping a healthy work culture.
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We begin by discussing why staff culture is important. In IR, many people are coming out of a toxic training program and are now expected to be department leaders. We take after our mentors, and we pick up both good and bad habits. So where does healthy staff culture start? Dr. Horner explains that it starts from the top. You have to play an active role in molding the culture, otherwise it will remain toxic or simply be uninspiring.
Next, we ask Dr. Horner how he inspires his staff. He shares many values as a parent and a leader. If he is tired and as a result doesn’t smile while at work, it can set the mood for a case, similarly to how it can add up and impact a home relationship on a day to day basis. When employees have negative feelings at work, this results in worse patient care.
Lastly, we talk about how to maintain culture once you have a good team onboard. Dr. Horner believes in checking in frequently by asking his techs and nurses how they are doing. He prioritizes their career growth and mobility, which he says may lose him employees over time, but in turn makes people enjoy coming to work because they feel like they are improving and advancing. He says you must be selfless as a leader. If you expect everything to stay static, you’re doing your staff and patients a disservice. Even a great team, if left static, will not go far. He encourages personal and professional development among his staff which is a huge part of the culture of growth he believes in.
RESOURCES
Harvard Business Review: https://hbr.org
Paper on Work Culture and Patient Care: https://asqblog.com/2015/02/25/barsade-oneill-2014-whats-love-got-to-do-with-it-a-longitudinal-study-of-the-culture-of-companionate-love-and-employee-and-client-outcomes-in-a-long-term-care-setting/
In this episode, Dr. Vishal Kumar interviews trauma surgeon Dr. Andre Campbell about his career path and policy interests, including gun safety, nationwide access to trauma care, and diversity and inclusion within surgical subspecialties.
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SHOW NOTES
Dr. Campbell starts the conversation by explaining how he was exposed to early mentorship, which guided him towards pursuing his interest in medicine. He outlines his journey, including his childhood in the Bronx, medical school at UCSF, and residency training. Dr. Andre emphasizes the importance of mentorship at all stages of one’s career. He personally became interested in medicine due to a sixth-grade teacher who sparked his interest in science.
Next, we discuss his journey of choosing trauma surgery as a specialty. He found it difficult to decide between medicine and surgery, so he first completed a medicine residency, and then applied to match into surgery afterwards. Dr. Campbell found himself gravitating towards ICU and trauma care, which led him to specialize in trauma surgery. He currently performs trauma, acute care, and elective surgery.
Dr. Campbell also talks about the importance of allowing himself to feel the pain of trauma patients and their families, instead of keeping a distance. With every patient loss, he steps back and thinks about lessons that he could learn and how he could do better next time.
Then, we shift to a conversation on gun violence, a health emergency in 2022. The incidence of gun violence has rebounded to a higher level than it was before the COVID-19 pandemic started. Dr. Campbell has served as an advocate for gun control, and he highlights the fact that shootings happen every day, but it is only high profile mass shootings that get media attention. He emphasizes that as healthcare providers “staying in our lane” means taking a stance on firearm laws, since our jobs are centered around taking care of injured people. He also talks about respecting gun owners and the complex role that guns play in American culture and symbolism. Dr. Campbell highlights recent progress being made with laws requiring stricter background checks, allocating more funds for hospital based violence intervention programs and psychiatric care, and continuing efforts for gun safety research. We look at the role of Level One trauma centers in providing care for the US population, including people who live in “trauma deserts” with no easy access to a trauma center. Dr. Campbell speaks about the benefits of implementing a nationwide trauma system.
Finally, Dr. Campbell shares his observations about increasing diversity within surgical subspecialties. Again, he notes that mentorship is a large factor, as well as intentional initiatives to build supportive environments for underrepresented minorities.
In this episode, guest host Dr. Jacob Fleming interviews Dr. Jason Cox about musculoskeletal interventions and how he uses ultrasound for diagnosis and intervention in his full spectrum musculoskeletal practice.
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We begin by discussing Dr. Cox’s path to MSK intervention. During his interventional training at University of Missouri, the musculoskeletal radiology program was rebuilt, and ultrasound was incorporated heavily. He used his ultrasound skills from vascular intervention in IR to learn musculoskeletal anatomy on ultrasound. He was drawn to MSK radiology due to the mechanical aspect of MSK work and the integration of visual spatial awareness and hand eye coordination involved in MSK ultrasound.
He started out by learning steroid injections for sports injuries, commonly rotator cuff injuries. He now does around 20 diagnostic or interventional ultrasound procedures each day in his clinic. He opened his clinic with a partner, and did it slowly while still working at his prior job. He started working at his new clinic on his vacation days until he could build up the clientele to leave his prior job. One of the biggest challenges in opening his MSK radiology clinic was finding a sonographer able to do the complex MSK cases he was doing.
The most common procedure Dr. Cox does at his clinic is ultrasound guided carpal tunnel release. He also does tendon barbotage for hydroxyapatite deposition disease for the rotator cuff tendons. His practice has grown largely due to the number of patients that are referred because they cannot get an MRI. He reads his ultrasound exams like an MRI report, with a high level of detail, differential diagnosis and recommendations.
RESOURCES
Institute for Advanced Medical Education: https://www.iame.com
Linked In: https://www.linkedin.com/in/jasoncoxmd
Ultrasound First Clinic: https://ultrasound-first.com
European Society of Musculoskeletal Radiology: https://www.essr.org
In this episode, host Dr. Ally Baheti interviews Dr. Jayson Brower about building a Y90 service line in his outpatient based lab (OBL).
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SHOW NOTES
First, Dr. Brower describes the IR/DR makeup of his practice and partnerships with surrounding hospitals. Inland Imaging’s collaboration with the Providence healthcare system was formed to provide quality outpatient imaging and avoid duplication and competition of services. Over time, they added interventional services, including interventional oncology procedures, to their joint venture.
The decision to move Y90 from the hospital to the outpatient setting was spurred by the need in the community, availability of more modern imaging equipment, and patient convenience. In 2019, it was not very common to perform Y90 in an OBL. Dr. Brower outlines the steps he took to move these services, starting with building consensus within the group. Next, he explained the benefits of the OBL to the hospital administration, which include freeing up time in the hospital for true emergencies and providing care for patients who prefer the OBL setting. Then, the group proactively reached out to payers and secured written agreements that they would provide coverage. After securing these agreements, they drafted pro formas, searched for adequate sites, and contacted vendors.
Since each state has different regulations for “hot labs” that use radioactive materials, Dr. Brower recommends working with your radiation safety officer to help walk you through the regulations. His OBL has a “mini hot lab” that allows him to draw up the Sirtex dose that he prescribes. Nuclear medicine technicians assist in transporting the radioactive material. Patients have pre-Y90 SPECT mapping close by, at another center.
RESOURCES
Inland Imaging Interventional Radiology: https://interventional.inlandimaging.com/
OEIS: https://oeisweb.com/
Radioactive Material (RAM) License: https://dpbh.nv.gov/Reg/RAM/dta/Licensing/Radioactive_Material_Program_(RAM)_-_Licensing/
In this episode, host Dr. Aaron Fritts interviews Dr. Ali Alikhani about his solo outpatient IR practice, how he leveraged his sales background in the OBL setting, and marketing advice for IRs in an outpatient practice.
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SHOW NOTES
Dr. Alikhani started working at an OBL three years out of fellowship. He became the solo practitioner at an outpatient center that had recently lost its physician to retirement. The practice is OBL based, and had a medical director and staff that flew him around to get trained for his first role. This OBL was part of a company that owns around 70 labs around the country. He primarily does embolization; his favorite procedures include uterine fibroid, prostatic artery, and genicular artery embolization. He works as a W2 employee, but there are 1099 locums IRs who are able to cover him for vacation.
Due to his background in marketing, he had a strong interest in building up this OBL and diversifying its services. He works with a marketing team including one employee who has worked at this company for 10 years and is very comfortable going to marketing meetings on her own. She helps plan which meetings he needs to attend, and gives Dr. Alikhani weekly reports on who she has met with during the past week. Together, they are building up the practice. Despite this strong marketing team, Dr. Alikhani still only works 60% at this OBL and has to work 40% at a separate OBL due to lack of patients. It takes time to build relationships with referring providers and build a large patient base.
Dr. Alikhani speaks on the responsibilities of being a solo IR at an OBL. It is a great responsibility that requires planning, teamwork and a willingness to make mistakes and learn. It is a stressful adjustment from hospital work, but it can also be a very rewarding shift with the right team in place. He recommends early career IRs to start out at an established OBL that knows how to run the business. Learn from this, and then open your own center if this is something you find yourself capable of and willing to do.
In this episode, our hosts Drs. Michael Barraza and Aaron Fritts interview Dr. John Pavlus about his methods of drain placement, monitoring, and removal, as well as his vision to design an ideal drainage system.
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In this episode, our hosts Drs. Michael Barraza and Aaron Fritts interview Dr. John Pavlus about his methods of drain placement, monitoring, and removal, as well as his vision to design an ideal drainage system.
Dr. Pavlus became interested in abscess drains when he noticed that across different institutions had very different indications, types, and methods of putting in drains. Dr. Pavlus prefers to place drains under ultrasound guidance, and he will also obtain a CT image afterwards to ensure the drain is in place. The doctors discuss their favorite guidewires to use: Dr. Pavlus prefers the Coons wire and Dr. Barraza prefers the Amplatz wire.
For deep pelvic cul-de-sac abscesses, Dr. Pavlus describes how he obtains transgluteal access and uses a Hawkins needle. Liver abscesses can be challenging, due to their variety of drainage contents (hematoma, bile, necrotic material), and increased time of drainage. We also discuss the debate between suction bulbs and gravity drainage bags, noting that research studies and personal experiences have not shown significant differences in the rate of fistula formation with either method. One exception is post-operative spinal drainage, where using suction could confer the risk of removing CSF.
To assess when a drain needs to be removed, Dr. Pavlus monitors the output and obtains a CT. He prefers to take ownership of drain care and remove drains that he originally placed, but if needed, he also collaborates with trauma surgeons to ensure that drains and sutures are removed properly. Dr. Pavlus also recognizes the need to standardize follow up care for drains. Dr. Barraza describes a workflow for drain checks at his fellowship site, which included daily rounds and a standardized checklist for each patient.
Finally, Dr. Pavlus speaks about his ongoing mission to design an ideal drainage system for various dwell times, viscosity of contents, and catheter sizes.
In this episode, guest host Dr. Jacob Fleming interviews Dr. Dan Nguyen about MSK and neurologic pain interventions, specifically how he evaluates and treats different types of headaches at his practice.
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Dr. Nguyen left academia and the East Coast 6 years ago, where he trained in neurointerventional radiology and pain intervention to open his own practice in Oklahoma City after visiting Dr. Beall. He now has a clinic where he sees musculoskeletal and neurologic pain patients. He enjoys the long term relationships he has built with many patients in his practice. He still does a degree of diagnostic work so as not to lose his skills.
Next, Dr. Nguyen discusses how he evaluates and treats headaches as a neurological pain interventionalist. Understanding the neuroanatomy of the face is key. He tries to understand the presentation of the patient’s headaches, whether it is located above the eyebrow, near the ear or at the jaw. He treats cervicogenic headache, trigeminal neuralgia and occipital neuralgia with a diagnostic block, radiofrequency ablation and neuromodulation. He also treats migrainous headaches. After determining whether the pain is musculogenic or neurogenic, he does a trigger point injection or a test injection of the nerve, followed by RFA and neuromodulation.
Dr. Nguyen tells us his approach to trigeminal neuralgia workup. There are three branches, and the Gasserian ganglion (trigeminal ganglion) lies deep to the foramen ovale. To approach it, he usually tries to target the most peripheral nerve branch. For V1, he evaluates the supraorbital, supratrochlear nerves, which you can see with ultrasound. For V2, he evaluates the infraorbital with ultrasound. The foramen rotundundum requires CT guidance to access. For V3 he evaluates the mental and alveolar nerves or the foramen ovale. He does diagnostic blocks, and if this provides relief to the patient they discuss radiofrequency ablation. He advises operators to take the longest path to the nerve to ensure the ablative needle is fully buried under the skin to avoid burns. He also discusses the rare outcome of anesthesia dolorosa which can cause facial numbness and pain after ablation of the Gasserian ganglion. He says that for most of his patients, they accept this potential risk due to the more likely possibility of relief from the excruciating pain they experience with trigeminal neuralgia.
RESOURCES
Dr. Nguyen Twitter: @neuroradiology
Narouze: Interventional Management of Head and Face Pain https://link.springer.com/book/10.1007/978-1-4614-8951-1
American Society of Spine Radiology: https://assrannualmeeting.org
American Society of Neuroradiology: https://www.asnr.org/annualmeeting/
In this episode, guest host Jill Sommerset interviews vascular surgeon Dr. Miguel Montero-Baker about his evolving use of ultrasound throughout his career in caring for critical limb-threatening ischemia (CLTI) patients.
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SHOW NOTES
Dr. Montero-Baker starts by outlining his journey from training in Costa Rica, Germany, and Arizona, to building a multidisciplinary limb salvage center at Methodist Houston. Despite his geographic relocations, he is still very involved in endovascular education in Latin America through HENDOLAT, an online community and annual conference.
Next, we delve into the uses for ultrasound during the workup stages for CLTI. Dr. Montero-Baker highlights the information that ultrasound can provide: locating the region and extent of disease, pursuing an open versus endovascular treatment approach, and the tools you will need. He points out that a lot of institutions currently only rely on pulse volume recording (PVR), ankle brachial index (ABI), and toe brachial index (TBI), and do not have access to a robust vascular lab for full ultrasounds. Dr. Montero-Baker discusses some hurdles preventing the widespread implementation of ultrasound, such as additional cost and variability in operators.
However, he believes that ultrasound can be a phenomenal tool if practices can invest the time to train vascular technologists and implement its use. We frame the ultrasound conversation around incentives for each party: the technologist can achieve higher job satisfaction and further subspecialize, the treating physician can have a better understanding of each patient’s disease and management, and the institution can minimize extended stays and readmissions. Additionally, ultrasound is very useful when institutions are facing the global contrast shortage or treating patients with renal disease.
Finally, we look at the pathophysiology of diabetic and chronic renal failure patients who have extreme below the knee and below the ankle disease. These patients with medial artery calcification patterns have very few treatment options and high limb loss rates. Dr. Montero-Baker describes a new method of pedal venous access for deep vein arterialization.
RESOURCES
BackTable en Espanol- Enfermedad Arterial Periférica y Salvamento de Extremidades en la Comunidad Latino Americana: https://www.backtable.com/shows/vi/podcasts/%20v/enfermedad-arterial-periferica-y-salvamento-de-extremidades-en-la-comunidad-latino-americana
Dr. Miguel Montero-Baker’s Twitter: https://twitter.com/monteromiguel
HENDOLAT: https://hendolat.com/
Society for Vascular Ultrasound:
In this episode, guest host Dr. Donald Garbett interviews Drs. Geogy Vatakencherry, Zaeem Billah, and Kartik Kansagra about the IR integrated residency, how it’s evolving, and what students should be doing to prepare for this rigorous training program.
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SHOW NOTES
We begin by discussing the VIR program at Kaiser LA. As the program director, Dr. Vatakencherry discusses how he built his residency program and how it has evolved since the inception of the integrated iR residencies. One integral part of this program is weekly continuity clinic, starting in your first year. Dr. Kansagra brought up the idea to Dr. Vatakencherry after noticing that other surgical specialties and interventional cardiology were doing this. This model allows residents to develop longitudinal relationships with patients, understand disease progression and the importance of preventive care and nonoperative management.
Next, Dr. Billah discusses his training at Kaiser LA, as a resident in the first year of the new integrated IR residency. They have a categorical program, with a surgery intern year included. He highly suggests that all IR residents should do a surgery year due to its similarity to IR and the skills it provides you. Whether on DR, ICU or IR, all IR residents have daily IR conferences. ICU training begins in the first year, which includes MICU, SICU and CCU rotations. In the PGY-5 year, they get consecutive rotations in stroke neurology and neurointervention.
Finally we discuss the future of the VIR integrated residency. Dr. Vatakencherry believes that clinic time is quintessential during IR residency to understand the nuances of “should vs. could” when it comes to operative intervention. In clinic, not only do you see what you do well but more importantly, you see what you don't do well and how you can fix that. This clinical experience cannot be replicated in a year of fellowship. Lastly, Dr. Vatakencherry gives some extremely pertinent advice to fourth year medical students applying to IR integrated residency.
In this episode, guest host Dr. Shamit Desai interviews Dr. Keerthi Prasad his path to starting an IR practice alongside interventional pain specialists.
In this episode, our host Dr. Aaron Fritts interviews physician-entrepreneur couple Drs. Kasie and Rockford Adkins about the path to starting their healthcare recruiting platform, Stat Careers.
In this episode, cohosts Dr. Michael Barraza and Dr. Aaron Fritts interview Dr. Chris Thomson, veterinary surgeon and interventional radiologist about how he learned veterinary IR, his area of focus in interventional oncology, and the future of the specialty.
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SHOW NOTES
Dr. Thomson begins by taking us through his training. During his residency at the University of Minnesota, Shamar Young taught him embolizations and interventional oncology at the medical school and the veterinary school there. He then adapted it to dogs. He then did a surgical oncology fellowship at Colorado State which grew his passion for practicing interventional oncology. There is no training specifically for IR; you train in your specialty of cardiology or oncology, then go on to learn IR skills later in practice.
In the interventional oncology world, Dr. Thomson does prostate artery embolizations for prostate tumors, chemoembolizations, and caval and urethral stents for malignant obstructions. He primarily treats cats and dogs, but occasionally he will help out with an intervention for an animal at the San Diego Zoo. He recently helped do renal sclerotherapy for a dik-dik to treat idiopathic renal hematuria. Dr. Thomson discusses some of the challenges he faces with the different sizes of animals he treats. The size of the animal and the size of the equipment often don’t match up well which poses many technical difficulties for the operator.
We end by discussing the future of veterinary IR. In the cardiovascular IR world, veterinary specialists are beginning to do endovascular valve replacements. In the interventional oncology world, radiofrequency ablation and cementoplasty for appendicular bone tumors is the next big procedure that will impact many patients. Dr. Thomson is excited about being able to provide this minimally invasive treatment for his cat and dog patients as it will prevent many amputations and allow his patients to receive chemotherapy while retaining the highest quality of life possible.
In this episode, host Dr. Eric Keller interviews Dr. Sean Tutton about palliative care as an interventionalist, how he became interested in palliative care, and why he believes it is a crucial aspect of patient care in interventional radiology.
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In this episode, host Dr. Michael Barraza interviews Dr. Kyle Cooper, interventional radiologist and Dr. Tahmeed Contractor, electrophysiologist about how IR and EP work together at their institution, including how they perform complex pacer lead removals, and how the have embraced collaboration over competition.
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SHOW NOTES
The doctors begin by discussing how they began working together. It was somewhat by chance that they started to work so closely, because the EP and the IR labs are directly across from each other at Loma Linda, where they work. They both began finding patients that had overlapping problems requiring intervention by both specialties, such as someone who needed a pacer lead out who also had an occluded AV fistula on the same side.
Their relationship developed further due to the nature of the complexity of some of the EP cases. They often have to remove multiple pacer leads that were placed in the patient over 30 years ago. When these devices were created, they were not designed to be removed, so it is often quite difficult to do. Furthermore, because they are mostly plastic, not metal, they often break during removal. When this happens, it is not uncommon to have to call IR to help retrieve the piece. Though a cardiothoracic surgeon is usually always scrubbed into EP cases, open heart surgery is only done if all else fails.
The two discuss how this collaboration has allowed them both to learn new skills. Dr. Contractor now does many lead extractions and will only call Dr. Cooper if there is a complication. Similarly, Dr. Cooper says he has learned many techniques from Dr. Contractor such as how to use intracardiac echo (ICE), or more commonly called intravascular ultrasound (IVUS) in IR for many more procedures than he was previously able to. Some of the challenges they have encountered is reimbursement and scheduling. With EP, CT surgery and IR are all in the room and helping, it complicates who gets paid. In general, IR bills for any venoplasty done during the procedure, and EP and CT surgery bill for the rest.
Host Aparna Baheti interviews Barbara Hamilton and Aarti Luhar about navigating training and early career during a pregnancy. They discuss factors to consider such as scheduling, parental leave policies, radiation exposure risks, and childcare.
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SHOW NOTES
Our guests start by sharing their paths to motherhood. Dr. Luhar was pregnant as a diagnostic radiology trainee, while Dr. Hamilton was pregnant as an attending. We talk about the benefits of being part of a large department or group during maternity leave, due to more flexibility of scheduling changes and availability of coverage. Both of our guests recommend that IRs reach out to their HR departments as soon as they feel comfortable sharing their pregnancy news. Establishing contact with the department is a helpful way to clarify parental leave policies, specifically if one qualifies for parental leave and how long the leave can be. Additionally, Dr. Luhar encourages listeners to reach out to colleagues who have been pregnant before, since they can be a valuable resource for insights on the granular details of practicing IR while pregnant.
In terms of radiation as an occupational exposure, Dr. Hamilton did not change her caseload during pregnancy. She shares her preference to wear extra radiation protection around her waist. Dr. Luhar reached out to her hospital’s radiation physicist for guidance. She received the advice to use standard radiation protection and follow the principle of ALARA (as low as reasonably achievable). Additionally, we discuss the risks of pathogen exposure and needle sticks. Both doctors agree that having supportive staff and colleagues can make the pregnancy process more manageable.
Additionally, we discuss unexpected challenges during pregnancy. Dr. Hamilton describes her experience with the risk of premature labor and bedrest. Dr. Luhar recounts the struggle of scheduling prenatal appointments and dealing with pregnancy complications while working a full caseload. We close the episode by giving advice for evaluating the culture of your work environment, relying on support systems that are in place, and not being afraid to ask important questions.
RESOURCES
Dr. Barbara Hamilton Twitter: @TSuperheroine
Dr. Barbara Hamilton Instagram: @TiredSuperheroine
SIR Pregnancy Toolkit: https://www.sirweb.org/practice-resources/toolkits/pregnancy-toolkit/
In this special crossover BackTable episode, Dr. Aaron Fritts and Dr. Julie Wei talk with Dr. Gerry Mattia, Chiropractor and Director of Rehabilitation of ViscoGen Clinic in Orlando, Florida.
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SHOW NOTES
First, Dr. Mattia recounts his journey to becoming a chiropractor, beginning with his medical history of aortic stenosis fixed by a chiropractor, his decision to enter chiropractic school, and starting his independent practice after graduation. Then, he explains how he deals with patients presenting with degenerative disc disease with spinal stenosis, which was the issue he resolved in Dr. Wei. A herniated disc is the most common cause of degenerative disc disease. The standard chiropractic treatment is cervical decompression to help the disc restore itself. Dr. Mattia also uses a level 4 laser to rehydrate the disc. For optimal results, he recommends that patients see him 4 times a week for 6 to 8 weeks in order to fully lift the pressure off of the brachial plexus. He notes that good chiropractors will use the correct formulas and appropriate technology while adjusting the patient gently.
Next, the doctors delve into why many physicians are wary of chiropractors, which is rooted in a 1988 legal case that prohibited doctors from referring their patients to chiropractors. Dr. Mattia encourages physicians to seek therapy before medical issues develop into very severe conditions. Additionally, Dr. Wei notes that medical culture often encourages physicians to put the health of their patients before theirs.
Then, Dr. Mattia discusses how younger people and surgeons can improve their neck health. He notes that excessive cell phone use can reverse the cervical curve, causing people to lose their normal lordotic curve, a structure which usually prevents compression. He also recommends strengthening the muscles in the neck and shoulders, sleeping with a cervical pillow, and going to a good chiropractor to get routine adjustments. Dr. Wei recommends avoiding slouching and adjusting screens to eye-level in OR. Both Dr. Wei and Dr. Mattia agree that maintaining a healthy body weight will have positive benefits on spinal health.
Finally, Dr. Mattia recommends which qualities to focus on when finding a good chiropractor. He recommends looking for an experienced, passionate family practice chiropractor. As a word of caution, he warns listeners to never let a chiropractor adjust them without reviewing their X-ray imaging first.
Dr. Shamit Desai talks with Dr. Kavi Devulapalli and Dr. Vishal Kadakia about Locums work, including the current market and opportunities, different practice models, navigating finances and taxes, and how to organize your life around this unique practice style. Meet the locums chameleon!
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SHOW NOTES
To start off, we discuss what locums means for each of these clinicians, including inpatient vs outpatient work. Most locums opportunities are in mid-sized cities and smaller cities, due to increased demand in these areas. Locums work is a way for IRs to take control of their practices, making it a very appealing work model. The ratio of IR to DR for each of these clinicians ranges from 70:30 up to 90:10. Employers need locums to prevent burnout of their FTE employees, and to reduce call in areas where IRs are overworked. Employers also look to locums to build service lines and bring in procedures that aren’t currently being done at their institutions. It is a rewarding opportunity for both employer and employee.
Next, we review job expectations and the difference between inpatient and outpatient locums work. There are generally two types of clients, one needing someone to fill the role of a person who works at FTE, and another where the IR department is made up of a roster of rotating locums providers. Being in locums, you get exposure to so many different people, and practices and you get to expand your network. This opens up many opportunities that you would not get at one location. Some of the downsides are the need to constantly adapt, use equipment you are not as familiar with, and work with staff who do not know your preferences or even glove size. However, you get to build your schedule, and you have the power to work where you want when you want.
Finally, we discuss some of the contracts, reimbursement, and insurance details. The three discuss the differences between being a W2 employee versus a 1099 employee, comparing what happens with health insurance and retirement. They also discuss the pros and cons of a 1099 versus owning an LLC versus starting an S corporation. All three physicians highly recommend researching these and speaking to a lawyer about your best options until you fully understand these concepts. They discuss licensure, credentialing and malpractice insurance, as well as whether they recommend using an agency for these as a locums. Lastly, they discuss reimbursement, including models such as a flat rate for a week versus a deconstructed model that consists of a daily rate, a call rate, and an overtime rate.
RESOURCES
Kavi Devulapalli Profiles Twitter: @linemonkeymd Blog: https://linemonkeymd.com
Vishal Kadakia Profiles LinkedIn: https://www.linkedin.com/in/theirdoc
In this episode, our guest host Dr. Vishal Kumar interviews medical anthropologist and social scientist Dr. Kelly Knight of UCSF. They discuss the meaning of structural competency, methods for incorporating this concept into medical education, and how it can be applied to alleviate physician burnout.
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SHOW NOTES
Dr. Knight starts by defining structural competency as the recognition of the underlying policies, systems, and hierarchies that produce social determinants of health. While these structures may sometimes be invisible, they have a large impact on health outcomes. Examination of these factors allows us to think about interventions that can make healthcare more equitable.
Next, we highlight effective ways to integrate structural competency into medical education. Dr. Knight shares information about national shared curricula that are designed with the flexibility for each institution to modify the content according to their community’s needs.
Finally, we examine redlining as an example of structural violence, signifying intentional disinvestment in marginalized communities. Dr. Knight believes that change starts with an initial acknowledgement and recognition of policies that make populations vulnerable to illness. She also encourages individual healthcare providers to take action by developing interpersonal communication skills, strategizing ways to make the clinical space more focused on healing, and working with elected individuals to create equity at a policy level. All of these efforts may allow for healthcare providers to reconnect with their original motivation to help patients and have a protective effect against burnout.
RESOURCES
Structural Competency Working Group: https://www.structcomp.org/
Teaching Structure: A Qualitative Evaluation of a Structural Competency Training for Resident Physicians: https://pubmed.ncbi.nlm.nih.gov/27896692/
Mountains Beyond Mountains: The Quest of Dr. Paul Farmer: https://www.amazon.com/Mountains-Beyond-Tracy-Kidder/dp/0812973011
The REPAIR Project: https://repair.ucsf.edu/home
Do No Harm Coalition: https://www.donoharmcoalition.org/
UCSF Health Equity Collaborative: https://thecollaborative.ucsf.edu/training-health-equity-collaborative
In this episode, host Dr. Mary Costantino interviews Dr. Kathy Krol, interventional radiologist and former SIR president about the evolution of interventional radiology, her various leadership roles, and the growth of women in IR.
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SHOW NOTES
We begin by discussing how Dr. Krol entered the field of radiology and subsequently became involved in special procedures in radiology, before the beginning of interventional radiology. At the time, there was only a 7 French stiff wire, a J wire, or a straight wire. She recalls how the introduction of two key instruments, the glide wire, and the stent, changed the entire practice and scope of the types of interventions radiologists could do.
Next, Dr. Krol talks about her involvement with SIR (Society of Interventional Radiology). She first joined a meeting at a hotel in San Francisco, where she was the only woman in the room, and repeatedly mistaken for a nurse. At the time, the society had recently allowed women to join, and since joining, she has never missed a SIR annual business meeting. During her time as the president of SIR, in 2006, some of the main issues were preserving IR as its own field among vascular surgery and interventional cardiology, forming an independent IR residency, and forming the idea of the outpatient-based lab (OBL) as a new space for IRs to work in.
Dr. Krol shares stories of her struggles as a woman in IR as well as in leadership positions. She began in radiology, where she had to work hard to learn procedures, and then even harder to prove to colleagues that she was capable. She was often mistaken for a tech or a nurse and resorted to wearing suits instead of dresses while in the IR suite performing procedures. She often had to take whatever role was given, but she used this to her advantage. One such instance is when she wanted to volunteer for SIR, they put her in coding and billing which was not her interest. She turned this around and became so invested in it that she has now helped create nearly all the CPT codes that exist for IR today.
In this episode, our host Dr. Chris Beck interviews interventional radiologist Dr. Riad Salem about indications, technique, and cross-specialty collaboration in portal vein recanalization in the cirrhotic patient population.
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In this episode, host Dr. Chris Beck interviews interventional radiologist Dr. George Behrens about how he built a robust multidisciplinary portal hypertension clinic in a community hospital, tips for common challenges during a TIPS, and post-TIPS management.
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SHOW NOTES
We begin by discussing Dr. Behrens portal hypertension practice. He sees patients in conjunction with hepatology and transplant surgery. The model of his clinic is the opposite of the standard practice. The specialists come to the community hospital, and their clinic gets referrals from tertiary hospitals in Chicago. This took years to build, and they received enormous pushback. This model encompasses patient-centered care because it removes many of the barriers that patients face to travel into Chicago for the workup and management plan of portal hypertension. In this clinic, they also evaluate the underlying cause of cirrhosis including more uncommon causes such as hemochromatosis, Wilson disease, and alpha 1 antitrypsin deficiency.
Next, Dr. Behrens details the typical procedure and provides tips for commonly encountered challenges during a TIPS (transjugular intrahepatic portosystemic shunt). He does all TIPS under general anesthesia. He drains ascites, then uses a multipurpose catheter to enter the hepatic vein, without a preference for which hepatic vein he is in. He uses a Launcher AL 11 1 ½ or 2 if he is having difficulty entering a hepatic vein. He then does a CO2 portogram. Next, he advances the cannula into the hepatic veins, unsheathes the cannula, then brings it back to about 2cm from the pedicle, close to the ostium of the hepatic vein. He discusses the differences in technique between the Rösch-Uchida and the Scorpion. He likes to place his stent with the proximal portion where the diaphragm crosses the right atrium and the distal part at the entry site of the portal vein. He uses a VIATORR stent, and always dilates to 8mmHg first, then re-measures pressures. His general rule for dilation is less than 12mmHg for bleeding and less than 8mmHg for ascites.
Dr. Behrens discusses follow-up for patients and post-procedure care. All patients are started on rifaximin 2 weeks prior to TIPS. If ascites drained was 4L or more, he gives 100g albumin and 20mg Lasix. He measures pressures via a right heart cath before and after the procedure. Depending on the MELD, he may send patients to the floor or home same day, while others go to the ICU. He starts all patients on lactulose and zinc 220mg BID the day of the procedure. He advises all patients against using PPIs due to the increased risk of encephalopathy. He maintains pre-procedure Lasix and spironolactone dosing for the first 3 months. At one month, patients get a TIPS US with velocities, CMP, CBC, and INR. At 3 months they get cross-sectional imaging and repeat labs. He starts managing diuretics at 3 months. After this, he sees patients every 6 months and screens for hepatocellular carcinoma.
RESOURCES
Argon Scorpion: https://www.argonmedical.com/products/scorpion
Cook Rösch-Uchida: https://www.cookmedical.com/products/ir_rups_webds/
Gore VIATORR: https://www.goremedical.com/products/viatorr
Medtronic Launcher: https://www.medtronic.com/us-en/healthcare-professionals/products/cardiovascular/catheters/launcher.html
MELD score: https://www.mdcalc.com/calc/78/meld-score-model-end-stage-liver-disease-12-older
Dr. Jacob Fleming talks with Dr. Alan Alper Sag about building a musculoskeletal (MSK) interventions practice at Duke University Medical Center, collaborating with other specialists, and future predictions for MSK IR.
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SHOW NOTES
In this episode, our host Dr. Jacob Fleming interviews Dr. Alan Sag about building a musculoskeletal (MSK) interventions practice at Duke University Medical Center, collaborating with other specialists, and future predictions for MSK IR.
Dr. Sag starts the episode by sharing his unique experience abroad. His first job was centered around helping to build an IR practice at a teaching hospital in Istanbul. This process helped him discover that the key to practice building was forming foundational cross-specialty relationships. These eventually led to more patient referrals and a higher level of care coordination.
When he transitioned to an academic position, Dr. Sag first saw an unmet need in bone cryoablation. He recognized that IR procedures could be powerful alternatives to opioid escalation. A key turning point for his department came when a local TV station covered one of his patient’s stories, and he saw a large increase in referrals. Dr. Sag emphasizes that it was important to ensure that the practice was set up with enough resources to accomodate a large volume of patients. Additionally, it was crucial to recognize when to say “no” to patients when a procedure was contraindicated for them. This patient-first approach also showed referring doctors that he was independently and objectively assessing patients, which helps with trust-building.
As we move onto discussing multidisciplinary care, Dr. Sag says that learning another specialty’s vocabulary can greatly enhance your communication and show your desire to collaborate. He encourages IRs to be flexible and learn which conditions are important to the referring doctors. When working with anesthesiology and PM&R, IRs can offer their services to enhance their pain palliation efforts. When working with oncologists, this pain palliation can allow cancer patients to continue participating in clinical trials.
Finally, we discuss the next frontiers of MSK interventions. Dr Sag is excited by the prospect of standardization of MSK training, internally cemented screws, and vertebral body stents.
RESOURCES
Dr. Alan Sag Twitter: https://twitter.com/AlanAlperMD?s=20&t=8RGQsroHPZ9Vyc-0lpkiVQ
Bone Cryoablation Media Coverage: https://www.wral.com/komen-s-kohl-tries-tumor-freezing-therapy-in-ongoing-cancer-fight/18974441/
Duke Center for Brain & Spine Metastasis: http://dukecancerinstitute.org/DCBSM
SpineJack System: https://strykerivs.com/products/families/spinejack-system
Society of Interventional Oncology (SIO): http://www.sio-central.org/
SIO’s “Language of Oncology” Course: http://www.sio-central.org/p/cm/ld/fid=385
Visible Body Anatomy Atlas: https://www.visiblebody.com/anatomy-and-physiology-apps/human-anatomy-atlas
e-Anatomy Atlas: https://www.imaios.com/en/e-Anatomy
Ep. 199- Advanced Minimally Invasive Pain Interventions: https://www.backtable.com/shows/vi/podcasts/199/advanced-minimally-invasive-pain-interventions
STREAM Meeting Founders Ari Isaacson and Sandeep Bagla tell us about what to expect at the next meeting in September, including PAE and GAE practice building tips, as well learn about new embolization procedures such as adhesive capsulitis and thyroid arterial embolization.
SHOW NOTES
In this episode, host Dr. Aaron Fritts and interventional radiologists Drs. Ari Isaacson and Sandeep Bagla discuss new programming for their upcoming STREAM Conference in September 2022.
See our “Resources” section below for a special promotion code for BackTable listeners!
As they enter their fifth year of hosting the STREAM, the doctors describe the conference’s evolution beyond procedural teaching of prostate artery embolization (PAE). This year, they will focus more programming on practical factors such as decision-making strategies, malpractice considerations (with both plaintiff and defense attorneys), and new frontiers of embolization. They highlight the increased efforts for cross-specialty collaboration, since the conference will include sessions on genicular artery, shoulder, and hemorrhoid embolization.
Finally, we share more ways to learn about PAE. Our guests describe opportunities to shadow at Prostate Centers USA and request to be proctored for initial cases.
RESOURCES
The STREAM Meeting: https://www.thestreammeeting.com/ Promotion Code for 25% off registration for the STREAM Meeting: BACKTABLE22
Prostate Centers USA: https://www.prostatecentersusa.com/
Dr. Sabeen Dhand interviews interventional radiologist Dr. David Kim about how he treats endoleaks, including how he raised his success rate from 50% to 90% and built a major endoleak referral center.
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SHOW NOTES
At the beginning of his career, Dr. Kim made an effort not to compete with other endovascular specialists but to find a complicated vascular problem and focus on embolization that others weren’t doing. Due to the increase in endovascular aneurysm repairs (EVARs), he saw an increasing endoleak case volume and realized he was one of only a few in the area that could treat them. He built relationships with the vascular surgeons and cardiologists and with the help of a scheduling assistant at a hospital and referrals from his Terumo device rep he now has a busy endoleak service.
Dr. Kim sees many variations of endoleaks. A typical type 2 endoleaks is due to retrograde flow from either a lumbar, inferior mesenteric, or median sacral back into the excluded aneurysm sack which causes increased pressure, flow, and sometimes enlargement or rupture after EVAR repair of an abdominal aortic aneurysm (AAA). Type 1 endoleaks are generally repaired by vascular surgery.
Dr. Kim uses a direct stick technique, rather than transarterial. He starts in CT with the patient prone, under general anesthesia. He uses an 18-gauge Hawkins needle with a blunt dissecting tip down to the posterior aspect of the aneurysm sack. He then inserts the sharp stylette to enter the sack. He exchanges the needle for an Amplatz wire which he inserts securely into the lumen to prevent dislodging during transport from CT to the angiosuite. He sutures the sheath with nylon rather than silk. Once in the angiosuite he uses a 4 French Glidecath and starts by doing an aortogram to determine the flow channels. If able to see the inflow, he deploys coils there and then works backward. After deploying Terumo coils, he finishes with Onyx to seal up the gaps. Using more coils and adding Onyx has been a key component in increasing his success rate from 50% to 90%.
Dr. Merve Ozen, interventional radiologist, and Dr. Mark Hoffman, minimally invasive gynecologic surgeon (MIGS), discuss how collaboration between IR and gynecologic surgery provides comprehensive medical, surgical, and interventional treatment options for women suffering from uterine fibroids, pelvic congestion syndrome and other causes of chronic pelvic pain.
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SHOW NOTES
In this episode, host Dr. Aparna Baheti interviews Dr. Merve Ozen, interventional radiologist, and Dr. Mark Hoffman, minimally invasive gynecologic surgeon (MIGS) about how collaboration between IR and gynecologic surgery provides comprehensive medical, surgical, and interventional treatment options for women suffering from uterine fibroids, pelvic congestion syndrome and other causes of chronic pelvic pain.
Drs. Hoffmann and Ozen began a combined clinic after a discussion between their two departments. Though IRs were enthusiastic about performing uterine fibroid embolization (UFE), they were not able to due to a lack of referring gynecologists. Dr. Hoffman was interested in this collaboration, and he knew a very supportive and motivated nurse who wanted to lead this initiative. He says that despite pushback from other MIGs in his department, he had a supportive department chair who allowed the project to go forward.
Next, Dr. Ozen describes a day in their collaborative clinic. She begins by reviewing imaging and patients for the day, ordering new imaging if needed, and discussing patients with Dr. Hoffman. They each see their patients which takes about 45 minutes per visit due to the complexity of chronic pelvic pain and the many potential causes and contributing factors. Some patients require meeting with both physicians to discuss all options. They see four to five patients each day. Every day runs differently depending on the patients and their individual needs, but it runs smoothly due to the supportive nursing staff.
Dr. Hoffman discusses medical management including birth control pills, which are often a first-line option or an option for someone who wants the least invasive treatment. He also offers hysterectomy (laparoscopic, robotic, vaginal, abdominal) for women who wish to never have more uterine bleeding, and myomectomy, with hysteroscopic myomectomy being the most minimally invasive and allowing patients to go home the same day after recovering from anesthesia. Dr. Ozen discusses UFE and treatments for other causes of pelvic pain. She does hypogastric nerve blocks for pain, ovarian vein embolization for pelvic congestion syndrome, and cryoablation for chronic pelvic pain. She has also been able to treat some unique ectopic pregnancies that Dr. Hoffman has seen, including a cervical and an abdominal ectopic pregnancy which provided lifesaving treatment without invasive surgical evacuation.
RESOURCES
BackTable Ep. 199: Advanced Minimially Invasive Pain Interventions with Dr. Prologo: https://www.backtable.com/shows/vi/podcasts/199/advanced-minimally-invasive-pain-interventions
Non-surgical management of abdominal ectopic pregnancy with uterine artery embolization: https://pubmed.ncbi.nlm.nih.gov/35321265/
In this episode of our Health Equity Series, guest host Dr. Vishal Kumar interviews emergency medicine resident Dr. Jamal Jefferson about the presence of law enforcement in emergency rooms and challenges with patient privacy and trust in the healthcare system.
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SHOW NOTES
In this episode, guest host Dr. Vishal Kumar interviews emergency medicine resident Dr. Jamal Jefferson about the presence of law enforcement in emergency rooms and its effects on patient privacy and trust in the healthcare system.
Dr. Jefferson explains the role that the emergency department plays in his community. He outlines its medical role, as well as its extension into “social emergency medicine.” This term refers to the fact that the ED can be an important access point to services that could improve social determinants of health. Overall the ED often sees community members in their most vulnerable states, and it has the opportunity to track trends in community needs.
Next, the doctors discuss how healthcare providers can be unknowingly complicit in further injustices to their patients. Dr. Jefferson urges physicians to think about the ramifications of their actions. For example, using a 5150 code to place a patient on psychiatric hold could affect court decisions and child custody outcomes in the future. Furthermore, when patient belongings are being itemized in a public space such as the ED, this routine procedure could trigger a downstream search/seizure, interrogation, and detainment of the patient.
Dr. Jefferson emphasizes the importance of being an active participant in protecting patient privacy. In his patient encounters, he separates the police from the doctor-patient relationship and dispels the idea that the medical team will report protected health information to the police. He explicitly lets patients know that the preceding events that brought them to the hospital do not have an impact on how he will treat them. Additionally, the negative experience of a single patient will send a ripple effect through the community. The patient’s friends and family members may trust the ED less, which delays care and increases morbidity and mortality.
Finally, the doctors highlight important research and court rulings over the criminalization of patients.
RESOURCES
A National Evaluation of the Effect of Trauma-Center Care on Mortality: https://www.nejm.org/doi/full/10.1056/nejmsa052049
Police Brutality and Black Health: Setting the Agenda for Public Health Scholars: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5388955/
Policing the Emergency Room (Harvard Law Review): https://harvardlawreview.org/2021/06/policing-the-emergency-room/
Weapons Use Among Hospital Security Personnel: https://cdn.ymaws.com/www.iahss.org/resource/collection/48907176-3B11-4B24-A7C0-FF756143C7DE/2014_Weapons_use_among_hosptial_security_personnel.pdf
Ferguson vs. Charleston: https://supreme.justia.com/cases/federal/us/532/67/
WhiteCoatsForBlackLives — Addressing Physicians’ Complicity in Criminalizing Communities:
https://www.nejm.org/doi/full/10.1056/NEJMp2023305
In this episode, host Dr. Aparna Baheti interviews interventional radiologist Dr. Ziv Haskal about the use of glue in peripheral applications. They discuss how to prepare and inject glue for portal vein embolization, type 2 endoleaks, and Dr. Haskal’s glue bullet technique.
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Dr. Ziv Haskal talks us through the use of glue in peripheral applications. He discusses how to prepare and inject glue for portal vein embolization, how to do the same for type 2 endoleaks, and also shares his glue bullet technique.
Glue is only approved for neurointerventional procedures in the US, though there are many off-label uses where glue is the superior embolic. The benefit of glue is the power it gives to the operator. By manipulating the oil to glue ratio and thus the viscosity, the operator has control of how far the glue will travel when injected which makes it a very versatile liquid embolic. Dr. Haskal commonly uses glue for portal vein, bronchial, lumbar and intercostal embolizations as well as in coagulopathic patients.
Dr. Haskal advises that one of the easiest places to start using glue is portal vein embolization. To prepare glue for a procedure, Dr. Haskal separates it from the rest of the back table, and always uses new gloves and a separate set of equipment. For a portal vein embolization, Dr. Haskal runs a microcatheter paraxially alongside the safety wire and makes U-turns into portal vein branches that he is targeting. For treating renal pseudoaneurysm or for finishing a coil embolization, Dr. Haskal uses the glue bullet method, which involves loading a syringe with dextrose and only a tiny amount of glue at the top of the syringe.
Regarding complications of glue, Dr. Haskal says that though many fear the glue solidifying and causing the catheter to get stuck in a vessel, the likelihood of this is near zero because the glue does not harden fast enough for this to happen. The most common complication is over embolization and downstream spillage, which can be problematic in end organ supply vessels. Finally, Dr. Haskel explains his technique for when the glue starts solidifying around the catheter which creates a glue tail catheter is drawn back.
RESOURCES
Glue for Type 2 Endoleak: https://www.jvir.org/article/S1051-0443(18)30849-2/fulltext
Global Embolization and Symposium Technologies (GEST): https://www.gestweb.org
Dr. Jacob Fleming interviews interventional pain specialist and former Super Bowl champion Dr. John Michels about his journey into the subspecialty, pathways for getting involved in interventional pain management, and his philosophy on comprehensive patient care.
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Dr. David Wood, interventional radiologist and chief medical officer of Advantage IR, tells us about his experiences with geniculate artery embolization (GAE) practice building in the office-based lab (OBL).
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In this episode, host Dr. Michael Barraza interviews Dr. David Wood, interventional radiologist and chief medical officer of Advantage IR, about building office based labs (OBLs), the untapped potential of the geniculate artery embolization (GAE) market, and how to build patient referrals for new OBLs.
We begin by discussing why Dr. Wood chose to do geniculate artery embolization (GAE) in his OBLs. He says that GAE makes a great procedure for an office setting because it is relatively easy, only requiring a C arm with digital subtraction angiography (DSA). It is also a quick procedure with little side effects and low rates of complications. He says that patients who get GAE are a unique patient population because they know they have arthritis, and have exhausted conservative measures or declined treatment options that they have been offered, which are often quite invasive.
Dr. Wood says his GAE patients are mostly self-referred. He has marketing liaisons for local clinics, but what he has found most effective is TV commercials in English and Spanish, because this reaches the populations that need the most help. His patient population for GAEs consists mostly of self referred patients, as well as referrals from PCPs and occasionally orthopedic or sports medicine providers.
Regarding how Dr. Wood evaluates which patients to treat, he says that he began by using the point of maximal tenderness as described by Sandeep Bagla and required MRI before patient selection. He now uses primarily X-ray and only treats pain rated at least 5 out of 10. He does not do GAE in patients who have had knee surgery or with a history of significant PAD or calcification seen on preoperative X-ray. He generally tells patients they can expect up to a 70% improvement of pain after geniculate artery embolization.
RESOURCES
BackTable Ep. 27: Geniculate Artery Embolization for OA with Dr. Sandeep Bagla and Dr. Ari Isaacson https://www.backtable.com/shows/vi/podcasts/27/geniculate-artery-embolization-for-osteoarthritis
BackTable Ep. 85: Genicular Artery Embolization for OA with Dr. Jafar Golzarian https://www.backtable.com/shows/vi/podcasts/85/genicular-artery-embolization-for-oa
Bagla GAE Publication: https://pubmed.ncbi.nlm.nih.gov/31837946/
Padia GAE Publication: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8542160/
In this episode, host Dr. Sabeen Dhand interviews Dr. John Rundback, interventional radiologist, about distal femoropopliteal disease, including the unique pathophysiology of this area, which stents work best at the adductor canal and the trifurcation, and tips for early operators.
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In this episode, host Dr. Sabeen Dhand interviews Dr. John Rundback, interventional radiologist, about distal femoropopliteal disease, including the unique pathophysiology of this area, which stents work best at the adductor canal and the trifurcation, and tips for early operators.
We begin by discussing peripheral arterial disease (PAD) pathophysiology, specifically in the challenging areas around the adductor canal (Hunter’s canal). Dr. Rundback describes how the femoral artery has twists and turns around this area and that it can experience compressive forces up to 15-20% during motions such as flexion of the knee. Due to this being the most dynamic location of the femoral artery, this is often where plaque rupture will happen, resulting in critical limb ischemia (CLI) and requiring urgent intervention.
The two discuss how traditional rigid stents do not work well in this area due to the dynamic nature of the region and the fact that the artery is tortuous and can cause rigid stents to fracture or cause intimal hyperplasia due to turbulent flow. Drug coated balloon (DCB) angioplasty generally does not work for this region due to poor durability. They discuss the utility of the Tack device, a scaffold with minimal metal which is better suited for focal dissections. Dr. Rundback emphasizes the importance of intravascular ultrasound (IVUS) during all distal femoropopliteal cases due to the complexity of the region and patient-to-patient variation. He uses IVUS to choose which device and what size to use because measuring on angiography is not accurate in these cases.
Finally, they discuss the Supera and BioMimics stents, including the indications, benefits, and ease of deployment of each. Dr. Rundback says that Supera, a woven nitinol stent, gives it the benefit of thermal memory. The difficulty with this stent is the need for aggressive vessel preparation and plaque modification, generally requiring lengthy angioplasty and possibly atherectomy. The BioMimics stent can rotate, curve, and shorten, which is optimal for this region to maintain swirling or helical blood flow rather than causing turbulent flow. The BioMimics stent is also very easy to deploy, and Dr. Rundback generally chooses this stent in locations where he can’t adequately prep the vessel.
RESOURCES
BioMimics 3D stent: https://www.veryanmed.com/international/products/biomimics-3d-vascular-stent-system/
Supera™ Stent: https://www.cardiovascular.abbott/int/en/hcp/products/peripheral-intervention/supera-stent-system/overview.html
Tack device: https://www.usa.philips.com/healthcare/product/HCIGTDTCKESYSTM/tack-endovascular-system-dissection-repair-device
In this episode, host Dr. Jacob Fleming interviews Dr. Douglas Beall, interventional radiologist, about extravertebral augmentation, new technology in interventional spine, and intrathecal drug pumps.
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In this episode, host Dr. Jacob Fleming interviews Dr. Douglas Beall, interventional radiologist, about extravertebral augmentation, new technology in interventional spine, and intrathecal drug pumps. This is the final installment of our 4-part BackTable VI series on osteoporosis treatment.
We begin by discussing insufficiency fractures outside of the vertebral body. Dr. Beall discusses how he has treated insufficiency fractures of the pelvis, sacrum, acetabulum, tibia, and calcaneus. He prefers to use a combination of rebar screws and cement, and he enjoys finding innovative solutions for patients without good options for pain relief. He discusses how he recently used this technique for an SI joint fusion.
Next, we discuss two exciting innovations that will propel the field of interventional spine forward in the coming years. First, they discuss disc augmentation with hydrogels such as PVA (polyvinyl alcohol), PEG (polyethylene glycol), and PVP (polyvinyl povidone) which can be used to augment the annulus and nucleus without any requirement for ablation or regeneration. Secondly, Dr. Beall discusses the possibilities of interspinous process devices such as the Minuteman® fusion device. He hopes that technology is moving from spacers (the current method) to anterior column support. He believes that this is possible via Kambin’s Triangle (the space between the exiting nerve root, superior articular process, and transverse process).
Finally, we discuss Dr. Beall’s newest book, ‘Intrathecal Pump Drug Delivery’. He attributes the small number of IRs doing this procedure to a lack of familiarity and a “how-to guide”. For this reason, he published his book, which includes types of medications used in intrathecal pumps, medication concentrations, trialing doses, and how the pump is used. He welcomes all IRs interested in learning how to incorporate intrathecal pumps into their practice to reach out to him and follow him on social media to keep up to date on training courses and webinars about this topic.
RESOURCES
Dr. Douglas Beall LinkedIn: https://www.linkedin.com/in/douglas-beall-604ba68
Dr. Douglas Beall Twitter: @DougBeall
Minuteman® interspinous-interlaminar fusion device: https://spinalsimplicity.com/minuteman/
Douglas Beall Books: Intrathecal Pump Drug Delivery Vertebral Augmentation: The Comprehensive Guide to Vertebroplasty, Kyphoplasty, and Implant Augmentation
In this episode, host Dr. Jacob Fleming interviews Dr. Douglas Beall, interventional radiologist, about the latest advances in vertebral augmentation, how to reduce complications, and tips for producing successful and sustainable outcomes.
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In this episode, host Dr. Jacob Fleming interviews Dr. Douglas Beall, interventional radiologist, about the latest advances in vertebral augmentation, how to reduce complications, and tips for producing successful and sustainable outcomes. This is the third installment of our 4-part BackTable VI series on osteoporosis treatment.
Dr. Beall begins by discussing the newest technique in the treatment of vertebral compression fractures, screw-assisted vertebral augmentation, with emphasis on how it can decrease the excessive vertebral motion induced by a fracture. He uses the three-column approach (anterior, middle, and posterior column) using SpineJack in the front and pedicle screws in the back. They also discuss vertebral body stents and shaped balloons, two emerging technologies that will be available soon.
Next, they discuss complications in kyphoplasty and vertebral body augmentation. Dr. Beall shares how to recognize various types of cement extravasation. Importantly, if the cement starts to form a lenticular shape, stop injecting because continued injection will cause the cement to enter the spinal canal. The lenticular, biconvex shape that occurs with this pattern is due to the anterior epidural ligaments and midline anterior epidural ligament. He says to let the cement harden in the anterior epidural space once you reach the basivertebral plexus, and then continue injecting. Extravasation, to some degree, is normal, and recognizing where it is going is the key to avoiding complications.
We end by discussing how to improve outcomes. Dr. Beall says that injecting more cement is the best way to produce better outcomes. Lastly, he adds that filling the cleft is the best way to achieve the greatest degree of pain reduction, which ultimately is what indicates a successful outcome.
RESOURCES
Dr. Douglas Beall Twitter: @DougBeall
BackTable VI Episode 94, Innovation in Spine Interventions with Dr. Douglas Beall: https://www.backtable.com/shows/vi/podcasts/94/innovation-in-spine-interventions
Cianfoni publication on Stent-Screw-Assisted Internal Fixation (SAIF): https://jnis.bmj.com/content/11/6/603
Venmans publication on Pulmonary Emboli during Vertebroplasty: www.ajnr.org/content/29/10/1983
In this episode, host Dr. Jacob Fleming interviews Dr. Douglas Beall about current osteoporosis diagnosis criteria, his treatment algorithm, and recent data showing efficacy of osteoanabolic agents and vertebroplasty.
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In this episode, host Dr. Jacob Fleming interviews Dr. Douglas Beall about current osteoporosis diagnosis criteria, his treatment algorithm, and recent data showing efficacy of osteoanabolic agents and vertebroplasty. This is the second installment of our 4-part BackTable VI series on osteoporosis treatment. As we continue our conversation from Ep. 208, Dr. Beall outlines his typical follow up protocol for his patients. This includes DEXA scans in the first and second years, prescriptions for antiresorptive and/or osteoanabolic agents, and possible Romosozumab injections. Dr. Beall emphasizes that thoroughness is key to treating the disease process, and each encounter is a reimbursable event that can benefit both the patient and the practice.
Next, we shift to talking about the American Association of Clinical Endocrinologists (AACE) diagnostic criteria for osteoporosis. Dr. Beall highlights the fact that there are 4 categories that encompass information about DEXA (T-scores), FRAX scores, and fragility fractures. Sole reliance on DEXA score cutoffs can lead to under-diagnosis and increased mortality risk for patients. Notably, any past fragility fracture in a postmenopausal woman is sufficient for an osteoporosis diagnosis. Dr. Beall shares that 82% of patients with fragility fractures do not have T-scores in the osteoporotic range. On the other hand, there are confounding factors that can give a falsely elevated T-score.
As we shift to discussing medications for osteoporosis, Dr. Beall emphasizes the need to consider the order in which they are prescribed. He advocates for initially using osteo anabolics (specifically a PTH analog) for 2 years to build up bone mineral density, and then maintaining that density with antiresorptives afterwards. He notes that with the risk of bisphosphonate side effects like osteonecrosis of the jaw and atypical femur fracture, it is unwise to prescribe these antiresorptives as an initial treatment.
Finally, we begin the conversation about vertebroplasty and recent trials proving its efficacy in reducing pain and improving function for patients. Tune in to our next 2 installments to learn about Dr. Beall’s clinical pearls for vertebral augmentation!
RESOURCES
Dr. Douglas Beall Twitter: @DougBeall
BackTable VI Episode 94, Innovation in Spine Interventions with Dr. Douglas Beall: https://www.backtable.com/shows/vi/podcasts/94/innovation-in-spine-interventions
Comparison of thoracolumbosacral orthosis and no orthosis for the treatment of thoracolumbar burst fractures: interim analysis of a multicenter randomized clinical equivalence trial (2009): https://pubmed.ncbi.nlm.nih.gov/19769510/
Comparative study of the treatment outcomes of osteoporotic compression fractures without neurologic injury using a rigid brace, a soft brace, and no brace: a prospective randomized controlled non-inferiority trial (2014): https://pubmed.ncbi.nlm.nih.gov/25471910/
The efficacy of conservative treatment of osteoporotic compression fractures on acute pain relief: a systematic review with meta-analysis (2015): https://pubmed.ncbi.nlm.nih.gov/25725810/
Clinical effect of balloon kyphoplasty in elderly patients with multiple osteoporotic vertebral fracture (2019): https://pubmed.ncbi.nlm.nih.gov/30837413/
In this episode, host Dr. Jacob Fleming interviews Dr. Douglas Beall about the importance of interventional radiologists stepping up to address the entire picture of osteoporosis and taking the initiative to treat the underlying cause of the disease.
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In this episode, host Dr. Jacob Fleming interviews Dr. Douglas Beall about the importance of interventional radiologists stepping up to address the entire picture of osteoporosis and taking the initiative to treat the underlying cause of the disease. This is the first installment of our 4-part BackTable VI series on osteoporosis treatment.
Dr. Beall starts by stating his mission: he not only performs vertebral augmentation; he also offers DXA scans and T-score analysis, prescribes osteoanabolic agents, and follows up with patients over time. Dr. Beall cites data showing that both vertebral augmentation and osteoporosis medications can improve patients’ quality of life and significantly reduce mortality.
Even with newer osteoanabolic agents like Teriparatide, Abaloparatide, and Romosozumab being approved for treatment, osteoporosis screening rates have dropped in recent years. This is a pressing concern, since osteoporosis is a growing societal burden, given the increasing population of elderly patients. Furthermore, treatment of osteoporosis allows patients to regain mobility, which reduces comorbidities. We finish this episode by discussing how IRs have the potential to learn about osteoanabolic medications, counsel patients, and take ownership of this disease process.
RESOURCES
Dr. Douglas Beall Twitter: @DougBeall
BackTable VI Episode 94, Innovation in Spine Interventions with Dr. Douglas Beall: https://www.backtable.com/shows/vi/podcasts/94/innovation-in-spine-interventions
Number Needed to Treat with Vertebral Augmentation to Save a Life: http://www.ajnr.org/content/early/2019/12/19/ajnr.A6367 Risk of Mortality Following Clinical Fractures: https://pubmed.ncbi.nlm.nih.gov/11069188/
Prospective and Multicenter Evaluation of Outcomes for Quality of Life and Activities of Daily Living for Balloon Kyphoplasty in the Treatment of Vertebral Compression Fractures: The EVOLVE Trial: https://journals.lww.com/neurosurgery/Fulltext/2019/01000/Prospective_and_Multicenter_Evaluation_of_Outcomes.20.aspx
En este episodio de BackTable, Dra. Gina Landinez habla con el Dr. Alejandro Mejia, cirujano trasplante de Methodist Dallas, y la Dra. Pilar Bayona, radiologista intervencionista de UT Southwestern, sobre la colaboración entre los cirujanos trasplantes y los radiólogos intervencionistas durante los trasplantes de hígados. Hablan sobre el papel de los radiólogos intervencionistas durante los periodos críticos de trasplante: el preoperatorio, el perioperatorio, y el postoperatorio.
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We talk with interventional cardiologist Dr. Gary Ansel about his career in medical device innovation, including the development of the Ansel Guiding Sheath and the Pounce Thrombectomy System (which was recently acquired by Surmodics, Inc.).
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In this episode, our host Dr. Bryan Hartley interviews interventional cardiologist Dr. Gary Ansel about his career in medical device innovation, including the development of the Ansel Guiding Sheath and the Pounce Thrombectomy System (which was recently acquired by Surmodics).
Dr. Ansel describes his early career and how he identified a clinical need within the realm of renal stenting. His collaboration with Cook Medical evolved into a guiding sheath that has now become widely popular. Dr. Ansel stresses the importance of ensuring that a device has a value proposition for all stakeholders– patients, doctors, hospitals, and payers. The added cost of a new device must provide overall benefits to the procedure.
Next, we discuss Dr. Ansel’s development of a percutaneous thrombectomy system over the course of twelve years, multiple patent applications, and various obstacles. Throughout this process, Dr. Ansel highlights the benefits of having the expertise of a knowledgeable business team. He also tells new entrepreneurs to focus on de-risking their ideas with patents and early sales, in order to make their offerings more attractive to potential investors and acquirers.
RESOURCES
Ansel Guiding Sheath: https://www.cookmedical.com/products/dfdfc483-b37b-49f2-8a78-937bf16ae831/
Pounce Thrombectomy System: https://pouncesystem.com/
As part of our Health Equity Series Dr. Vishal Kumar talks with Shane Snowdon about current challenges in healthcare for LGTBQ+ patients, how we can improve communication, reduce fear and misunderstanding, and be a true patient advocate, starting with our own education.
SHOW NOTES
In this episode, guest host Dr. Vishal Kumar and educator/advocate Shane Snowdon discuss unique barriers to care for LGBTQ+ individuals, as well as strategies for healthcare providers can create nonjudgemental environments for this community.
Shane starts by outlining the history of LGBTQ+ healthcare in the United States, noting that it first came to public attention in the midst of the HIV/AIDS epidemic of the 1980s. In the 2020s, the major concerns for LGBTQ+ health access have been centered around gender-affirming care for youths and adults. Shane emphasizes that the process of coming out to healthcare providers empowers LGTBQ+ individuals to “claim an identity that they had been taught to dispense and conceal.” The concern is that when they become known as LGBTQ+, will the provider and system treat them and their families with the respect and care with which they treat people who do not identify as LGBTQ+? Shane says that discrimination in healthcare makes it more likely for patients to delay their screenings and follow up appointments, leading to less engagement in care and worse medical outcomes.
Next, we shift to discuss specific patient-provider communication techniques. Shane addresses the fact that there will be moments when providers make the mistake of misgendering patients. Shane advises providers to acknowledge the mistake in the moment, apologize, and affirm the patient’s self identity. This well-meaning approach can help build trust and give the provider an opportunity to specify the patient’s preferred identifiers in the electronic health record. Furthermore, we discuss the unique role of the radiologist in providing LGBTQ+ care, as it is often radiologists who learn that someone is transgender, through imaging. Radiologists can reach out to the patient in a sensitive and respectful way and notify their colleagues of the need for clarification in the electronic medical record.
Finally, we discuss healthcare systems and the need for foundational policies, integrated education about LGBTQ+ patients across all healthcare topics, and adequate resources for LGBTQ+ staff and patients. Shane highlights the Healthcare Equality Index, a specific tool that healthcare systems can use to self-assess their level of health equity and learn additional strategies to make their care more LGBTQ+-friendly.
RESOURCES
Healthcare Equality Index: https://www.hrc.org/resources/healthcare-equality-index
Transgender Patients: What Radiologists Need to Know: https://pubmed.ncbi.nlm.nih.gov/29629811/
Physicians as Political Pawns– The Texas Directive on Gender-Affirming Care and Other Moves: https://www.nejm.org/doi/full/10.1056/NEJMp2203746
Affordable Care Act, Section 1557: https://www.hhs.gov/civil-rights/for-individuals/section-1557/index.html
The Trevor Project: https://www.thetrevorproject.org/
Gender Spectrum: https://genderspectrum.org/
The Joint Commission’s LGBTQ+ Field Guide: https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/health-equity/lgbtfieldguide_web_linked_verpdf.pdf?db=web&hash=FD725DC02CFE6E4F21A35EBD839BBE97&hash=FD725DC02CFE6E4F21A35EBD839BBE97
Transgender and Gender Diverse Health Care: The Fenway Guide: https://www.amazon.com/Transgender-Gender-Diverse-Health-Care-ebook/dp/B09648R5HG
Dr. Karen Brown explains how she improved paracentesis workflow by creating a service that has shortened procedure time, decreased hospital length of stay, and improved patient and referring provider satisfaction.
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In this episode, host Dr. Aaron Fritts interviews Dr. Karen Brown, Section Chief for Interventional Radiology at the University of Utah about how she improved workflow by creating a paracentesis service that has shortened procedure time, decreased hospital length of stay, and improved patient and referring provider satisfaction.
Dr. Brown begins by reviewing the standard workflow for performing paracentesis before implementing her new program. She says paracentesis used to be done in a procedure room, and would often take quite long, delaying other procedures that were a better use of the room. Though a simple procedure, paracentesis can take quite some time to fully drain the ascites.
Dr. Brown and colleagues conducted a trial that compared standard wall suction to the Renova pump. Patients preferred Renova due to less capturing of bowel and adjusting of the catheter. They found that by using the Renova pump, they could cut the procedure time down by almost half. She says that hiring an advanced practice provider (APP) that was designated to paracentesis was key to improving the efficiency of the daily IR workflow. The other advantage to Renova is its portability. She says that this helped her get paracenteses out of procedure rooms because the APP can now do paracenteses anywhere, even at the bedside for an inpatient.
We end by discussing recommendations for IRs who are interested in improving efficiency in their practices. Dr. Brown says that the key is to make the case to administrators or purchasers that procedure room time is money. By speeding up the process for paracentesis, she has also been able to increase the number of paracenteses they do per year and decrease hospital length of stay for patients who are waiting for a paracentesis before discharge, which has saved both time and money.
RESOURCES
Dr. Brown’s publication in Diagnosic and Interventional Radiology: https://www.dirjournal.org/en/paracentesis-faster-and-easier-using-the-renovarp-pump-132424
RenovaRP® Paracentesis Pump: https://www.gi-supply.com/products/paracentesis-management/renovarp-pump/
In this episode Vascular Surgeon Jim Melton and Interventional Radiologist Blake Parsons give us the lay of the land on recent reimbursement cuts in the OBL/ASC space, including peripheral artery disease treatments and embolization procedures, as well as projections of what to expect in the next few years.
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In this episode, host Dr. Aaron Fritts interviews interventional radiologist Dr. Blake Parsons and vascular surgeon Dr. Jim Melton about navigating recent Medicaid reimbursement cuts in their hybrid Office Based Lab (OBL) and Ambulatory Surgery Center (ASC), CardioVascular Health Clinic. This episode largely follows a question and answer format, where our guests respond to previously-submitted audience questions.
The guests start by outlining recent vascular surgery and interventional radiology reimbursement cuts from 2022, as well as sharing information on future cuts through 2026. Most cuts are PAD-focused, but they also include pain management procedures like kyphoplasty. Dr. Parsons advises IRs to think about diversifying their practices to encompass procedures outside of PAD. He summarizes the average profits generated in various types of IR cases. He also predicts that there will be more reimbursement cuts on embolization cases, as prostate and geniculate embolizations become more popular. To protect profit margins by means of cost reduction, the doctors negotiate with vendor pricing and try to leverage disposables against capital.
Dr. Melton describes the current political landscape and physician advocacy efforts. While industry has started to position themselves to help advocate for OBLs and ASCs, Dr. Melton believes that industry and physicians should be more politically active. He encourages physicians to get involved with their medical societies and reach out to local representatives and senators in order to highlight the benefits of patient care in an OBL/ASC setting– faster recovery, lower risk of infection, and overall lower cost for the healthcare system.
RESOURCES
CardioVascular Health Clinic: https://cvhealthclinic.com/
SIRPAC: https://www.sirweb.org/advocacy/sirpac/
OEIS: https://oeisociety.com/
We talk with interventional radiologist Dr. Stephen Wang about building an IVC filter retrieval program, the current guidelines on filter placement, and how to minimize the complications of filters.
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In this episode, host Dr. Christopher Beck interviews interventional radiologist Dr. Stephen Wang. They discuss building an IVC filter retrieval program, the current guidelines on filter placement, and the long-term risks of IVC filters.
We start by discussing the joint consensus published in JVIR in 2020, a collaboration between vascular, cardiology, and IR societies. Dr. Wang notes that the main indication for placement of an IVC filter is an acute deep venous thrombosis (DVT) or pulmonary embolism (PE) in someone with a contraindication to anticoagulation. He says that they often collaborate with hematology to provide the best patient care, and they have even collaborated with hematology to set up a filter clinic.
Next, they touch on the long-term risks of IVC filters. They discuss the PREPIC-1 and PREPIC-2 studies which were studies looking at mortality and risk reduction in patients with IVC filters. These studies demonstrated a low level of evidence that IVC filters being placed were actually working. Even more compelling, the risk of putting in filters often outweighs the benefit. Dr. Wang says that for a filter that is in for longer than five years, there is a 13% risk of partial or complete inferior vena cava (IVC) thrombosis. Additionally, at five years, 70% of filters perforated outside of the IVC and were touching or perforating a retroperitoneal structure.
Finally, they discuss the filter retrieval program that Dr. Wang built at Kaiser. Important aspects of the process were educating primary care doctors, coordinating with critical care and hematology, and involving the anticoagulation clinic. He says he created a current procedural terminology (CPT) code-based list and hired a physician extender as filter lead to monitor and update the list. He was able to get his EPIC team on board by creating a safety net based on a procedural code. Ultimately, he raised the IVC filter retrieval rate from 38% in Northern California to 54% after his grand rounds and up to 80% after integrating his program into EPIC which allowed a provider to click a single button that would notify the patient that they were due to come in for their IVC filter retrieval.
RESOURCES
SIR Clinical Practice Guidelines for IVC Filters: https://www.jvir.org/article/S1051-0443(20)30531-5/fulltext
PREPIC-1: https://www.nejm.org/doi/full/10.1056/NEJM199802123380701
PREPIC-2: https://jamanetwork.com/journals/jama/fullarticle/2279714
Dr. Wang’s paper: Long-term complications of inferior vena cava filters: https://www.jvsvenous.org/article/S2213-333X(16)30148-2/fulltext
Eric J. Keller talks with Isabel Newton, Susan Jackson and Margaret Simor from the Interventional Initiative about informed consent and helping patients make informed choices with newly developed Patient Decision Aids!
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In this episode, our host Dr. Eric Keller interviews a panel of leaders from the Interventional Initiative, a not-for-profit organization devoted to raising awareness of minimally invasive image-guided procedures (MIIPs) among patients and referring clinicians. Our guests are interventional radiologists Drs. Susan Jackson and Isabel Newton and nurse and hospital administrator Margaret Simor.
We start by discussing the origins of the Interventional Initiative, which started in 2015. After recognizing the public’s knowledge gap within interventional radiology procedures, the team decided to embark on a docuseries project to capture the impact that the field of IR could have on patients’ lives. This docuseries, entitled “Without a Scalpel,” is available on many streaming platforms. The series follows interventional radiologists and their patients in a variety of procedures and medical settings. Presenting new information within a film format has created a welcoming introduction to the field for both patients and physicians.
Next, we shift to discussing the Interventional Initiative’s most recent project, a collection of patient decision aids. These materials are unique because they are specifically crafted to meet health literacy levels in the general public. They also provide statistics and graphics that clearly communicate benefits, risks, and alternatives to IR procedures. Ms. Simor, speaking from the experience of an IR nurse, recognizes the knowledge gaps that patients struggle with when giving informed consent. She looks forward to sharing the decision aids with other providers. Dr. Jackson advocates for presenting the decision aids in a variety of formats (paper, online, app-based, EHR-accessible) so that they are most available to as many people as possible.
Dr. Newton describes the success of early clinical trials, which show that using the patient decision aids enriches physician-patient conversations, enhances patient autonomy, and even makes patients perceive that they spent more time with the physician. She encourages anyone who is interested in helping beta test the decision aid to reach out to the Interventional Initiative.
RESOURCES
The Interventional Initiative: https://www.theii.org/
The Interventional Initiative Twitter: @Interventional2
Without a Scalpel Docuseries: https://www.theii.org/the-docuseries
Vascular Surgeon Krishna Mannava and Vive Vascular VP of Operations Kristin Longwell give advice on staffing the OBL/ASC based on their experiences over the last few years, including the essentials positions to start with, whether or not to use consulting firms, and sourcing your staff.
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In this episode, host Dr. Aaron Fritts interviews vascular surgeon Dr. Krishna Mannava and Kristin Longwell, vascular technologist and VP of operations and from Vive Vascular. They discuss staffing in the office based lab, cultivating company culture, and how to recruit and retain good employees.
We begin by discussing where to start with staffing when building your office based lab (OBL). First, you must determine what needs to be in house and what will be outsourced. They had help from a consulting firm that helped with hiring, the interview process, and establishing human resources policies. They began with two registered nurses (RNs), two radiologic technologists (RTs), one ultrasound technologist and one front desk operator. Dr. Mannava says he needs one RN to run a room and one for pre and post op. Similarly, he needs one RT to run the C-arm, and one helping tableside. Out of house needs are extensive and include billing, legal, IT, housekeeping, web development, and purchasing.
Next, they discuss some challenges of running an OBL. They approached growth by maintaining open communication with their employees. All employees are hourly and have concrete schedules. Many are willing to work outside of their job definition to help out wherever needed during a day. Every afternoon, they have one RN and one RT work late, and they rotate through this schedule so everyone can maintain work life balance.
Finally, they discuss company culture. Dr. Mannava explains that one year into their venture, they had a company retreat to revamp their mission which helped personalize it and was empowering for the employees. He believes that employees are customers, and he wants his employees to feel valued and excited about work. This helps with retention and ultimately saves money by avoiding high turnover. Kristen implemented a daily huddle, weekly updates, monthly operational meetings and annual retreats to keep employees engaged and ensure staff are all on the same page. Dr. Mannava ends by saying that he tries to instill a sense of gratitude at his workplace and he believes that it is his job to promote the work culture he wants in a top down fashion.
RESOURCES
VIVE Vascular https://www.vivevascular.com
Outpatient Endovascular and Interventional Society (OEIS) 2022: https://oeisociety.com/meetings/2022-annual-meeting/
Dr. Vishal Kumar talks with special guest Dante D. King about some of the historical origins of health inequities, and persistent biases we see in our healthcare settings today. *Trigger Warning: Sexual assault is mentioned from 9:29-17:30.
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In this episode, guest host Dr. Vishal Kumar interviews educator and author Dante King about America’s history of black subjugation and persistent biases in our healthcare settings today.
First, Mr. King gives examples of historical case law and statutes that disenfranchised African Americans and placed them in derogatory and undignified positions. Some examples include the Fugitive Slave Act (1850), as well as various state laws that sought to claim ownership over black people and make sexually assault of black women legally permissible. A key court decision, Geroge v. State (1872) had ruled that rape was only considered a crime when committed against white women. We follow this thread of dehumanization of black women through modern day medicine, in which the maternal mortality rate reflects significantly higher rates in African American women.
Dr. Kumar highlights recent studies that show the presence of implicit bias, as well as its intergenerational effects. He notes that privilege involves more than just perks and benefits; it encompasses the lack of barriers and obstacles in society. He also encourages listeners to realize that healthcare providers deny the benefit of the doubt to certain populations, which results in harmful under-intervention or over-intervention.
RESOURCES
Dante King Website: https://www.danteking.com/
Dante King Twitter: https://twitter.com/danteking2020
The 400 Year Holocaust: https://www.amazon.com/400-Year-Holocaust-Americas-Psychopathic-Sociopathic-ebook/dp/B09Q9C43Z9
The Human Doctor Podcast: https://podcasts.apple.com/us/podcast/the-human-doctor/id1571000871
Yale Preschool Study: https://medicine.yale.edu/childstudy/zigler/publications/Preschool Implicit Bias Policy Brief_final_9_26_276766_5379_v1.pdf
Race and Intergenerational Economic Opportunity Study: http://www.equality-of-opportunity.org/assets/documents/race_paper.pdf
We talk with Dr. Reza Rajebi and Dr. Kavi Devulapalli about what constitutes a good job in interventional radiology, how to spot red flags when you're job searching, and when to pivot in your career.
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In this episode, host Dr. Aaron Fritts interviews interventional radiologists Drs. Reza Rajebi and Kavi Devulapalli about what constitutes a good job versus a bad job in interventional radiology including red flags to look for, the importance of mentorship and when to pivot in your career.
The three begin by discussing their training and various jobs they have held. Dr. Devulapalli took the first job he got out of residency, then worked with an interventional cardiologist building a multidisciplinary OBL. Now he does locums and teleradiology from home. Dr. Rajebi started in academics, then transitioned to private practice at a traditional IR and DR group. He is now at an OBL, now doing a mix of locums. Dr. Fritts currently does locums and DR in Dallas.
They discuss what makes an ideal IR job, as well as what leads to job dissatisfaction. They agree that the people you work with are the most important aspect of a good job. Supportive colleagues who share your vision and a pathway for professional growth are also key requirements. Job dissatisfaction in IR is often due to lack of autonomy, inability to build your practice, private equity buyouts such as paths to partnership, and politics such as hospital contracts. They discuss how to spot red flags when job hunting. Dr. Rajebi advises to be aware of false promises, to do robust research, and to ask like minded people what they think of the position.
They end by discussing when to pivot in a job you are unhappy with. Dr. Rajebi says not to pivot until you are sure you will get 3 out of 4 things that make an ideal job: location, salary, job satisfaction, and work life balance. Dr. Devulapalli shares his experience with job dissatisfaction and advice on mentorship, noting that you should not pivot too early or too often. He says that the moment you start having negative feelings about your job is when mentorship really matters. He advises to give it a year and use that time to reflect in order to pivot and find a better opportunity.
RESOURCES
Dr. Kavi Devulapalli’s blog: https://linemonkeymd.com/
Dr. Reza Rajebi’s paper on issues for the early career IR: https://pubmed.ncbi.nlm.nih.gov/33726963/
We talk with Dr. Luke Wilkins about his stenting algorithm for treating peripheral artery disease, including a step by step discussion of the decision tree when deciding whether or not to stent.
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In this episode, our host Dr. Aparna Baheti interviews interventional radiologist Dr. Luke Wilkins about his treatment algorithm for Peripheral Arterial Disease (PAD). This algorithm is linked below, under “Resources.”
Dr. Wilkins starts by explaining his treatment decisions for non-occlusive lesions. If the lesion is less than 10 cm he prefers to use directional atherectomy and percutaneous transluminal angioplasty (PTA). However, if the lesion is greater than 10 cm, directional atherectomy poses the risk of distal embolization, so he will only perform PTA. In both cases, he recommends using IVUS to evaluate the efficacy of the treatment and then proceeding with a drug-coated balloon (DCB) to prevent re-stenosis.
On the other hand, if the disease is occlusive, Dr. Wilkins first attempts to cross the lesion. This can be achieved by going through microchannels with a guidewire or boring through the occlusion with a crossing device. If the lesion is unable to be crossed, he attempts subintimal recanalization. We discuss spontaneous re-entry into the true lumen, as well as re-entry devices like the Outback and the Pioneer catheters. We also take a detour into the Subintimal Arterial Flossing with Anterograde-Retrograde Intervention (SAFARI) technique that can be used if re-entry is challenging. After crossing is complete, Dr. Wilkins evaluates vessel diameter. In his experience, vessels that are wider than 5 mm have better stent patency, so he will place a drug eluting stent. In vessels of smaller diameters, Dr. Wilkins relies on other approaches such as interwoven stents with smaller diameters, directional atherectomy, and Tacks (to treat dissection flaps).
Finally, Dr. Wilkins discusses medical management and follow-up care for PAD patients. He recommends dual antiplatelet therapy, smoking cessation, and if claudication was an initial concern, patient education on the importance of walking. He follows up with patients in 1, 6, and 9 months, and then annually. During each follow up appointment, he checks ABI, PVR, and arterial duplex for clinical improvement.
RESOURCES
PAD Stenting Algorithm Decision Tree: https://www.backtable.com/shows/vi/podcasts/200/pad-stenting-algorithm
TASC Guidelines: https://journals.sagepub.com/doi/10.1177/1358863X15597877?url_ver=Z39.88-2003𝔯_id=ori:rid:crossref.org𝔯_dat=cr_pub%20%200pubmed
Articles Mentioned: Schneider PA, Laird JR, Doros G, Gao Q, Ansel G, Brodmann M, Micari A, Shishehbor MH, Tepe G, Zeller T. Mortality not correlated with paclitaxel exposure: an independent patient-level meta-analysis of a drug-coated balloon. Journal of the American College of Cardiology. 2019 May 28;73(20):2550-63. Secemsky EA, Kundi H, Weinberg I, Jaff MR, Krawisz A, Parikh SA, Beckman JA, Mustapha J, Rosenfield K, Yeh RW. Association of survival with femoropopliteal artery revascularization with drug-coated devices. JAMA cardiology. 2019 Apr 1;4(4):332-40. Freisinger E, Koeppe J, Gerss J, Goerlich D, Malyar NM, Marschall U, Faldum A, Reinecke H. Mortality after use of paclitaxel-based devices in peripheral arteries: a real-world safety analysis. European heart journal. 2020 Oct 7;41(38):3732-9.
We talk with interventional radiologist Dr. David Prologo about minimally invasive pain interventions, multidisciplinary pain management, and how he built a successful pain practice.
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In this episode, host Dr. Michael Barraza interviews Dr. David Prologo, director of interventional radiology at Emory about minimally invasive pain interventions, multidisciplinary pain management, and how he created a booming practice that is well known by patients and providers nationally.
Dr. Prologo begins by discussing his training in obesity medicine and how his interests in pain management developed. He discusses his book, The Catching Point, which explores weight loss culture and the fault of society and medical providers in placing the blame on patients and the new options available in IR for weight loss. He says his interest in pain management was similar to his interest in obesity medicine. He was curious about how he could use his tools and skills as an IR to treat obesity and pain with minimally invasive procedures.
Next, they discuss how IR fits into the multidisciplinary team that plays a role in pain management. He explains that the combination of technology and an IRs position in the hospital makes them ideal for the job. He says a key is to maintain relationships with all other specialties by focusing initially on procedures that other specialties don't perform, in order to build rapport. He also notes that the procedures he performs result in rapid pain reduction and greatly decrease length of stay which is a huge incentive for hospitals and other specialties to seek out IR and make referrals.
Finally, the two discuss the types of patients Dr. Prologo treats, and the procedures he does. He divides patient population into neoplastic versus non neoplastic pain, and spine versus non spine pain. He sees 90% of patients in clinic for procedure planning. Dr. Prologo emphasizes the importance of advocating for patients and continuing to see them even if they do not need an IR procedure. He discusses his 8, 3, 3, 3 method for percutaneous cryoneurolysis and discusses the various outcomes he is able to achieve in pain reduction. Dr. Prologo minimizes non responders by doing test blocks, understanding central desensitization, and selecting patients for procedures appropriately.
RESOURCES
Interventional Cryoneurolysis: An Illustrative Approach: https://pubmed.ncbi.nlm.nih.gov/33308581/
Focused Cryo: https://gra.org/company/213/Focused_Cryo.html
Nantes criteria for pudendal neuralgia: https://pubmed.ncbi.nlm.nih.gov/17828787/
The Catching Point https://www.catchingpoint.com
David Prologo Website: https://www.drprologo.com/about
Interventional radiologists Dr. Shamit Desai and Dr. Saud Ahmed discuss the advantages of community training programs including practice building, resident and attending relationships, and diversity of job opportunities after training.
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In this episode, host Dr. Aaron Fritts interviews Dr. Shamit Desai and Dr. Saud Ahmed, interventional radiologists at Franciscan St. James, about advantages of community training programs including practice building, resident and attending relationships, and diversity of job opportunities after training.
The three begin by discussing current IR training pathways, and what Franciscan St. James offers. Dr. Ahmed is the PD for the early specialization in interventional radiology (ESIR) spot at their program, which has been running for three years. They have 3-4 radiology residents per year, and the diagnostic radiology residency is well established. There are no fellows there, which allows residents ample hands-on experience from the beginning of residency, and facetime with attendings.
Next, we discuss the advantages that a small community hospital affords. At their institution, both the IR department as well as the radiology residents have the opportunity to build rapport and trust with referring providers. This is how they are able to build the practice base that is often taken for granted at an academic institution. The community hospital also gives residents more clinical experience; they are taking the IR consults as first years, collaborating on clinical management and rounding with attendings.
Lastly, we discuss the benefit of an ESIR program compared to the integrated IR pathway. They discuss how the diagnostic radiology training is uncompromised which prepares trainees very well for job opportunities after training. They argue that having trained in a community setting makes you more marketable when applying for jobs, especially in private practice. The residents at St. James are prepared to go into practice with a broad diagnostic and interventional skill set, but also understand how to be efficient with procedures and build a practice, which is a huge advantage that is simply not taught at academic institutions.
RESOURCES
Franciscan St. James Radiology: https://www.franciscanradiology.com
SIR ESIR Program List: https://www.sirweb.org/learning-center/ir-residency/esir/
SIR Integrated IR Program List: https://www.sirweb.org/learning-center/ir-residency/integrated/
Vascular surgeon Dr. Martin Schroeder discusses the Covered Endovascular Reconstruction of Aortic Bifurcation (CERAB) technique for treating aortoiliac disease, including patient workup, procedure steps, and pitfalls to avoid with stent placement.
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In this episode, vascular surgeon Dr. Martin Schroeder and our host Dr. Sabeen Dhand discuss the CERAB (Covered Endovascular Reconstruction of Aortic Bifurcation) procedure with all of its steps, including planning, arterial access, recanalization, reconstruction. First, Dr. Schroeder emphasizes that CERAB is ideal for patients with TASC C and TASC D lesions. For planning purposes, he prefers CT angiogram to MRI, since CT is better at showing calcifications and previous stents. At this stage, he measures the intraluminal area. Next, he gains percutaneous ultrasound-guided groin access, and he uses a ProGlide preclose system. He takes an endovascular measurement of the aortic diameter and places a covered stent above the aortic bifurcation. Generally, Dr. Schroeder says that it is ideal to stent below the inferior mesenteric artery, but it can be covered if needed. He flares the proximal end of the stent in order to oppose the graft onto the aorta, create a seal, and prevent a Type I endoleak. Finally, Dr. Schroeder reviews the placement of the iliac stents, the last step in creating a new aortic bifurcation. He shares his 15/15 rule: aortic stent placed 15mm above the aortic bifurcation, and iliac stents placed 15mm within the aortic stent. His general CERAB tips include advancing the sheath before uncovering the stent, making sure that you are always in the intimal space, and staying calm and focused.
RESOURCES
Vascupedia CERAB Webinar: https://vascupedia.com/video/the-cerab-technique-from-a-to-z-part-1/
VBX Stent: https://www.goremedical.com/products/vbx
We talk with Interventional Radiologist Dr. Carin Gonsalves about how her practice built a multidisciplinary Pulmonary Embolism (PE) Response team, including where to start, developing efficient workflows, and obtaining the equipment you need for success.
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In this episode, hosts Dr. Michael Barraza and Dr. Aaron Fritts interview Dr. Carin Gonsalves, interventional radiologist, about building a pulmonary embolism response team (PERT) and the evolution of pulmonary embolism (PE) treatment including large bore suction thrombectomy devices and the importance of multidisciplinary effort in care of patients with PEs.
Dr. Gonsalves discusses how she came to be Division Director of the PERT program at Jefferson University, and her collaborations with Geno Merli, cofounder of the PERT Consortium. Her interest in advancing PE treatment stemmed from her years of performing pulmonary arteriography and catheter directed thrombolysis before the inception of suction thrombectomy devices. She discusses the difficulty she had in obtaining these new devices, and how after 11 months of discussions, the hospital agreed to purchase the necessary equipment to enable the PE response team.
She discusses how the PERT is activated when a patient presents with suspected PE. Her team is comprised of five subspecialties including IR, Pulmonary Critical Care, Vascular Surgery, Cardiothoracic Surgery, and Cardiology. She emphasizes how having a group of experts improves patient care by cutting down on critical decision time. She enjoys sharing the responsibility of evaluating treatment approaches based on the current literature and the diversity of experience in the group.
Finally, we discuss advances in technology for treatment of PE. Dr. Gonsalves enjoys the ease of use and wide range of clots she can treat including acute, subacute and chronic. These devices have been game changers for PE; many patients are poor surgical candidates and have contraindications to thrombolysis. They end by discussing novel uses of these devices that Dr. Gonsalves performs including removal of clot in transit (mobile clot in the IVC, SVC, RA or RV) and vegetations on the tricuspid valve or a pacemaker lead.
RESOURCES
The PERT Consortium: https://pertconsortium.org Inari PEERLESS RCT: https://www.inarimedical.com/peerless/ Inari FlowTriever: https://www.inarimedical.com/flowtriever/ Inari ClotTriever: https://www.inarimedical.com/clottriever-int/ Inari FlowSaver: https://www.inarimedical.com/flowsaver/ AngioVac: https://www.angiovac.com
Our hosts Dr. Aparna Baheti and Dr. Michael Barraza talk with Dr. Mina Makary about what constitutes a conflict of interest, and how we can reduce bias in research without stifling innovation.
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In this episode, our hosts Dr. Ally Behati and Dr. Michael Barraza interview Dr. Mina Makary about his recent article with the Applied Ethics in IR Working Group about physician conflicts of interest and disclosures in image-guided research publications.
Dr. Makary walks us through the study design. The analysis over one year of JVIR articles had two goals. Firstly, the study aimed to assess the prevalence of disclosures in US-based IR research. Additionally, the researchers inspected the level of agreement between disclosed financial relationships and open payment data for top-cited image-guided procedure research. Since 2013, the open payment data has been available on the CMS Open Payment database.
Key results showed that disclosures were reported in 29% of JVIR publications in 2019. When comparing reported versus actual financial relationships, it was found that 97% of researchers failed to disclose at least one active financial relationship. Furthermore, there was an average of $58k in undisclosed payments for each publication.
Finally, we discuss important takeaways from this study. While industry support is a necessary driver of IR device innovation and practice building, it can influence research agendas. Dr. Makary advises all IRs to be cognizant of the underreporting of financial relationships and how this could make authors implicitly or explicitly biased in their research. He advocates for the construction of an open global registry that automatically links payment information to research disclosures.
RESOURCES
Potential Bias in Image-Guided Procedure Research: A Retrospective Analysis of Disclosed Conflicts of Interest and Open Payment Records: https://pubmed.ncbi.nlm.nih.gov/34756998/
In Science We Trust? (A response to the above study): https://www.jvir.org/article/S1051-0443(21)01446-9/fulltext
CMS Open Payments Database: https://openpaymentsdata.cms.gov/
Dr. Vishal Kumar invites Tawny Newsome and Elaine Martin to the show to discuss how we talk about race, and the language of oppression.
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We begin by discussing the JAMA tweet from 2021, reading “No physician is racist, so how can there be structural racism in health care?”. Newsome relates this to arguments she hears often from the tech industry stating that algorithms and computers cannot be racist. She adds that humans created the programs and wrote the medical journals, which means that biases will be present, and that neither computers nor physicians are entirely objective, and both can indeed be racist.
Next, the three discuss the power of language, and the critical relationship of language and the biases we hold. Elaine Martin speaks to her experience as a nurse in San Francisco, and what she notices about the language that is used when interacting with patients. She reflects on how medical providers' choice of language can be dismissive or hurtful to patients. She shares experiences from her family members interactions with medical providers, and how she has learned to communicate with patients differently based on these experiences. They discuss a New York Times article by Rachel Gross about the linguistic origins of the pudendal nerve and its ties to patients with pudendal neuralgia who feel shame due to their condition.
Finally, our guests give advice to current medical trainees. They discuss how we can examine our current structures and systems and change them where we identify problems. They express their hope that future generations of medical providers will take the time to examine their biases and dismantle harmful and dismissive treatment of marginalized groups.
RESOURCES
Tawny Newsome's Instagram, Twitter: @trondynewman, Subscribe to Tawny's podcasts: @suboptimalpods Yo, Is This Racist? Instagram, Twitter: @yoisthisracist Elaine Martin LinkedIn: https://www.linkedin.com/in/elaine-martin-4b618128/ JAMA: https://jamanetwork.com/journals/jama Taking the 'Shame Part' Out of Female Anatomy by Rachel Gross: https://www.nytimes.com/2021/09/21/science/pudendum-women-anatomy.html Vishal Kumar, MD: https://radiology.ucsf.edu/people/vishal-kumar
Special guest The White Coat Investor James M. Dahle talks with Christopher Beck about where physicians can start when it comes to financial literacy, including common financial mistakes docs make when start practicing, a primer on mortgage rates, and tips on insurance.
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In this episode, White Coat Investor founder Dr. James Dahle and our host Dr. Chris Beck discuss strategies for physicians seeking to manage their personal finances and gain financial freedom.
First, Dr. Dahle explains the reasoning behind the famous quote, “live like a resident.” He explains that for an early career physician, their greatest wealth-building tool is their income. The income jump from residency to attending years can be extremely useful for quickly paying off student loans. Then, he moves on to discuss another way to resolve student debt, the Public Service Loan Forgiveness (PSLF) program. This option is ideal for physicians who have spent a significant amount of time working for a nonprofit institution (for example, during training and in academic medicine).
Dr. Dahle advises all physicians to reflect on their priorities when deciding where to allocate their assets. Possible categories could include retirement funds, 529 college savings funds, payment of high-interest debt, and emergency funds. We talk about the power of having a written plan to stay on track with financial goals and prevent ourselves from making rash decisions.
Next, we discuss different financial vehicles that can provide benefits for physicians. The “back door Roth IRA” strategy allows for yearly contributions to a tax-free retirement fund, even when a physician’s income exceeds the maximum limit for the conventional Roth IRA. Additionally, the funds in a Health Savings Account (HSA) can be used for investment, and then withdrawn at a later date, penalty-free. Dr. Dahle explains the difference between fixed rate and variable rate mortgages, noting that the latter is better for short-term loans because interest rates are unlikely to dramatically increase from year to year. Finally, Dr. Dahle covers the advantages of buying disability insurance as a way to protect physician income, especially for those working in procedural specialties.
RESOURCES
White Coat Investor: https://www.whitecoatinvestor.com/
White Coat Investor Podcast: https://www.whitecoatinvestor.com/wci-podcast/
White Coat Investor Email: editor@whitecoatinvestor.com
Passive Income MD: https://passiveincomemd.com/
Physician on FIRE: https://www.physicianonfire.com/
Vascular surgeon Krishna Mannava and Chas Sanders (founder of MARGIN) discuss their approach to choosing which disposables and devices to stock up on in the outpatient facility, and how to plan for supply chain issues.
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In this episode, host Dr. Aaron Fritts interviews Dr. Krishna Mannava, vascular surgeon and owner of Vive Vascular and Chas Sanders, founder and CEO of MARGIN, LLC about supply chain in an office-based lab (OBL), focusing on disposables and how to pivot amidst impending reimbursement cuts.
The three start by discussing how Dr. Mannava chose to source equipment when building his OBL. He was introduced to Chas Sanders of MARGIN through his advisory firm as they were looking at ways to approach vendors and build inventory. Chas advises against all inclusive packages with one company. Dr. Mannava states that MARGIN has not only helped him get good deals on equipment, but they have mediated relationships with companies and sales reps which has been crucial for him.
Next, they discuss supply chain issues and the impact on healthcare and Vive Vascular. Chas believes the best way to offset this is by not putting all your eggs in one basket. For an OBL, it is better to have a surplus of disposables and throw some out rather than cancel a surgery due to a backorder or recall. Chas shares his thoughts on Management Service Organizations (MSOs) for shared resources, stating that while they can be helpful with sourcing and pricing of supplies, an MSO takes around 10% of revenue which for many OBLs means paying for more than you need. They also discuss the future of multispecialty endovascular centers, and the potential for physician collaboration.
Finally, they discuss reimbursement cuts and how to compensate for this loss. Chas recommends reassessing products, evaluating procedure mix and looking at capacity, as these can all be adjusted to improve profits. Dr. Mannava adds that front desk personnel can help by ensuring insurance, coding and charges are accurate.
RESOURCES
Vive Vascular: https://www.vivevascular.com
MARGIN, LLC: https://www.margin.care
En este episodio de BackTable Español, Dra. Gina Landinez entrevista a Dr. Miguel Montero-Baker sobre la enfermidad arterial periférica y salvamento de extremidades en la comunidad latinoamericana.
In this episode of BackTable Español, Dr. Gina Landinez interviews Dr. Miguel Montero about peripheral arterial disease and limb salvage in the Latin American community.
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Los dos doctores discuten el camino de Dr. Montero-Baker a convirtirse en un Cirujano vascular enfocado en el salvamento de extremidades, su experiencia de construir un centro de preservación, y diferencias culturales entre los pacientes latinoamericanos y estadounidenses. Además Dr. Montero-Baker comparte sus consejos sobre sus técnicas, su equipo preferido, y como superó los retos institucionales para empezar un programa del salvamento extremidad. Finalmente, él enfatiza la importancia de la prevención y la educación del paciente sobre la enfermedad arterial periférica.
The two doctors discuss Dr. Montero's path to becoming an interventional radiologist focused on limb salvage, his experience building a preservation center, and cultural differences between Latin American and US patients. Additionally, Dr. Montero shares his advice on his techniques, his preferred equipment, and how he overcame institutional challenges to start a limb salvage program. Finally, he emphasizes the importance of prevention and patient education about peripheral arterial disease.
In this episode we talk with Dr. John Lipman about his journey to going solo and opening an Outpatient Based Lab (OBL) dedicated to minimally invasive women's interventions, including Uterine Fibroid Embolization (UFE). John also gives us advice on the importance of finding your Ikigai in practice, the secret to a long and happy career!
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In this episode, interventional radiologist Dr. John Lipman joins host Dr. Aaron Fritts to discuss how he came to be one of the first IRs to own an office-based lab (OBL) and how he decided to specialize in uterine fibroid embolization (UFE).
Dr. Lipman begins by discussing his path to independent practice. After training at Georgetown, Brigham and Women’s and Yale, he worked in a private practice in Atlanta. In 2004, after 14 years and a growing desire to be an independent IR, he found a hospital to partner with where he could work independently. He started with professional fees only before landing a 50/50 joint venture deal with the hospital. He installed an MRI and angio suite and used a retired ER for his recovery rooms.
In 2015 he opened his OBL, the Atlanta Fibroid Center. He was able to lease equipment and buy the real estate with loans and capital he had from his prior practice. He decided to specialize in uterine fibroid embolization for his practice rather than performing a variety of procedures. He says that ultimately, he decided to specialize in what he was most passionate about.
The two discuss how Dr. Lipman received enormous pushback and criticism from many who thought opening a center that only offered one procedure was impossible. He used the antagonism as fuel, and after consulting women's groups in Atlanta he opened an OBL that focused on quality and privacy. Dr. Lipman ends by discussing how OBLs are the future of medicine and that they are a method for physicians to take back ownership of medicine from hospital administrators and recover the patient physician relationship.
RESOURCES
Outpatient Endovascular and Interventional Society: https://oeisociety.com
Atlanta Fibroid Center: https://atlii.com/
In this episode, Interventional Radiologist Sabeen Dhand talks with Interventional Cardiologist S. Jay Mathews about novel techniques for arterial thrombectomy, including a discussion on using large bore devices, a variety of technique tips and tricks, and what's on the horizon for new devices/techniques.
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In this episode, interventional cardiologist Dr. S. Jay Mathews and our host Dr. Sabeen Dhand discuss various devices used in arterial thrombectomy, including large bore aspiration catheters, the preclose system, separators, and stentrievers.
Dr. Mathews clarifies the definition of “large bore” as a catheter that is 8 Fr or larger. He notes these devices face some resistance in the interventional community, due the belief that arteries may be size prohibitive. However, he notes that the pre-close systems make arterial closure very feasible. Large bore catheters are able to achieve higher aspiration force compared to smaller catheters. Dr. Mathews prefers to use the Lightning 7 or 12 systems from Penumbra because of their angled/atraumatic catheter tips and their flexibility in navigation.
In cases of highly organized thrombus, Dr. Mathews may use separators to break up the clot into smaller and more manageable parts. He also speaks about using filters to capture the clot, but always in conjunction with aspiration, to prevent distal embolization.
The doctors also discuss the role of thrombolysis. Although thrombolysis procedure time is shorter than that of thrombectomy, patients remain ischemic for longer, leading to more reperfusion symptoms. Before placing a lysis catheter, Dr. Mathews recommends re-establishing some flow and creating a channel for more effective delivery of tPA.
Finally, we talk about new research in thrombus morphology and how this will affect future innovation in ultrasonic energy and nano-magnetic particles.
RESOURCES
Penumbra Lightning Catheter: https://www.penumbrainc.com/indigo-lightning/
Noninvasive thrombectomy of graft by nano-magnetic ablating particles: https://www.nature.com/articles/s41598-021-86291-2
The episode begins by discussing the training of a sales rep, which includes learning customer relations, procedure and product details as well as the disease states and anatomy of procedures. Aaron Weeks discusses how a key aspect of sales is understanding product compatibility and knowing what alternatives are available.
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In this episode, Aaron Weeks, program manager at Cook Medical joins host Dr. Aaron Fritts to discuss what it takes to become a sales rep, qualities of a good sales rep, and how to establish customer rapport.
The episode begins by discussing the training of a sales rep, which includes learning customer relations, procedure and product details as well as the disease states and anatomy of procedures. Aaron Weeks discusses how a key aspect of sales is understanding product compatibility and knowing what alternatives are available.
The speakers discuss degrees and pay next, and Weeks clarifies that an MBA is not a requirement. He says around half of IR sales reps now were previously techs or nurses because they know the procedures well, making them great trainees and knowledgeable reps. Pay is variable, but often starts as a base salary when training, with quotas or other incentives added later on.
Next, the speakers discuss what qualities make a good sales rep and pitfalls to avoid on the job. Weeks notes the importance of emotional intelligence and being able to read the room. He notes that those who are easily frustrated or trying to make a quick sale will not be as successful. The speakers agree that one of the biggest strengths of a good sales rep is knowing their product's limitations and when to step away.
The speakers touch on the difficulties that COVID has placed on the job. Weeks discusses how he stays up to date on current products and techniques being used for the procedures he covers. He says podcasts, virtual society meetings and other digital media outlets have played a key role in this aspect of his job.
RESOURCES
JVIR Website: https://www.jvir.org
Salesforce Website: https://www.salesforce.com
Cook Medical Website: https://www.cookmedical.com
Aaron Weeks Linkedin: https://www.linkedin.com/in/aaron-weeks-753bb1
In this episode Dr. Kumar and Dr. Bennett discuss various levels of racism found in healthcare, and share allegories of racism as outlined by Dr. Camara P. Jones, including the gardeners tale.
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In this episode, guest host Dr. Vishal Kumar interviews Dr. Ayanna Bennett about how to train ourselves to recognize perpetuated health disparities within the medical system and how we can actively work to dismantle them.
The doctors first talk about understanding racism on an institutional level, which results in a “machine” that selectively delivers better and worse aspects of healthcare to different populations. Dr. Bennett emphasizes that every disease process shows race disparities not because of inherent biological differences in racial groups, but because of unequal frequencies and quality of contact with healthcare systems.
Throughout the episode, they reference the allegories of Dr. Camara Jones, a physician-epidemiologist and civil rights activist. These allegories provide a framework for discussing nature vs. nurture for health outcomes and also privilege defined as the lack of barriers to entry.
In terms of actionable steps that providers can take toward reducing health inequity, Dr. Bennett encourages us to learn and engage with the communities that they serve. She advises us to be “counter-stereotypical” and show interest in patients’ lives outside of the healthcare setting. Finally, she calls us to analyze the impact that our institutions have on maintaining the health of the community as a whole, rather than solely focusing on individual patients.
RESOURCES
The Gardener’s Tale Allegory by Dr. Camara Jones: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1446334/
Tedx Talk by Dr. Camara Jones: https://www.youtube.com/watch?v=GNhcY6fTyBM
Dr. Sabeen Dhand talks with Neurointerventionalist Dr. Ansaar Rai from about his approach to posterior circulation strokes, including patient selection, technique and devices, and pitfalls to avoid.
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In this episode, neurointerventional radiologist Dr. Ansaar Rai joins Dr. Sabeen Dhand to discuss posterior circulation stroke, including when to treat with thrombectomy, techniques, and advances in stroke research in recent years. They discuss factors to consider when deciding to treat posterior circulation strokes with thrombectomy. Dr. Rai reports that age is the most important factor, followed by comorbidities and severity of clinical symptoms. He discusses the variability in presentation of basilar artery strokes, ranging from mild ataxia to coma. He treats these aggressively with thrombectomy, especially for young patients. For isolated PCA strokes, he often treats with intra arterial TPA only.
Dr. Rai next discusses landmark clinical trials, as well as his own research looking at stroke burden. He found that 2% of all acute ischemic strokes occur in the posterior circulation. Importantly, he postulates that there will never be good posterior circulation trials due to lack of equipoise and difficulty in randomizing to a medical treatment only arm.
Dr. Rai uses general anesthesia for posterior circulation strokes. He prefers femoral access, and uses an 8Fr femoral short sheath and a guide catheter (ideally 088), rather than a balloon guide catheter. He then uses an 070 or 072 intermediate aspiration catheter navigated over an 024 microwire (Aristotle) or 027 microcatheter (Duo or XT-27) into the basilar. After trying many techniques, he prefers aspiration using the ADAPT technique. If he has to cross clot, he uses a stent retriever such as Trevo, Embotrap or Solitaire. Due to the delicate vasculature and high risk in posterior circulation thrombectomies, Dr. Rai always uses a J wire, biplane imaging and emphasizes that knowing the anatomy on CT is key to decreasing complications such as dissection or distal embolization.
RESOURCES
ASPECTS score: https://www.ahajournals.org/doi/10.1161/STROKEAHA.117.016745
Route 92 Medical SUMMIT MAX Clinical trial: https://evtoday.com/news/route-92-medicals-monopoint-reperfusion-system-studied-in-pivotal-summit-max-trial#:~:text=According%20to%20Route%2092%20Medical%2C%20SUMMIT%20MAX%20is,sites%20in%20the%20United%20States%20and%20New%20Zealand.
The Greater Cincinnati Northern Kentucky Stroke Study: https://www.gcnkss.com
MR RESUE trial: https://www.ahajournals.org/doi/full/10.1161/strokeaha.113.001443
IMS3 trial: https://evtoday.com/news/ims-3-substudy-shows-delays-in-stroke-treatment-leads-to-worse-outcomes#:~:text=IMS%203%20was%20a%20multicenter%20international%20trial%20in,received%20tPA%20within%203%20hours%20of%20stroke%20onset.
SWIFT PRIME trial: https://evtoday.com/news/covidien-commences-enrollment-for-swift-prime-acute-ischemic-stroke-study#:~:text=The%20SWIFT%20PRIME%20study%20will%20evaluate%20acute%20ischemic,will%20also%20include%20an%20extensive%20health%20economics%20analysis.
ADAPT technique trial by Turc: https://www.ahajournals.org/doi/10.1161/STROKEAHA.119.025753
BEST trial: https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(19)30395-3/fulltext#:~:text=The%20BEST%20trial%20was%20a%20multicentre%2C%20prospective%2C%20open-label%2C,the%20institutional%20review%20board%20of%20each%20participating%20site.
ATTENTION trial: https://pubmed.ncbi.nlm.nih.gov/35102797/
Dr. Fred Bertino educates us on anticoagulation regimens for patients after deep venous interventions.
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In this episode, pediatric interventional radiologist Dr. Fred Bertino joins our host Dr. Chris Beck to discuss new data on anticoagulation regimes before, during, and after venous stenting and/or mechanical thrombectomy.
Dr. Bertino starts by reviewing the difference between the compositions of arterial versus venous clots. Arterial clots are formed as a response to endothelial injury and exposure of von Willebrand factor, so these clots are usually platelet-rich. On the other hand, venous clots are formed due to stasis, and these are usually platelet-poor. Therefore, antiplatelet therapy may not be ideal for venous clots. However, Dr. Bertino notes that stent placement can cause endothelial injury at the apposition points of the stent, so the treatment algorithm can become more complex in these cases.
The doctors note that there are non-thrombotic diseases that require venous stenting, such as May Thurner syndrome. Dr. Bertino says that addressing this early in the pediatric population can be a safe way to prevent future DVT, as long as children are monitored carefully.
Next, Dr. Bertino walks us through his preferred anticoagulation routine for stent placement. Four hours before the procedure, he starts with a dose of Factor Xa inhibitor (apixaban or rivaroxaban) to prevent in-stent thrombosis. The patient is maintained on heparin during the procedure. After the procedure, anticoagulation varies depending on whether a stent was placed, or solely mechanical thrombectomy was performed.
Finally, the doctors discuss preferred anticoagulation for special scenarios such as covered stents (which can be more thrombophilic) and patients with malignancies. Dr. Bertino encourages IRs to reach out to their hematology colleagues to stay updated on anticoagulation research, as well as physical and occupational therapists to help patients form long-term DVT prevention plans.
RESOURCES
Find this episode on backtable.com to see the full library of resources mentioned by Dr. Fred Bertino.
Interventional Radiologist Dr. Preston Smith and healthcare attorney Patrick Souter join us to discuss strategies for navigating the legal world of non-compete agreements and exclusive contracts.
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First, we review the vocabulary and examples of each type of agreement. Mr. Souter emphasizes that contrary to popular misconceptions, non-compete agreements are enforceable, as long as they are reasonable in scope, geographic location, and time frame. Additionally, he calls attention to “backdoor noncompetes,” which are clauses that, while not officially called “noncompetes,” still restrict a physician’s ability to practice medicine in a certain location. These include non-circumvention and non-solicitation agreements. Dr. Smith advises listeners to be wary of any terms that seem far-reaching or unreasonable, and to have a legal professional review the terms of the agreement.
Next, we discuss exclusive contracts between large radiology practices and hospitals. While they are legal, they cannot be entered into for antitrust purposes of trying to prevent others from entering the marketplace. Exclusive contracts can serve as a barrier for independently practicing IRs to gain hospital privileges. Mr. Souter advises independent IRs to speak with hospital CMOs and provide reasonable explanations for why their services would be efficient and necessary for quality patient care.
We talk with Interventional Radiologist Dr. Sandeep Bagla about the challenges of clinical research in private practice, and the inspiration behind building a new practice paradigm in collaboration with Urology colleagues.
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In this episode, interventional radiologist and entrepreneur Dr. Sandeep Bagla joins our host Dr. Aaron Fritts to discuss the founding and multispecialty focus of Prostate Centers USA, a rapidly expanding network of office based labs (OBLs).
Dr. Bagla describes why he decided to shift away from his former private practice and embark on a new venture that would eventually become Prostate Centers USA. Dr. Bagla sought to focus on embolization, a novel area of interventional radiology. He recounts the process of conducting prostate artery embolization clinical trials in a private practice environment, including challenges encountered and lessons learned about changing FDA regulations.
Dr. Bagla developed Prostate Centers USA from a vision of collaboration with urologists to provide comprehensive procedural and clinical care. He describes how he pitched his collaborative approach to urologists and how he dealt with pushback. He also describes why the centers’ ownership structures and focused training pathways are attractive to physicians. Finally, Dr. Bagla highlights technologies that allow for ease of communication between the team members, such as task management systems and centralized monitoring systems.
RESOURCES
Ep. 164 Collaborative Approach to Prostate Artery Embolization (PAE) for BPH: https://www.backtable.com/shows/vi/podcasts/164/collaborative-approach-to-prostate-artery-embolization-pae-for-bph
Prostate Centers USA: https://www.prostatecentersusa.com/
Outpatient Endovascular and Interventional Society (OEIS) Annual Meeting: https://oeisociety.com/
Co-hosts Dr. Christopher Beck and Dr. Aaron Fritts discuss cholecystostomy tube placement for acute cholecystitis, including the pros and cons of different techniques, and pitfalls to avoid.
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In this episode, our hosts Dr. Aaron Fritts and Dr. Chris Beck compare their procedural techniques for placing cholecystostomy tubes.
They start the conversation by discussing patient workup. Dr. Beck always obtains an ultrasound and sometimes a HIDA scan. He also orders coagulation tests and checks if the patient is on anticoagulation medication in order to stratify the risk of the procedure and counsel the patient accordingly.
Next, the doctors discuss pros and cons of transhepatic and transperitoneal approaches. Dr. Fritts usually prefers a transhepatic approach because it minimizes the risk of biliary leaks. He also believes that it is easier to stick the gallbladder in an area where it is affixed to the liver. Dr. Beck emphasizes that the gallbladder is a dynamic organ, so doing this procedure under ultrasound with fluoroscopy will allow real-time visualization of the needle.
Finally, they consider different needle and drainage options. There are a variety of needles that can be used, including AccuStick, Yueh, and spinal needles. With drainage, the doctors highlight the differences between drainage bags and JP bulbs, noting that the former relies on drainage of infected bile by gravity, and the latter provides additional vacuum suction.
In this episode, our host Dr. Eric Keller interviews his longtime mentor, interventional radiologist Dr. Bob Vogelzang about the evolution of their mentor mentee relationship overtime and ways to create benefits for both mentors and mentees.
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A common idea throughout this episode is that no single definition of mentorship exists. Dr. Vogelzang highlights the importance of a flat structure, in which the mentee and the mentor feel comfortable to ask questions and explore an area of shared interest. Dr. Keller emphasizes the reality that mentoring relationships will grow and change with career development and geographic relocation.
Overall, both doctors agree that an effective mentoring relationship should be driven by feasible projects that motivate both parties.
Interventional Radiologist Dr. Chris Ingraham discusses his approach to treating solid organ and pelvic trauma, including embolization technique and IR's role in workflow efficiency for better trauma care.
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In this episode, interventional radiologist Dr. Chris Ingraham and our host Dr. Michael Barraza discuss the role of IR in the trauma setting and approaches to embolization for trauma to the spleen, liver, kidneys, and pelvis.
Dr. Ingraham outlines Harborview Medical Center’s workup of trauma patients and describes the collaboration between the emergency, trauma surgery, and interventional radiology departments. Although CT provides more comprehensive imaging, Dr. Ingraham says that taking a patient directly to an angiogram could address the trauma quicker and prevent more complications. He also speaks about empiric embolization, noting that extravasation can be intermittent and not visible on imaging.
Overall, Dr. Ingraham recommends over-sizing coils, since patients are usually hypotensive and vasoconstrictive during active bleeding. Vessel diameter will eventually increase as patients are resuscitated.
When embolizing the spleen, Dr. Ingraham emphasizes that the goal is to prevent the need for splenectomy, especially in young patients, because of its role in immunologic responses. He advocates for proximal embolization in order to decrease the blood flow into the spleen and allow for splenic lacerations to clot and heal.
In liver embolization, Dr. Ingraham notes that there could be a laceration to the liver’s venous system, and embolization of the arterial system could reduce the dual blood supply of the liver. In these patients, there can be a higher risk of necrosis and biliary injury.
Finally, we discuss follow up care with pulse exams and monitoring of hemodynamic stability.
RESOURCES
Balloons Up: Reduced Time to Angioembolization: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7903099/
SIR Trauma Guidelines, 2020: https://www.jvir.org/article/S1051-0443(19)30952-2/fulltext
Dr. Aparna Baheti talks with Dr. Timothy Huber about performing thyroid nodule ablation procedures, including patient selection, technique pearls and pitfalls, and how to incorporate the procedure into your practice.
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In this episode, interventional radiologist Dr. Tim Huber and our host Dr. Ally Baheti discuss the process of thyroid nodule radiofrequency ablation, including patient selection, workup, procedural technique, and follow up.
Dr. Huber describes the most common indication for ablation, which is the presence of benign thyroid nodules that cause compressive symptoms. These can affect quality of life when they restrict a patient’s ability to swallow, breathe, and speak. He recommends ablation for symptomatic nodules that are over 2 cm in diameter. Dr. Huber also mentions functional nodules as more challenging cases, but still treatable with ablation. Though ablation for thyroid malignancies is rare, it is a field of active and growing research.
In his workup, Dr. Huber uses ultrasound to assess nodular composition, vasculature, size, and nearby enlarged lymph nodes. Next, he obtains two benign fine needle aspiration samples and checks TSH levels before proceeding with ablation. During the procedure, he anesthetizes the skin of the neck with lidocaine, and periodically checks in with patients about pain level. Dr. Huber describes his “trans-isthmic approach” that keeps the needle as stable as possible. He exercises caution when ablating near the “danger triangle” containing the recurrent laryngeal nerve which innervates the vocal cords. While ablating posterior to anterior, Dr. Huber tracks echogenic changes on ultrasound.
After the procedure, patients are monitored for one hour and then followed up in one month, and then three months over the next year. Dr. Huber warns interventionalists that post-ablation zones may look disfigured on ultrasound, but this will revert back to normal within 3-6 months.
RESOURCES
European Thyroid Association Guidelines: https://www.eurothyroid.com/guidelines/eta_guidelines.html
Korean Society of Thyroid Radiology Guidelines: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6005940/
Vascular Surgeon Dr. Mazin Foteh and our host Dr. Sabeen Dhand consider various factors that can influence the choice of treatment methods for calcified common femoral artery (CFA) disease, including discussing the pros and cons of an endovascular vs surgical approach.
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Shockwave Medical https://shockwavemedical.com/?utm_source=CFA-Backtable-Podcast&utm_campaign=Backtable-Podcast
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In this episode, vascular surgeon Dr. Mazin Foteh and our host Dr. Sabeen Dhand consider various factors that can influence the choice of treatment methods for common femoral artery (CFA) disease.
To start, Dr. Foteh describes risk factors of common femoral disease, such as smoking, renal failure, and diabetes. He notes that CFA lesions are usually calcified and homogenous because they are composed of layers of calcium, lipid, and platelets deposited in fibrin sheaths. He further distinguishes between partially occluded and fully occluded CFA lesions.
Dr. Foteh reviews key tips to minimize complications during an open endarterectomy. To maximize exposure, he recommends making a longitudinal incision rather than a medial groin incision. Before closing, he also ensures that he checks 3-4 cm proximal and distal to the CFA and stents the external iliac artery if needed. Dr. Foteh opts for general anesthesia over local anesthesia, in case of unforeseen complications.
With an endovascular approach, Dr. Foteh finds that shock wave lithotripsy has been most effective at cracking calcium, changing vessel compliance, and ultimately increasing luminal gain. He uses this technique first, examines the results, and then uses a drug-coated balloon or stent as needed. Dr. Foteh emphasizes that lithotripsy is beneficial for the patient because it provides an additional avenue of endovascular treatment and it does not influence the outcome of future endarterectomies.
RESOURCES
Clinical Trial Investigating the Efficacy of the Supera Peripheral Stent System for the Treatment of the Common Femoral Artery: https://clinicaltrials.gov/ct2/show/NCT02804113
Interventional Radiologist Dr. Jonathan Gross and host Dr. Aaron Fritts discuss the results from his recent JVIR Media article on the quantifiable environmental impact of operating an interventional radiology practice for one week. Guess how many road trips around the world it equates to!?
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In this episode, interventional radiologist Dr. Jonathan Gross and our host Dr. Aaron Fritts discuss the results from Dr. Gross’s recent JVIR article on the quantifiable environmental impact of operating an IR practice for one week.
Dr. Gross begins by describing his lifelong interest in environmental sustainability. He developed the idea for this study because he recognized the discordance between his conscientious practices at home and his less sustainable practices in the IR suite. Dr. Gross acclimates us to vocabulary that is used in the article and defines the measurements of “life cycle assessment” and “volume of greenhouse gases.”
Many listeners will be surprised to find out that material waste makes up less than 2% of all greenhouse gas emissions in an IR suite. The majority of emissions is actually produced by air conditioning and air exchange systems, which frequently and unnecessarily run when IR suites are not being used.
Finally, Dr. Gross shares ways to reduce the environmental impacts of IR, such as installing motion-sensor lights, using re-processed equipment instead of single-use equipment, and streamlining procedure packs.
RESOURCES
The Environmental Impact of Interventional Radiology: An Evaluation of Greenhouse Gas Emissions from an Academic Interventional Radiology Practice: https://pubmed.ncbi.nlm.nih.gov/33794372/
Environmental Impacts of Abdominal Imaging: A Pilot Investigation: https://pubmed.ncbi.nlm.nih.gov/30158086/
Interventional Radiologist Donald Garbett and our host Sabeen Dhand discuss their standard workups and procedural decision making for GI bleeds, including radial vs. femoral approach and preferred embolics.
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In this episode, interventional radiologist Dr. Donald Garbett and our host Dr. Sabeen Dhand discuss their standard workups and procedural decision making for GI bleeds.
The doctors start by describing the workup. Dr. Garbett says that the majority of his cases are referred from GI, either when GI cannot find the bleed or cannot access the bleed because of excessive bleeding into the GI lumen. Dr. Garbett often uses triple phase CT angiography. He emphasizes the importance of doing triple phase, in order to distinguish between arterial bleeds and varices, as this difference will guide further treatment decisions.
In non-emergency situations, Dr. Garbett prefers transradial access. He discusses his use of various embolic agents such as glue and combination of both detachable and pushable coils. Dr. Dhand mentions newer embolics such as Onyx. He adds that he sometimes administers a low dose of glucagon to inhibit bowel movements.
Finally, the doctors share various pearls of wisdom for GI embolization, such as the advantages of provocative angiogram, treatment decisions when a patient is crashing, and variceal indications for balloon-occluded retrograde transvenous obliteration (BRTO) and transjugular intrahepatic portosystemic shunt (TIPS).
RESOURCES
Ep. 118 BRTO vs. PARTO in Gastric Variceal Bleeding: https://www.backtable.com/shows/vi/podcasts/47/brto-vs-parto-in-gastric-variceal-bleeding
YouTube Video: Embolization and Provocative Angiography in Lower GI Bleeds: https://youtu.be/0MESQkTG6hI
Interventional Neuroradiologist Dr. Hannes Nordmeyer and Biomedical Engineer Dr. Matt Gounis discuss compositions of tough clots, approaches to stroke thrombectomy, and bailout stenting.
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In this episode, interventional neuroradiologist Dr. Hannes Nordmeyer, biomedical engineering professor Dr. Matt Gounis, and our host Dr. Michael Barraza discuss compositions of tough clots, approaches for stroke thrombectomy, and bailout stenting.
Dr. Nordmeyer believes that interventionalists are still struggling to find the most effective method for pulling clots. He says that the use of double stent retrievers has shown high success rates, but it would be ideal to have one retriever that can work on its own. He describes his equipment setup for a standard large vessel occlusion. Dr. Nordmeyer notes clot location and behavior within the first two passes determines whether or not the operator should continue with the stent retrieval approach or change the approach.
Dr. Gounis evaluates various devices by defining “success” as achievement of TICI 3 with the first pass. He comments on the current development of very large bore aspiration catheters, such as the 088 Millipede catheter and the Tenzing catheter. He also emphasizes that the success of the procedure relies largely on the composition of the embolus. Fibrin-rich clots are less likely to integrate with the stent retriever. We discuss Dr. Nordmeyer’s technique, which utilizes a microcatheter and the NIMBUS device to pin and retrieve the challenging clot.
We also cover bailout stenting and the benefits of recanalization when clot removal is not possible.
RESOURCES
SWIFT DIRECT Trial: https://www.swift-direct.ch/the-swift-direct-trial/
Preclinical Evaluation of Millipede 088 Intracranial Aspiration Catheter: https://pubmed.ncbi.nlm.nih.gov/32606100/
The Novel Tenzing 7 Delivery Catheter Designed to Deliver Intermediate Catheters to the Face of Embolus Without Crossing: https://jnis.bmj.com/content/13/8/722
Factors Influencing Recanalization After Mechanical Thrombectomy With First-Pass Effect for Acute Ischemic Stroke: https://www.frontiersin.org/articles/10.3389/fneur.2021.628523/full
NIMBUS Geometric Clot Extractor: https://www.jnjmedicaldevices.com/en-EMEA/news-events/cerenovus-launches-nimbustm-geometric-clot-extractor-remove-tough-clots
Emergency medicine physician and podcast founder Dr. Gita Pensa and our co-hosts Dr. Chris Beck and Dr. Aaron Fritts discuss methods of navigating malpractice lawsuits, maintaining professional identity, and prioritizing mental health.
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In this episode, emergency medicine physician and podcast founder Dr. Gita Pensa and our co-hosts Dr. Chris Beck and Dr. Aaron Fritts discuss methods of navigating malpractice lawsuits, maintaining professional identity, and prioritizing mental health.
Dr. Pensa starts by outlining her personal experience with a twelve year-long malpractice suit, which inspired her to start her own podcast, “Doctors and Litigation: The L Word.” She says that despite the fact that most physicians will face lawsuits in their career, there is a current lack of physician-centered educational resources over malpractice litigation. To combat this, she encourages physicians to share their experiences and learn from one another.
The doctors walk through major steps of a lawsuit, starting with the process of getting served with papers. Dr. Pensa emphasizes that it is important to recognize that this step could be used as the first tactical move in a lawsuit and designed to make physicians feel uneasy. The next step after getting served should always be to call the insurance carrier and have them start the process of initiating a claim. Dr. Pensa strongly advises against accessing or editing patient charts after getting served, as these actions are recorded in the EMR and can be used against the physician. Finally, Dr. Pensa discusses the process of deposition and how it serves as both a fact-finding mission and a strategic way to distort a physician’s words. She recommends practicing with lawyers to answer deposition questions clearly and concisely.
Throughout the episode, the doctors highlight the importance of maintaining one’s mental health during the litigation process. They advise listeners to seek support from friends, family, colleagues, and professionals, as long as the specific details of the case are not discussed. To close, Dr. Pensa reminds the audience that malpractice lawsuits usually have financial motivations, and they may not be an accurate representation of a physician’s competence or compassion for patients.
RESOURCES
Doctors and Litigation: The L Word: https://doctorsandlitigation.com/
“The Defendant” by Sarah Charles: https://www.amazon.com/Defendant-Sarah-Charles/dp/0394746635
“Adverse Events, Stress, and Litigation” by Sarah Charles: https://www.amazon.com/Adverse-Events-Stress-Litigation-Physicians/dp/0195171489
“How to Survive a Medical Malpractice Lawsuit” by Ilene Brenner: https://www.amazon.com/How-Survive-Medical-Malpractice-Lawsuit-ebook/dp/B005C65X2M
“When Good Doctors Get Sued” by Angela Dodge and Steven Fitzer: https://www.amazon.com/When-Good-Doctors-Get-Sued/dp/0977751104
Dr. Aaron Fritts talks with mentor Dr. David Ball about dealing with complications throughout our professional career, including why physicians have trouble with it, and advice for what not to do when they happen.
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In this episode, interventional radiologist Dr. David Ball and our host Dr. Aaron Fritts discuss the inevitability of unforeseen procedural complications, strategies to navigate patient and family communication, and lessons to take away from these experiences.
To start, Dr. Ball recognizes the difficulty involved with addressing complications that cause patient injury, damage to physician reputation, and financial consequences. He emphasizes that it is therapeutic to speak about these outcomes with trainees and colleagues for learning purposes.
Dr. Ball shares complications stories from his career and describes key takeaways from each. He describes the benefits of forming good relationships with patients and families prior to starting the case, performing a thorough check of all risk factors before the first puncture, and taking responsibility for complications that arise during the case. Finally, he discusses the balance between taking accountability for complications and being vulnerable to malpractice lawsuits.
RESOURCES
BackTable Episode 154, Complications Survey Results (Podcast): https://www.backtable.com/shows/vi/podcasts/154/discussing-the-complications-survey-results
BackTable Episode 154 (Video): https://youtu.be/MuRISnu4gKU
CLI fighters Dr. Kumar Madassery and Dr. Sabeen Dhand discuss their approach to treating calcified arteries below the knee, including looking at newer technologies and choosing the appropriate device to effect real durable change to the calcified wall.
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In this episode, interventional radiologist Dr. Kumar Madassery and our host Dr. Sabeen Dhand discuss atherosclerosis in tibial vessels below the knee and devices for atherectomy, angioplasty, and dissection repair.
While non-invasive imaging for calcium is still lacking, Dr. Madassery encourages operators to look for calcium on X-ray and ultrasound. He believes that visualization with ultrasound will improve if there is greater collaboration and standardization across all operators. Next, Dr. Madassery differentiates between intimal and medial calcifications. He notes that medial calcifications usually present as “railroad tracks” in diabetic and end-stage renal failure patients, while intimal calcifications lead to plaque ruptures. Each type is distinguishable with the use of intravascular ultrasound (IVUS).
Dr. Madassery walks through his approach to calcified lesions. He says that using angiogram to identify whether a lesion is stenotic or occlusive is a crucial first step. He also emphasizes the importance of having a wire escalation strategy. The doctors highlight orbital and laser atherectomy, scoring balloons, and intravascular lithotripsy (IVL).
Finally, Dr. Madassery describes his perspective on arterial dissection, a common complication of balloon angioplasty. The decision to treat dissections is dependent on the operator, but he gives advice on weighing the pros and cons of treating. He speaks about the advantages of using the self-expanding Tack system to stent only specific problematic regions.
Dr. Aparna Baheti and Dr. Amy Taylor discuss the considerations around returning to academic interventional radiology after starting a career in private practice.
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In this episode, interventional radiologist Dr. Amy Taylor and our host Dr. Ally Baheti discuss factors that can facilitate the transition from private practice to academic medicine.
Dr. Taylor speaks about the course that her career has taken since she completed her fellowship. She highlights contrasts between the private and academic spheres, noting that each allows freedom in different aspects of the job. She encourages IRs to take sufficient time to evaluate their culture fit in their current roles before deciding to transition.
When navigating her transition back into academic medicine, Dr. Taylor notes that her former fellowship attendings provided strong support and advice. She advocates for normalizing conversations about career changes.
RESOURCES
SIR Foundation Research Grants: https://apply.sirfoundation.org/
In this Trainee Focus episode, guest host Sunny Murthy talks with Universtiy of Virginia program director Dr. Luke Wilkins about what it takes to become an interventional radiology resident, including tips on finding the right program fit and how to crush the interview day.
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In this episode, University of Virginia interventional radiology and diagnostic radiology program director Dr. Luke Wilkins and our guest host Sunny Murthy discuss the factors that contribute to a successful IR residency application and interview.
With the USMLE Step 1 exam moving towards a pass/fail system, Dr. Wilkins emphasizes that it is important for applicants to distinguish themselves by finding ways to show dedication to the field of IR. We also discuss the benefits of having exposure to different programs prior to the application cycle, whether it is through rotations, virtual communication, or SIR involvement.
Dr. Wilkins encourages each applicant to recognize programs that fit best with their personality and learning style. He offers his perspective on good program characteristics to look for, such as flexibility in career preparation and wide case variety. Finally, Dr. Wilkins speaks about how authenticity in the application process can maximize benefits for both applicants and programs.
RESOURCES
SIR Residents, Fellows, Students Section: http://rfs.sirweb.org/
CLI fighters Dr. Bryan Fisher and Dr. Sabeen Dhand discuss their approach to treating calcified arteries above the knee, including looking at newer technologies and choosing the appropriate device to effect real durable change to the calcified wall.
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In this episode, vascular surgeon Dr. Bryan Fisher and our host Dr. Sabeen Dhand discuss treatments, intravascular ultrasound (IVUS), and device selection for calcified lesions above the knee.
First, Dr. Fisher discusses common risk factors for above the knee calcifications, including diabetes, end-stage renal disease, and smoking. In his diagnostic workup, he highlights the benefits of using CT for showing atherosclerotic disease, as well as IVUS for viewing intimal and medial calcifications.
With intimal calcifications, Dr. Fisher prefers to use an atherectomy device. For severely stenotic regions, he notes that orbital atherectomy can clear the way for other devices to pass through. After atherectomy, he usually performs IVUS to identify the luminal gain and assess the degree of plaque modification.
The doctors talk about new frontiers in technology such as intravascular lithotripsy, a technique that has been modified from urological treatment. The intermittent delivery of focal energy cracks calcium deposits and minimizes the risk of vessel rupture. Additionally, they discuss optical coherence tomography and how it can assist in visualizing the results of lithotripsy.
Overall, Dr. Fisher believes that angioplasties will likely cause injury to intimal walls, but these effects can be minimized by knowledge of vessel architecture and proper device selection.
RESOURCES
The Surgical Clinic: https://thesurgicalclinics.com/
Shockwave Intravascular Lithotripsy: https://shockwavemedical.com/clinicians/international/peripheral/
Dr. Eric Keller talks with Dr. Lola Oladini from Stanford Medicine Department of Radiology about what makes optimal training for Interventional Radiologists, including discussion on the variety of strengths of programs across the country, balancing diagnostics with procedural training, and what it means in being a "clinical IR".
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In this episode, interventional radiology residents Dr. Lola Oladini and Dr. Eric Keller discuss ideas to strengthen IR/DR residency training in multiple aspects, including clinical exposure, practice building, and personalization for the learner’s career goals.
Dr. Oladini shares preliminary results from her research, which consisted of interviews with various IR stakeholders. She highlights common themes on what interviewees value in a residency program: longitudinal patient care experience, practice-building education, exposure to interdisciplinary collaboration, exposure to clinical decision making, strong diagnostic radiology training, and graduated autonomy. She also shares common concerns that interviewees had about the disconnects between clinical education in residency training and real world practices that may not have the same clinical focus. Additionally, residents spoke about balancing the paradigm between wanting to get early IR exposure and training to be excellent diagnostic radiologists.
Finally, the doctors discuss different interpretations of the commonly used term, “clinical IR,” and brainstorm ways that residency programs can involve trainees in patient-centered initiatives and cross-speciality relationship building.
RESOURCES
SIR Residency Essentials: https://www.sirweb.org/learning-center/learning-center/residency-essentials-and-fundamentals/residency-essentials/
Dr. Aditya Bagrodia and Dr. Aaron Fritts talk with Dr. Phillip Pierorazio from Penn Urology about his Operate with Zen podcast and tips for surgeon wellness. They cover Dr. Pierorazio's motivation for starting a wellness podcast, preventing physician burnout, achieving work-life balance, and managing healthy competitiveness.
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In this crossover episode of BackTable Urology and BackTable VI, Dr. Aaron Fritts and Dr. Aditya Bagrodia speak with Dr. Phil Pierorazio about surgeon wellness and his mindfulness podcast, Operate with Zen.
First, Dr. Pierorazio discusses his motivation for starting the Operate with Zen podcast. During the pandemic, he crafted a new goal for himself: to be happier in surgery. He defines mindfulness as taking a moment to enjoy his livelihood and being more present at work and at home. Next, the doctors tackle the topic of physician burnout. All three doctors agree that burnout is not a badge of honor and are glad that the culture of medicine is progressing towards one that reprimands toxic attitudes early in training.
As for managing work-life balance, Dr. Pierorazio explains that once he started creating boundaries for his work schedule, he expanded what he could do. He encourages other surgeons to trust that their colleagues can handle emergencies, even if the patients are not their own patients. Collaboration with colleagues also leads to healthy competitiveness, a concept in which physicians stop comparing themselves to each other and instead celebrate their fellow colleagues. Dr. Pierorazio recommends channeling toxic competitive energy towards a drive to better a broader institution and patient care.
Finally, Dr. Pierorazio shares two of his personal tips for wellness. He avidly journals each day in order to exercise gratitude, reflect on his day, and set priorities for the next day. Finally, he emphasizes the importance of finding a wellness mentor or counselor in order to expand surgeon wellness and talent.
Dr. Renato Abu Hana walks us through how to perform fallopian tube recanalization for infertility, including patient selection, HSG and recanalization technique, as well as pitfalls to avoid.
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In this episode, interventional radiologist Dr. Renato Abu Hana and our host Dr. Chris Beck discuss fallopian tube recanalization procedure and patient counseling.
Tubal occlusion is one of the leading causes of infertility, and can be diagnosed with a hysterosalpingogram (HSG), a procedure that uses X-ray to check for blockages. Blockages can be cured by subsequent selective salpingography. Since the HSG can be a sensitive gynecologic examination with little to no sedation, Dr. Hana shares advice on how to explain the procedure to patients and make them feel more comfortable during the exam.
Dr. Hana describes his HSG procedure to us. He notes that the initial speculum insertion can be difficult because of differences in cervical anatomy. He also discusses patient positioning, different tool sets, and his method of injection. To address complications and risks, Dr. Hana recommends prescribing antibiotics to prevent post-procedural infection. Additionally, he emphasizes the need to minimize radiation exposure as much as possible in a patient who is trying to become pregnant.
Finally, we highlight the benefits of fallopian tube recanalization, which include low risk of complications, potentially large impacts on the patients’ ability to conceive, and medical cost savings (when used as an alternative to in vitro fertilization).
We talk with Dr. Cullen Ruff about common misconceptions when it comes to IV contrast and issues with the "contrast allergy", including ways we can improve patient care and clinical workflows by clarifying the true source of these reactions.
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In this episode, diagnostic radiologist Dr. Cullen Ruff and our host Dr. Chris Beck discuss the research and patient education surrounding contrast allergies.
Dr. Cullen starts the episode by commenting on the history of contrast media, noting that the earlier ionic contrast agents are more allergenic than the more recent non-ionic ones. By knowing the time period during which many radiologists switched to non-ionic agents (around 1985), we can identify during a medical history which of these types caused a patient’s allergic reaction.
The doctors discuss current research, which shows that substituting for a different contrast media is more effective than giving steroid premedication and using the allergy-inducing contrast media. Unfortunately, many patients are unable to recall the year when they experienced their allergy or the name of the contrast agent given. This lack of information makes it difficult to administer a substitute contrast media to the patient.
To address these workflow inefficiencies, Dr. Cullen advocates for individualized patient education over specific contrast allergies. He believes that taking the time to discuss allergies and giving the patient the name of their allergen, in writing, is essential for future imaging studies. He advises against the use of the vague and nonsensical term of “iodine allergy”, noting that patients are never allergic to the iodine itself, but rather a different component in the iodinated contrast media.
Finally, we discuss Dr. Cullen’s book, “Looking Within: Understanding Ourselves Through Human Imaging” in which he shares patient stories and introduces the general public to the retrospective and predictive values of diagnostic imaging.
RESOURCES
“Patients Have a Very Limited Knowledge of Their Contrast Allergies”: https://www.clinicalimaging.org/article/S0899-7071(21)00324-7/fulltext
“Prevention of Allergic-like Reactions at Repeat CT: Steroid Pretreatment versus Contrast Material Substitution”: https://pubmed.ncbi.nlm.nih.gov/34342504/
“Iodine Allergy: Common Misperceptions”: https://academic.oup.com/ajhp/article-abstract/78/9/781/6129459
American College of Radiology Manual on Contrast Media, 2021: https://www.acr.org/Clinical-Resources/Contrast-Manual
Dr. Cullen’s book, “Looking Within: Understanding Ourselves Through Human Imaging”: https://www.cullenruff.com/books
“The Immunology of the Vermiform Appendix: A Review of the Literature”: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5011360/
We talk with Dr. Mary Costantino and Dr. Goke Akinwande about their experiences and advice on making equipment purchase decisions for OBLs and outpatient centers, including pitfalls to avoid.
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In this episode, interventional radiologists Dr. Mary Constantino, Dr. Goke Akinwande, and Dr. Aaron Fritts discuss the process of choosing and financing equipment for office-based labs (OBLs). This episode focuses on three major types of equipment: C-arms or fixed units, disposables, and ultrasound machines.
First, the doctors discuss the fundamental differences between mobile C-arms and fixed units. Drs. Constantino and Akinwande agree that while the fixed unit is more ergonomically advantageous, it carries significantly more cost. While a fixed unit must be incorporated into the architectural planning of the OBL, a C-arm can be adapted to an existing space. Both doctors emphasize the importance of vendor support and knowing that they have quick access to technicians in the area.
Dr. Constantino provides her perspective on disposables and device partnerships, noting that an IR’s priority should be obtaining the equipment that allows them to operate to the best of their abilities. Dr. Akinwande obtains most of his disposables through consignment inventory in order to minimize waste.
Finally, the doctors talk about ultrasound technology and situations where different types may be more appropriate than others. Overall, they emphasize that while the OBL model grants autonomy to IRs, this pursuit introduces a large financial risk that should be carefully considered.
RESOURCES
Midwest Institute for Non-Surgical Therapy: https://www.mintstl.com/
Advanced Vascular Centers: https://www.advancedvascularcenters.com/
Dr. Donald Garbett interviews Dr. Joseph Couvillon about how he helped his group build an OBL practice in a rural setting, including the importance of hitting the pavement and phones to drive awareness with referring docs. Dr. Couvillon also raves about his recent trip to East Africa to help out the Road2IR team.
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In this episode, interventional radiologist Dr. Joe Couvillon and our guest host Dr. Donald Garbett discuss the opportunities and obstacles that arise with building an OBL practice in the Shenandoah Valley and lessons learned from Dr. Couvillon’s trip to Tanzania with Road2IR.
Dr. Couvillon recounts the process of building up his referral base for uterine fibroid embolizations (UFEs) in his practice, and shares his current experience in doing the same for peripheral arterial disease (PAD). He employs marketing strategies such as reading noninvasive studies and offering his services, as well as fostering a collaborative approach with cardiologists and vascular surgeons. He also speaks to the importance of reaching out to the referring doctors’ staff (NPs, PAs, and administrative assistants), since they can influence referral patterns.
In addition, Dr. Couvillon updates us on his recent trip with Road2IR. He gives his perspective on teaching procedures to IR fellows in Tanzania and being inspired by their enthusiasm and resourcefulness.
RESOURCES
Bringing IR to East Africa: The Road2IR Story: https://www.backtable.com/shows/vi/podcasts/104/bringing-ir-to-east-africa-the-road2ir-story
Road2IR: https://www.road2ir.org/
Interventional radiologist Michael Barraza talks with orthopedic spine surgeon Thomas Andreshak about his approach to vertebral augmentation for compression fractures, including unipedicular vs. bipedicular approach, technique pearls, and post-procedure care.
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In this episode, orthopedic surgeon Dr.Thomas Andreshak and our host Dr. Michael Barraza discuss kyphoplasty technique, including different methods of imaging, approaches, sedation, and follow-up.
Dr. Andreshak starts with obtaining a standing X-ray because it allows him to better observe cases of spondylolisthesis. He describes both unipedicular and bipedicular approaches, noting that the unipedicular approach can allow for greater cost savings, less cement used, and lower radiation exposure.
The doctors also review the stages of bone healing: hematoma formation, fibrocartilage formation, bony callus formation, and bone remodeling. Dr. Andreshak warns against overfilling the vertebra, which creates stiffness and puts stress on the adjacent endplate. Finally, they discuss follow-up and considerations for future treatment if pain persists.
RESOURCES
Consulting Orthopedic Associates: https://consulting-ortho.com/
Kyphon Assist: https://www.medtronic.com/us-en/healthcare-professionals/products/spinal-orthopaedic/vertebral-augmentation/kyphon-assist.html
Urologist Dr. Claus Roehrborn and Interventional Radiologist Dr. Sandeep Bagla discuss the pros and cons of Prostate Artery Embolization (PAE) compared to other Minimally Invasive Surgical Treatments (MISTS) for Benign Prostate Hyperplasia (BPH). They also discuss the importance of a collaborative, multidisciplinary approach when offering these treatment options, including agreeing on the best treatment for the patient.
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In this episode, urologist Dr. Claus Roehrborn and interventional radiologist Dr. Sandeep Bagla discuss benign prostatic hyperplasia (BPH) and prostate artery embolization (PAE) in the context of counseling patients and cross-specialty collaboration.
Dr. Roehrborn starts by reviewing the history of BPH treatment, from medications like alpha-blockers and anticholinergics, to minimally invasive options like UroLift, Rezum, and PAE. He emphasizes that the latter options are growing in popularity, since they provide treatment alternatives for patients who are concerned about side effects from medications, or have not experienced symptom relief from medications.
Dr. Sandeep Bagla describes Prostate Cancer USA’s philosophy on IR/Urology partnership and how it can ultimately benefit patients. This model provides the patient with both an IR suite for the PAE procedure and a urology clinic for diagnostic assessment, determination of PAE candidacy, and follow-up assessment.
Both doctors describe ideal patients for PAE. These are usually patients with a gland size above 60 g, confirmed bladder function, and a desire to preserve ejaculation function. Contraindications include urinary retention, chronic prostatitis, and heavily calcified glands.
Finally, they describe how they manage minor short-term complications such as frequency and dysuria with medication. They track symptom relief using the International Prostate Symptom Score (IPSS), Dr. Bagla notes that the largest drop in IPSS usually occurs about 4-5 weeks post-procedure.
Vascular Surgeon Daniel Han discusses management of persistent false lumen perfusion in chronic aortic dissection, including the Knickerbocker Technique.
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In this episode, vascular surgeon Dr. Daniel Han and our host Dr. Sabeen Dhand discuss various techniques involved in repairing chronic aortic dissections, including Thoracic Endovascular Aortic Repair (TEVAR), Knickerbocker, and candy plug.
Dr. Han starts by reviewing the differences between a true lumen and a false lumen. False lumens are usually formed by a dominant entry tear in the aortic wall with additional fenestrations present. Since the false lumen lacks the three walls of the aorta, it is more easily perfused and compresses the true lumen. He further subdivides aortic dissection into hyperacute, acute, subacute, and chronic dissections, all depending on the chronicity of the tear. With treatment, the goal is to achieve aortic remodeling and fuse the true and false lumens. Dr. Han notes that the more chronic the dissection, the harder it will be to remodel the aorta back to its original state, since it has already started remodeling in the dissected state.
The doctors discuss TEVAR and follow-up results in which Dr. Han would choose to re-intervene. He explains the Knickerbocker technique, in which he uses a balloon to selectively rupture the dissected septum. This establishes contact between the stent graft and the other side of the aorta, effectively creating a physical barrier to retrograde flow in the thoracic aorta. Dr. Han also discusses the candy-plug technique, which results in immediate cessation of blood flow into the thoracic aorta.
RESOURCES
BackTable VI Episode 142: Type B Aortic Dissections with Dr. Frank Arko: https://www.backtable.com/shows/vi/podcasts/142/type-b-aortic-dissections
Favorable Impact of Thoracic Endovascular Aortic Repair on Survival of Patients with Acute Uncomplicated Type B Aortic Dissection: https://pubmed.ncbi.nlm.nih.gov/29914833/
Outcomes of Thoracic Endovascular Aortic Repair for Chronic Aortic Dissections: https://pubmed.ncbi.nlm.nih.gov/29157682/
Interventional Cardiologist Behnam Tehrani and Interventional Radiologist Reha Butros from Inova Health System tell us about their team approach to endovascular treatment of chronic thromboembolic pulmonary hypertension (CTEPH) with Balloon Pulmonary Angioplasty (BPA).
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In this episode, interventional radiologist Dr. Reha Butros, interventional cardiologist Dr. Behnam Tehrani, and our host Dr. Michael Barraza discuss chronic thromboembolic pulmonary hypertension (CTEPH) and medical, endovascular, and surgical treatment options for CTEPH.
CTEPH affects patients of all different ages and medical histories. While it has been associated with prior pulmonary embolism, it can also arise in patients due to blood clotting disorders and infected pacemakers. Both Dr. Butros and Dr. Tehrani stress the importance of collaborating with pulmonary hypertension experts to identify CTEPH patients before right sided heart failure occurs. CTEPH is diagnosed with dual energy CT, which shows perfusion, and right heart catheterization, which measures blood pressure.
The three treatment options discussed are medical management, balloon pulmonary angioplasty (BPA), and pulmonary thromboendarterectomy (PTE). Medical management is discussed as an initial treatment for CTEPH, while PTE can be appropriate for good surgical candidates. Finally, Dr. Butros and Dr. Tehrani present BPA as an appropriate treatment for patients of all ages. BPA over multiple sessions and increasing balloon size has been shown to be effective at promoting pulmonary artery remodeling and dilation. The doctors share their own experiences with learning BPA technique, noting that it has a learning curve, but it is ultimately rewarding when patients’ quality of life is improved.
Neurosurgeon Dr. Nam Tran from Moffitt Cancer Center talks with us about RF ablation for painful spinal metastases, including patient selection and the importance of a multidisciplinary approach.
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In this episode, neurosurgeon Dr. Nam Tran and our host Dr. Michael Barraza discuss minimally invasive procedures to treat both primary spine tumors and spine metastases.
Dr. Tran describes the flexibility that kyphoplasty and spinal ablation can grant patients who are not suitable candidates for open surgical decompression. These minimally invasive procedures can reduce hospital stays from 4-5 days to just one night.
Dr. Tran views ablation not only from a palliative pain reduction perspective, but also from an oncologic perspective that aims to reduce tumor burden. Dr. Tran says the ideal candidate for ablation is a patient who has isolated disease to the anterior column of the spine. With larger lesions, Dr. Tran relies on his neurosurgical background to take an aggressive approach in treating the entire vertebra.
The doctors also discuss research studies that have made ablation more widely accepted and available (all articles are linked below).
RESOURCES
OPuS One Study: https://pubmed.ncbi.nlm.nih.gov/33129427/
CAFE Study: https://www.clinicaltrials.gov/ct2/show/study/NCT00211237
Dr. Aparna Baheti talks with Dr. Saher Sabri from MedStar Georgetown University Hospital about his approach to Balloon-occluded retrograde transvenous obliteration (BRTO) for portal hypertension, including advanced tips and tricks.
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In this episode, Dr. Saher Sabri and our host Dr. Aparna Baheti discuss PARTO, BRTO, and combined TIPS and BRTO procedures.
First, they discuss differences between PARTO (Plug-Assisted Retrograde Transvenous Obliteration) and BRTO (Balloon-Occluded Retrograde Transvenous Obliteration). Dr. Sabri walks us through the steps of both, noting that it is important to study the shunt before the procedure to identify its narrowest part. He also emphasizes the need to confirm successful balloon occlusion before starting embolization. This can require minor adjustments to balloon size and positioning.
To identify the endpoint for injection, Dr. Sabri tracks sclerosant movement up to the diaphragm and then down to the gastric varix. He confirms that the shunt has been obliterated and prevented from recruiting other outflows in the future.
When considering combined TIPS and BRTO procedure, Dr. Sabri focuses on key indications such as bleeding gastric varices, high-risk esophageal varices, and ascites. He prefers to do the TIPS procedure first, then the BRTO, then re-measuring the gradient and deciding if more ballooning of the TIPS is needed.
Finally, the doctors discuss post-procedural follow up and imaging. Dr. Sabri aims to have CT imaging within 2-4 weeks after BRTO and an ultrasound within 2 weeks after TIPS.
Dr. Nainesh Parikh from Moffitt Cancer Center discusses his approach to ablation of small renal masses, including workup, technique, and device selection. He also tells us why he has the best job ever!
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In this episode, Dr. Nainesh Parikh and our host Dr. Michael Barraza discuss tips for renal ablation and multispecialty care for kidney cancers.
First, they delve into the decision-making process for choosing between cryoablation and microwave ablation. Dr. Parikh believes that cryoablation is relatively safe to use in lesions near the collection system; however, it can cause a large inflammatory response in surrounding tissues. On the other hand, he prefers to use microwave ablation on exophytic lesions. Both doctors share their experiences with tricky lesions near the spine and various nerves. They also discuss the usage of pre-ablation embolization lesions larger than 5 cm.
Throughout the episode, the doctors emphasize the importance of constant communication with urologists, since embolization and ablation can provide significant benefits for patients who are poor surgical candidates. Collaboration can help the medical team better manage recurrences as they arise. Dr. Parikh notes that follow up care for image-guided procedures should occur around four weeks, which is sooner than the conventional urology follow up period.
Finally, Dr. Parikh gives pearls of wisdom regarding the advantages of hydrodissection, pneumodissection, and CT fluoroscopy for a safer and more efficient procedure.
RESOURCES
Moffitt Cancer Center IR Page: https://moffitt.org/for-healthcare-professionals/clinical-programs-and-services/radiology-diagnostic-imaging-and-interventional-radiology-program/
Dr. Christopher Beck talks with Dr. Driss Raissi about his approach to Microwave Ablation of Liver Lesions, including workup, technique, and tips and tricks for a successful ablation treatment.
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In this episode, Dr. Driss Raissi and our host Dr. Chris Beck discuss the planning, technique, and follow-up considerations for microwave ablation of liver lesions.
First, they talk through the process of mapping out the tumor. Dr. Raissi often attends tumor boards to contribute to the variety of treatment perspectives and gain consensus for microwave ablation from colleagues in different specialties. He also discusses the differences between cirrhotic and steatotic livers because the latter can limit the efficiency of microwave energy delivery.
During the procedure, Dr. Raissi appreciates the simplicity of a one-needle device. He offers advice for maneuvering near critical organs: direct the tip of the needle towards the critical structure to gain control. Additionally, he prefers to align the long axis of the needle with the long axis of the tumor and to minimize the number of new liver punctured by overlapping ablation zones.
The doctors also discuss the need to balance clean margins with preservation of liver tissue, noting that lesions in different lobes can be treated in different sessions. Finally, they cover telehealth follow-ups and MRI follow-up during the subsequent month.
Throughout this episode, we refer to findings about microwave ablation from previous publications, which are linked below.
RESOURCES
Comparison of microwave ablation and radiofrequency ablation for hepatocellular carcinoma: a systematic review and meta-analysis: https://pubmed.ncbi.nlm.nih.gov/30676100/
Liver microwave ablation: a systematic review of various FDA-approved systems: https://pubmed.ncbi.nlm.nih.gov/30506218/
Early Outcomes with Single-antenna High-powered Percutaneous Microwave Ablation for Primary and Secondary Hepatic Malignancies: Safety, Effectiveness, and Predictors of Ablative Failure: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7110402/
In Part II of our Lung Biopsy Series Dr. Fred Lee and Dr. Christopher Beck discuss Pleural and Parenchymal Blood Patching to prevent Pneumothorax, including results of the recent JVIR article from Sept 2021.
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In this episode, Dr. Fred Lee and our host Dr. Chris Beck discuss the use of parenchymal and pleural blood patches to reduce the rate of lung biopsy re-interventions.
First, Dr. Lee describes why he has incorporated parenchymal blood patching at the end of most biopsies, noting that it is a straightforward procedure that only adds on a few extra minutes to the overall biopsy, and it can reduce the rate of re-intervention. Both doctors agree that minimizing the need for chest tubes can greatly improve the patient experience.
Pleural blood patches are used as a salvage technique in the event of a pneumothorax. Dr. Lee walks through his process of re-inflating the lung, finishing the biopsy, and using a three-way stopcock to inject blood onto the pleural surface and along the needle track. He notes that there are other valid ways of treating intraprocedural pneumothoraces (saline, fibrin plug, etc); however, he prefers the pleural blood patch because of its liquid-to-solid clotting transition, minimal time, minimal cost, and relatively low risk.
Throughout this episode, we cite data from Dr. Lee’s previous publications, which are cited below.
RESOURCES
Percutaneous Lung Biopsy with Pleural and Parenchymal Blood Patching: Results and Complications from 1,112 Core Biopsies: https://www.jvir.org/article/S1051-0443(21)01202-1/fulltext
CT-Guided Lung Biopsies: Pleural Blood Patching Reduces the Rate of Chest Tube Placement for Postbiopsy Pneumothorax: www.ajronline.org/doi/full/10.2214/AJR.10.6324
Pulmonary Intraparenchymal Blood Patching Decreases the Rate of Pneumothorax-Related Complications following Percutaneous CT–Guided Needle Biopsy: www.jvir.org/article/S1051-0443…6)32178-9/fulltext
We start off Part 1 of a 2 part series with Dr. Fred Lee discussing Percutaneous Lung Biopsy Technique, with tips and tricks to help your daily practice.
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In this episode, Dr. Fred Lee and our host Dr. Chris Beck discuss tips for achieving safe and successful percutaneous lung biopsies.
They start by discussing the increasing popularity of core biopsy (as opposed to fine needle aspiration), since an adequate amount of specimen is needed for genetic testing and personalized medicine. Dr. Lee emphasizes that knowing the goals of lung biopsy for each individual patient helps him decide how much specimen to collect and how the specimen should be handled.
Next, Dr. Lee walks through his lung biopsy technique. He outlines the difference between conventional CT and CT with fluoroscopy. While CT with fluoroscopy can be more efficient, it poses radiation risk to the patient and the physician. To minimize radiation risks, he advises IRs to intermittently tap the foot pedal and stand lateral to the CT scanner. The doctors also discuss some of the trickiest lung regions to biopsy and ways to avoid pneumothorax.
Finally, Dr. Lee comments on the choice between percutaneous lung biopsies and electromagnetic navigation bronchoscopy, noting that each procedure has different advantages and risks. He encourages interventional radiologists and interventional pulmonologists to explore these options and take evidence-based approaches.
Throughout this episode, we cite data from Dr. Lee’s previous publications, which are cited below.
RESOURCES
Percutaneous Lung Biopsy with Pleural and Parenchymal Blood Patching: Results and Complications from 1,112 Core Biopsies: https://www.jvir.org/article/S1051-0443(21)01202-1/fulltext
We talk with Vascular Surgeon John Martin about his entrepreneurial journey to becoming CMO of Butterfly Network, Inc., and their mission to revolutionize medical imaging and medical education.
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In this installment of the BackTable Innovation Series, Dr. John Martin, Chief Medical Officer of Butterfly Network, and our host Dr. Bryan Hartley discuss Dr. Martin’s work in clinical software development, nonprofit efforts, and the revolutionary Ultrasound-on-Chip technology.
Dr. Martin traces his entrepreneurial journey back to his vascular surgery fellowship years, when he developed software programs to automate risk stratification and track patient outcomes. He emphasizes that it is important to take risks and “bet on yourself” when you know that your product can bring benefits to patients and physicians.
Dr. Martin also advises listeners to be open to partnerships with larger companies who can bring their ideas to fruition. This collaborative mindset brought him into the nonprofit world, where he worked with industry and government leaders to found a free cardiovascular screening initiative called Dare to CARE.
In his current role at Butterfly Network, Dr. Martin aims to make bedside ultrasound care affordable and accessible to all patients across the globe. He highlights the fact that the portable Butterfly probe has been successfully employed in contexts such as medical education, the COVID response, and his own cancer diagnosis. Overall, Dr. Martin believes that ultrasound access will benefit all medical specialties and help physicians make more efficient and informed clinical decisions.
RESOURCES
The Butterfly Network: https://www.butterflynetwork.com/
Dare to CARE: http://www.daretocare.us/
The BackTable hosts get together to discuss the results of the recent complications survey, including some stories from the audience as well some of their own experiences.
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Two months ago, we invited our listeners to participate in an anonymous Complications Survey. Our goal was to encourage open and honest conversations about procedural complications and what we can learn from them. In this episode, our BackTable hosts conduct a roundtable discussion about the results of the survey and share their personal experiences with complications.
The hosts start with distinguishing between complications from high-risk procedures and unexpected complications that arise in healthy individuals, noting that the latter type takes a larger toll on an IR. They emphasize the important role of case selection in minimizing complications and how each of them presents complication risks to patients during the informed consent process.
Next, the hosts read through complication stories that respondents submitted. Each host also shares stories about the aftermath of their own complications and how to communicate these to patients, families, and referring doctors.
Finally, we highlight an important survey finding: 76% of respondents do not think that complications are discussed enough among endovascular and interventional specialists. In the future, we hope to bring more attention to procedural complications and share advice on how we can collectively minimize risks for our patients and support each other in dealing with complications.
We would like to give special thanks to all of our BackTable community members who submitted their insights on complications! If you have a show topic or guest suggestion on the subject of dealing with or preventing complications, reach out to us on our website or social media.
RESOURCES
BackTable Ep. 54: Coping with Procedure Complications: https://www.backtable.com/shows/vi/podcasts/45/coping-with-procedure-complications
“Doctors and Litigation: The L Word” Podcast: https://podcasts.apple.com/us/podcast/doctors-and-litigation-the-l-word/id1469155084
Dr. Christopher Beck and Dr. Aaron Fritts discuss the Mediport placement procedure, including differences in technique (tie-down vs snug pocket), tips and tricks, and avoiding complications.
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In this episode, our co-hosts Dr. Chris Beck and Dr. Aaron Fritts share their tips and techniques to make Mediport placement more efficient and comfortable for both IRs and patients.
They start by discussing common reasons for port placement, noting that the majority of patients need them for chemotherapy, but they can also be helpful for patients who need access for frequent blood transfusions. As for contraindications, it is best to wait on patients who are currently experiencing active infections. Radiation burns, mastectomies, and bleeding disorders are not absolute contraindications, but these conditions can present challenges to port placement that might require extra planning.
Next, they walk through a port placement procedure, giving insights to their personal preferences. Dr. Beck uses the micropuncture needle to administer lidocaine along the track that he will be tunneling, to reduce the number of sticks. Both doctors aim to create a “snug pocket” for the Mediport, which reduces to suture it into place. As for avoiding complications, they prescribe antibiotics depending on the hospital protocols and exercise caution with patients who are sensitive to arrhythmias. Finally, they discuss the satisfaction of port removal and emotional significance for patients.
This episode is also available in video format on our BackTable YouTube channel (linked below).
RESOURCES
Watch the Video Podcast: https://youtu.be/PwDqG3av3eE
We talk with Dr. Alex Barnacle about her approach to the workup of Vascular Anomalies, including the importance of correct nomenclature and multidisciplinary teams for accurate diagnosis and long-term success.
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In this episode, Dr. Alex Barnacle and our host Dr. Chris Beck discuss the diagnosis and treatments of different vascular anomalies, as well as considerations in treating a pediatric population.
We start by reviewing the terminology of vascular anomalies, noting that the terms can be complicated and misleading for providers and for patients. Dr. Barnacle explains categories delineated by the ISSVA (International Society for the Study of Vascular Anomalies). She emphasizes the importance of combining imaging and physical examination to correctly differentiate between capillary, venous, lymphatic, and arterial malformations.
Next, Dr. Barnacle highlights the interdisciplinary nature of her joint clinics, which involve a variety of specialties (dermatologists, orthopedic surgeons, plastic surgeons, and others) and physical therapists. All play a role in diagnosing, treating, and following up with patients.
When discussing sclerotherapy, we cover considerations such as sedation, sclerosing agent, two needle technique, and potential complications. Dr. Barnacle talks about managing patient and family expectations, emphasizing that large lesions may require multiple interventions. We conclude by reflecting on the current state of pediatric IR and the future growth of the field.
RESOURCES
Commentary on Electrosclerotherapy as a Novel Treatment Option for Hypertrophic Capillary Malformations: https://pubmed.ncbi.nlm.nih.gov/31574036/
ISSVA Classification for Vascular Anomalies: https://www.issva.org/UserFiles/file/ISSVA-Classification-2018.pdf
ISSVA website: https://www.issva.org/
We talk with Dr. David Liu about the life cycle of innovation projects, developing ideas strategically, and his mentorship work with Creative Destruction Lab.
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In this episode, Dr. David Liu and our host Dr. Bryan Hartley discuss the intersections of medicine, engineering, and business in innovation.
Dr. Liu describes his background in computer science and how it helped him develop a problem-solving mindset. Within the IR space, he believes that innovation can be divided into three categories: disease management, technical refinement of procedures, and transformational technologies. Dr. Liu outlines his projects that fall into these categories, including an app for Y90 dosimetry, gesture based control for the angio suite, and collaboration through virtual reality.
We also discuss how innovation and execution are processes that require diverse perspectives. Dr. Liu summarizes important business concepts such as the various stages of a company’s evolution (start up, small cap, mid cap, and large cap) and two different types of investment (accretive vs. dilutive). Bringing a product to the marketplace involves multiple milestones such as establishment of intellectual property rights, proof of concept, first in human clinical trials, and regulatory approval. Achieving these milestones helps a company “de-risk” itself and become more attractive to investors.
RESOURCES
NZ Technologies: https://nztech.ca/
Imaging Reality: https://www.imagingreality.com/
Creative Destruction Lab: https://www.creativedestructionlab.com/
Nuestro primer episodio de Backtable en español está aquí. Las doctoras Gloria Salazar y Gina Landinez discuten COVID, las demandas médicas y endovasculres de nuestra población Iberoamericana y como convertir un ”no” en un “si".
Our first episode of BackTable en Español is here! With a growing demand for outreach in the Latin American community, Drs. Gloria Salazar, MD, FSIR and Gina Landinez MD talk about COVID, growing medical needs of our Spanish speaking community, and how to find opportunity when turning a “no” to a “yes”.
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En este episodio de BackTable, la radióloga intervencionista Dra. Gina Landinez entrevista a la Dra. Gloria Salazar, la jefa de división de radiología vascular e intervencionista de UNC Chapel Hill , sobre las desigualdades de salud en las comunidades minoritarias, su camino médico, y sus consejos para los aprendices médicos latinos.
Nacida por padres chilenos, la Dra. Salazar creció en Brasil. Desde su niñez, tuvo aspiraciones de ser doctora en los Estados Unidos y por eso, tuvo la motivación para aprender inglés a una temprana edad. Como alumna médica de la Universidad Federal de Sāo Paulo, tuvo excelentes mentores quienes fomentaron una curiosidad de pesquisa en ella. Fue ahí que nació su deseo de participar en el desarrollo del campo de la medicina.
La Dra. Salazar explica cómo su perspectiva sobre la salud cambió a través de sus experiencias como fellow y attending en el Hospital de Massachusetts General, donde el treinta por ciento de los pacientes eran latinos. Durante la pandemia, ella se dio cuenta que los pacientes latinos con COVID-19 enfrentaban retos únicos, como la barrera lingüística y dificultades económicas que impactan su recuperación. Ella recalca la relación entre las comunidades inmigrantes y el acceso a salud básica y describe como esta pandemia funciona como un despertar y llamada de conciencia tanto como para ella como para todos sus compañeros médicos, al enfatizar las divisiones existentes en nuestro sistema de salud. Sin embargo, cree que la competencia cultural y la colaboración internacional entre radiólogos puede mejorar las vidas de pacientes estadounidenses y latinos.
Finalmente, refleja en los factores más importantes en su éxito hoy en día. Reconoce que la persistencia inculcada por sus padres desde joven le proveía la fuerza de superar los retos profesionales y personales. Adicionalmente, destaca la importancia de los buenos mentores quienes pudieron iniciar sus intereses médicos y clarificar sus caminos. Finalmente, explica el fenómeno del “síndrome impostor” y anima a los médicos en formación a creer en sí mismos.
We talk with Dr. Robert Ryu about Imposter Syndrome. What is it, why is it so common in medicine, and how do we effectively deal with it?
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In this episode, Dr. Robert Ryu and our host Dr. Michael Barraza discuss the prevalence and implications of imposter syndrome. They open up about personal experiences with imposter syndrome and share strategies for overcoming feelings of inadequacy.
Dr. Ryu distinguishes between self-examination (critically assessing the situation and figuring out if you have the resources to succeed) and imposter-like feelings (constantly questioning yourself and unwillingness to acknowledge your achievements), noting that there is a whole spectrum of thoughts and feelings in between the two terms.
As a new department chair, Dr. Ryu acknowledges that he had experienced some insecurities with adjusting to the role. After learning about imposter syndrome, he has become interested in how it affects the medical community. He also emphasizes the important role of medical schools and residency programs in raising awareness of this topic to prevent burnout.
The doctors wrap up the episode by discussing their personal strategies for managing self doubt. For Dr. Barraza, extensive preparation brings confidence. For Dr. Ryu, reaching out to others for support and keeping a larger goal in mind has proven to be beneficial.
RESOURCES
The Imposter Phenomenon in High Achieving Women: Dynamics and Therapeutic Intervention: https://psycnet.apa.org/doiLanding?doi=10.1037%2Fh0086006
How to Deal with Imposter Syndrome (TIME article): https://time.com/5312483/how-to-deal-with-impostor-syndrome/
We talk with Dr. Leah Houston, founder of HPEC, about the healthcare applications of Blockchain Technology and Self-Sovereign Identity (SSI), including the importance of giving physicians control over their own professional digital identity. Thank you to Dr. Tim Yates for co-hosting!
SHOW NOTES
In this episode, our co-hosts Dr. Tim Yates and Dr. Aaron Fritts invite Dr. Leah Houston, founder and CEO of Humanitarian Physicians Empowerment Community (HPEC), to discuss blockchain technology and how she is applying it to healthcare.
Dr. Houston describes how she was initially introduced to blockchain through investing; however, she learned more about the technology and felt compelled to seek ways to use the technology to decentralize healthcare and allow physicians to regain autonomy as well as patient trust. She describes her vision of creating self-sovereign identities (SSI) for physicians that would allow them to carry digital assets like credentials, medical documentation, and payments. From the patient’s perspective, SSI could help them easily access their medical records.
HPEC is a physician-owned and physician-led company that aims to help them regain control over their practice of medicine. Dr. Houston describes the process of crowdfunding through other physicians and friends/family that has allowed her team to develop and test their product, a mobile application. She encourages any interested physician to get involved in development and/or pilot testing through the HPEC website.
RESOURCES
Humanitarian Physicians Empowerment Community (HPEC): https://www.hpec.io/
World Wide Web Consortium: https://www.w3.org/
We talk with Dr. Blake Parsons about his approach to Radial vs. Femoral access for Prostate Artery Embolization for BPH, including patient selection, device considerations, and practice pearls.
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In this episode, Dr. Blake Parsons and our host Dr. Chris Beck discuss access sites for prostate artery embolization, along with advice for visualizing pelvic anatomy, procedural tips, and post-operative care.
We start by comparing radial and femoral access. Dr. Parsons prefers femoral access because it is faster, although both approaches share the same amount of bleeding risk. Radial access may offer more pushability and may be more appropriate for patients with tortuous iliac arteries. Additionally, we discuss the closure methods for each approach-- TR Band for radial access, and Angio-Seal for femoral access.
Since pelvic anatomy varies from patient to patient, it can be challenging and time-consuming to identify the prostate artery. Dr. Parsons recommends using the obturator and pudendal arteries as landmarks. He also emphasizes that resources like lectures, meetings, papers, and courses can help IRs gain exposure and confidence in the pelvic anatomy.
Finally, we talk about managing patient expectations about post-operative pain and dysuria relief. Dr. Parsons prescribes antibiotics, Medrol Dosepak, and Pyridium. The timeline for improvement in benign prostatic hyperplasia is different in each patient, but improvement can be tracked with the IPSS score at follow up appointments.
RESOURCES
STREAM Meeting: https://www.thestreammeeting.com/
We talk with Dr. Sahil Mehta, founder of MedSchoolCoach, about how a side gig as an MCAT and med school tutor scaled up into a successful business. We also talk about the importance of passion projects of all types and sizes in preventing burnout, and avoiding "analysis paralysis" when it comes to starting a new business.
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In this episode, physician entrepreneurs Dr. Sahil Mehta and Dr. Aaron Fritts discuss how they started their passion projects and share business operations advice for budding entrepreneurs.
Dr. Mehta starts the show by telling the origin story of MedSchoolCoach, an online educational platform created to help students achieve their goals of entering medicine. MedSchoolCoach offers academic and career resources for high school, college, and medical students. While Dr. Mehta was a medical student when he originally had the idea for the company, the majority of business development occurred in his IR fellowship year.
The doctors talk about how passion projects can protect against burnout and actually relieve academic and financial stress from working in clinical practice. They also emphasize how they can apply business concepts to enhance their clinical practices. For example, marketing MedSchoolCoach to consumers taught Dr. Mehta how to better market IR procedures directly to patients.
Scaling up a business can present obstacles, so Dr. Mehta outlines strategies for hiring the right people, conducting market research, and making effective use of social media. He highlights the fact that motivated and talented employees can always learn specific industry knowledge.
To anyone who is debating whether or not to pursue a passion project, Dr. Mehta advises them to avoid over-analysis and jump into the idea because it will always be a learning experience.
RESOURCES
MedSchoolCoach: https://www.medschoolcoach.com/
Entrepreneurship in Medicine Panel: https://www.prospectivedoctor.com/entrepreneurship-in-medicine/
Interventional Radiologists Dr. Jeffrey Chick and Dr. Ravi Srinivasa tell us all about the latest and greatest in Spyglass Interventions, including how and where they're being used for lithotripsy, as well as upcoming training opportunities for those interested.
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In this episode, Dr. Ravi Srinivasa, Dr. Jeff Chick, and our host Dr. Michael Barraza discuss the SpyGlass Direct Visualization System and its benefits for endoscopic procedures.
The doctors begin with a short introduction to previous single-use endoscopes, noting challenges like limited flexibility and incompatibility with existing hospital infrastructure. The SpyGlass overcomes these obstacles by providing on demand irrigation, four-way flexion, recording capabilities, and its own compatible ancillary devices. Dr. Srinivasa describes his use of the Spyglass in targeted biopsies and lithotripsies.
Dr. Chick emphasizes that any IR can easily access and use this device, whether they are in a private, academic, solo, or hybrid practice. The minimal setup and ideal dimensions of the SpyGlass make it adaptable to many parts of the body. Finally, the doctors discuss upcoming educational content from Boston Scientific that will help IRs learn how to use the device and adapt it to their practices.
RESOURCES
Spyglass Direct Visualization System: https://www.bostonscientific.com/en-US/products/single-use-scopes/spyglass-ds-direct-visualization-system.html
We talk with STREAM meeting founders Dr. Ari Isaacson and Dr. Sandeep Bagla about its origin story, as well as what they have planned at STREAM 2021 for docs who want to learn Prostate Artery Embolization, Musculoskeletal Embolizations, and new techniques for Pain Therapy.
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In this episode, Dr. Ari Isaacson, Dr. Sandeep Bagla, and our host Dr. Michael Barraza discuss the evolution of the STREAM conference and new developments for the September 2021 meeting.
Starting from 2017, the STREAM conference has attracted minimally invasive specialists seeking practical education and training. While the conference originally revolved around prostate artery embolization, it has since expanded to include topics such as genicular artery embolization, peripheral artery disease, and musculoskeletal interventions.
Drs. Isaacson and Bagla highlight the wide variety of speakers, which include urologists, orthopedic surgeons, and medical malpractice lawyers. They both emphasize that this dynamic conference responds to the audience’s interests and has an overall laid-back atmosphere. This year will also be the first one to feature a case competition for students and residents. Click the link below to register for the conference and apply the BackTable promotional code!
RESOURCES
STREAM Meeting: https://www.thestreammeeting.com/
For attendings, use the code “BACKTABLE” for 50% off registration fee.
For residents/fellows/students, use the code “BACKTABLETRAINEE” for 100% off registration fee.
Dr. Sabeen Dhand talks with Dr. Blaise Baxter and Dr. Satoshi Tateshima about direct aspiration vs. co-aspiration technique when treating ischemic stroke. In this first episode of a multi-part series covering treatment of ischemic stroke they discuss radial vs. femoral approach, anatomic considerations, and tips and tricks with both techniques.
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In this episode, neurointerventional specialists Drs. Blaise Baxter, Satoshi Tateshima, and Sabeen Dhand discuss anatomical considerations and procedural techniques in direct aspiration and co-aspiration for ischemic stroke treatment.
The episode starts with a discussion about radial versus femoral approaches. While femoral access remains the most common method, device innovations are making brachial and radial access more available. Dr. Baxter and Dr. Tateshima describe the use of co-aspiration in their frontline techniques. However, Dr. Tateshima notes that he prefers to use direct aspiration in posterior circulation, since the vessel size may be unknown. Dr. Baxter also emphasizes that with co-aspiration, it is important to size-match the catheter with the vessel.
The choice of direct aspiration vs. co-aspiration depends largely on the location of the clot. The doctors walk through different considerations for M1, M2, and M3 strokes. Additionally, they talk about studies that compare the aspiration techniques and outcome factors such as improvements in TICI and mRS scores. Finally, they speak about the rewarding nature of stroke interventions and exciting new developments in the field.
RESOURCES
ASTER Randomized Clinical Trial: https://pubmed.ncbi.nlm.nih.gov/28763550/
SAVE vs. ADAPT for Acute Stroke: https://bmcneurol.biomedcentral.com/articles/10.1186/s12883-019-1291-9
We chat with seasoned Marketing Director Dianne Keen about the strategies that are helping doctors build sustainable practices, add service lines, and work toward patient-centered collaborative care with referring providers. Listen to learn about Dianne's "Trifecta" approach!
SHOW NOTES
In this episode, radiology marketing director Dianne Keen and our host Dr. Aaron Fritts delve into effective marketing strategies for IR practices. Throughout the episode, they emphasize the need to educate referring physicians and patients about how IR services can help them.
Dianne describes her “IR Practice Growth Trifecta” as a framework for success. All three parts-- the IR, the clinic infrastructure, and the marketing talent, are essential for communicating with colleagues and patients. Dianne emphasizes the importance of finding a marketing specialist who is knowledgeable about the field of IR, and specifically, details about the procedures that they are marketing. She encourages IRs to invite marketing specialists to shadow them in the lab and the clinic to build this knowledge.
To build relationships with referring doctors, it is important to identify receptive doctors in each specialty and stay in touch with them regularly. Dianne recommends focusing on the most relevant procedures to their practices, sending updates about their patients, and avoiding divisive messaging between referring doctors and their patients.
Finally, we discuss marketing channels and ways to embrace new forms of patient engagement, such as social media. Overall, marketing should be well-crafted and succinct, whether it is transmitted through social media, print, or community events.
RESOURCES
Northside Radiology Associates: https://northsideradiology.com/
SIR Toolkit for “Developing Your Practice”: https://www.sirweb.org/practice-resources/toolkits/practice-development-toolkits/
Interventional Radiologist Sabeen Dhand talks with Vascular Surgeon Frank Arko about endovascular treatment of Type B Aortic Dissections (TBAD), including patient selection, appropriate sizing, and complications to avoid.
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In this episode, vascular surgeon Dr. Frank Arko and our host Dr. Sabeen Dhand give an overview of type B aortic dissections, which includes different methods of classifying dissections, workup and imaging, thoracic endovascular aortic repair (TEVAR), potential complications, and timeline for follow up care.
Dr. Arko starts the episode by defining vocabulary terms related to aortic dissections. He describes the Stanford and DeBakey classification systems that are used to signify the location of the dissection and the method of treatment (medical management or surgical/endovascular repair). He also distinguishes between complicated/uncomplicated dissections, as well as acute/subacute/chronic dissections.
When Dr. Arko discusses TEVAR, he mentions three important complications to be aware of: retrograde type A dissection, stroke, and spinal cord ischemia. He emphasizes that in the debate between optimal medical therapy and early TEVAR, more research on how to minimize these complications is needed before recommending widespread use of early TEVAR. During his walk through of the procedure, Dr. Arko also gives his insight on adjunct techniques such as PETTICOAT.
Finally, the doctors discuss special considerations for patients with pleural effusion, chronic hypertension, type II thoracoabdominal aneurysms, and connective tissue disorders.
RESOURCES
INSTEAD-XL Trial- https://pubmed.ncbi.nlm.nih.gov/23922146/
Dr. Eric Therasse discusses the results of a randomized clinical trial demonstrating benefit of drug eluting balloon (DEB) over balloon angioplasty alone in treatment of Dysfunctional Hemodialysis Access.
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In this episode, Dr. Eric Therasse, an author of the recent JVIR article titled “Safety and Efficacy of Paclitaxel-Eluting Balloon Angioplasty for Dysfunctional Hemodialysis Access,” and our host Dr. Christopher Beck discuss the study design, outcomes, and implications for further research in the use of drug eluting balloons (DEBs) for hemodialysis access.
In this study, the control group received “plain old balloon angioplasty” (POBA), while the treatment group received angioplasty with Biotronik’s Passeo 18-Lux DEB. Dr. Therasse describes the angiographic endpoints, with primary endpoint as late lumen loss (to measure the degree of restenosis), and secondary endpoints as hemodialysis access failure and mortality at 12 months. He emphasizes that the clinical endpoints of this study were more significant than the angiographic endpoints because they showed that when treating dysfunctional hemodialysis access, there is decreased incidence and severity of restenosis with DEB compared with POBA.
Additionally, the doctors walk through obstacles that arose during the study, which included coordination of data collection across multiple centers, low patient enrollment rate, strict exclusion criteria, and the need for re-intervention prior to the standardized follow up date. Dr. Therasse comments on the increasing use of DEBs in clinical practices and their future cost-effectiveness. He also references other helpful articles for interested listeners (linked below).
RESOURCES
Safety and Efficacy of Paclitaxel-Eluting Balloon Angioplasty for Dysfunctional Hemodialysis Access: https://www.jvir.org/article/S1051-0443(20)30961-1/fulltext
Drug-Coated Balloons for Dysfunctional Dialysis Arteriovenous Fistulas: https://www.nejm.org/doi/10.1056/NEJMoa1914617?url_ver=Z39.88-2003𝔯_id=ori:rid:crossref.org𝔯_dat=cr_pub%20%200pubmed
The Lutonix AV Randomized Trial of Paclitaxel-Coated Balloons in Arteriovenous Fistula Stenosis: https://www.jvir.org/article/S1051-0443(19)30817-6/fulltext
Bryan Hartley talks with physician entrepreneur Dr. Mahmood Razavi about the essential elements of successfully starting a medtech company, as well as pitfalls to avoid.
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In this episode, serial entrepreneur Dr. Mahmood Razavi and our host Dr. Bryan Hartley discuss factors to consider when starting a medical technology company, steps of the innovation process, and fundraising strategies.
Dr. Razavi recounts his path into entrepreneurship, emphasizing the importance of finding innovative mentors. He advises listeners to go beyond merely observing other successful innovators and instead, actively engaging and asking them questions. The doctors bring up the concept of filing a provisional patent in the early stages of product development, which can allow an entrepreneur to protect their intellectual property as they seek guidance from others.
A critical decision point arises when an entrepreneur must decide whether or not they should establish a new product for an existing company or establish a completely new company. If the product is a different iteration of a design that already exists it might be worthwhile to innovate within the structure of an existing company. If you are creating a completely new device class that addresses a new clinical need or disease, there could be potential to start a company.
The startup process requires entrepreneurs to recruit team members and raise funds. Dr. Razavi uses equity as a recruiting tool to bring business and engineering experts into the company. He also describes various methods of funding, including venture capital and strategic partnerships and the pros and cons of each.
We talk with Vascular Access Surgeon Ari Kramer about AV Fistula and Graft Maintenance in dialysis patients from creation to long-term care, as well as tips and tricks for treating stenoses.
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In this episode, vascular access surgeon Dr. Ari Kramer and our host Dr. Chris Beck discuss the creation, management, and salvage of AV fistulas and grafts.
Dr. Kramer describes the referral patterns that lead dialysis patients to his practice, citing the need to coordinate dialysis care around a common surgical practice. He works closely with nephrologists and dialysis centers to ensure quality of care and streamlined patient management. During an initial workup, Dr. Kramer includes a physical assessment and an echocardiogram to establish a baseline.
The doctors discuss the pros and cons of using AV fistulas versus grafts. While AV fistulas are autogenic and carry a lower risk of infection, there is a risk that these may not mature. On the other hand, AV grafts are fully matured but they carry a higher risk of infection and require a higher intervention rate. Dr. Kramer emphasizes the importance of understanding a patient’s cardiac performance and history before selecting a method of AV access. He also schedules periodic follow-up appointments to ensure that the access site reaches maturity, which is evaluated by the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines.
Dr. Kramer walks us through devices and procedures for angioplasty, stent placement, and drug coated balloon placement. Finally, he addresses strategies for managing re-stenosis and considerations for patient preferences regarding surgical revision.
RESOURCES
Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guideline for Vascular Access: 2019 Update: https://www.ajkd.org/article/S0272-6386(19)31137-0/fulltext#secsectitle0720
American Society of Diagnostic and Interventional Nephrology (ASDIN): https://www.asdin.org/page/A2
Kidney Academy (use code “backtable21” for free access): https://www.kidneyacademy.com/
Dr. Sabeen Dhand talks with Dr. Lorenzo Patrone about how to be your best at giving an amazing, engaging presentation.
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In this episode, interventional radiologists Dr. Lorenzo Patrone and Dr. Sabeen Dhand discuss their best tips for creating and delivering quality presentations.
Due to the highly visual nature of interventional radiology, both doctors agree that PowerPoints are a great way to communicate information to audiences. Dr. Patrone recommends learning how to fully utilize PowerPoint functionalities such as embedded videos, animations, and transitions. Specifically, looped videos can help show blood flow. Interspersing dynamic presentation features can better illustrate important points; however, overuse of these can be distracting and unprofessional.
As for presentation delivery, both doctors agree that showing authentic personality can engage audiences. They advise listeners to embrace talking about complications and posing questions to the audience. Finally, they discuss considerations to keep in mind for different types of presentation formats, such as online webinars, industry-sponsored events, and debates. Overall, Dr. Patrone advises doctors to only speak on behalf of products that they truly believe in.
RESOURCES
Vascupedia: https://vascupedia.com/
Envato Presentation Templates: https://elements.envato.com/presentation-templates
Dr. Rakesh Ahuja walks us through the Pathway to Becoming a Y-90 Authorized user as a Resident, as well as the standard post-training pathway.
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In this episode, interventional radiologist Dr. Rakesh Ahuja and our host Dr. Michael Barraza continue the BackTable Trainee Series by discussing the meaning, benefits, and pathway for residents to become Y90 Authorized Users (AU).
The doctors discuss what it means to be an AU in interventional oncology, a rapidly growing field. The major benefit of Y90 licensing is that AUs can have the freedom to independently prescribe and administer customized doses to patients. Additionally, AU status can make a physician more marketable to private practices and it can allow them to perform cases on their own schedule. AU status is transferable to different sites and states, and it does not expire.
Dr. Ahuja speaks about eligibility requirements and emphasizes that trainees do not have to be board certified in radiology to start Y90 training. Supervised clinical training throughout an IR/DR residency will make most PGY-5 residents eligible to start the Authorized User training process. While this alternate pathway of Y90 Authorization can be faster than the traditional pathway (waiting until after board certification from the American Board of Radiology), it is important to work with local radiation safety officers to ensure that all eligibility and training criteria are met.
RESOURCES
US Nuclear Regulatory Commission Y90 Licensing Guidance- https://www.nrc.gov/docs/ML1920/ML19204A272.pdf
We chat with MedSchoolCoach Founder Dr. Sahil Mehta and 1st Year IR Resident Dr. Elias Farah about what inspired them to go into IR, and advice on getting into the specialty via the existing training pathways.
SHOW NOTES
In this episode, interventional radiologist Dr. Sahil Mehta, integrated DR/IR resident Dr. Elias Farah, and our host Dr. Aaron Fritts continue the BackTable Trainee Series by discussing how they each discovered the field of interventional radiology (IR), recent trends in the IR match process, and the importance of raising awareness of the IR specialty.
With the recent shift towards integrated IR residencies, medical students now have the opportunity to experience a mix of diagnostic and interventional radiology training from PGY-2 through PGY-4, and then dedicate time to IR training during PGY-5 and PGY-6.
As a recent IR applicant and now a resident, Dr. Farah walks us through his process of applying to residency. He outlines the steps that he took to prepare and the number of programs that he applied to. We also address the fact that IR has grown to be one of the most competitive specialties to match into. Dr. Mehta emphasizes that applicants’ average USMLE scores and number of publications have increased in the last few years, so it is important for applicants to demonstrate their genuine interest in the field and be prepared to speak about this during the interview.
The doctors close by discussing why increased awareness of IR can benefit both providers and patients. They highlight organizations that advance this mission, including the Society of Interventional Radiology (SIR) and the Interventional Institute.
RESOURCES
Society of Interventional Radiologists (SIR) Online Education Resources: https://www.sirweb.org/learning-center/rfs-landing-page/medical-student-and-resident-educational-resources/
SIR Residents, Fellows, and Students (SIR RFS): http://rfs.sirweb.org/
The Interventional Initiative: http://www.theii.org/
Beth Israel Deaconess IR Residency: https://www.bidmc.org/medical-education/medical-education-by-department/radiology/residencies-in-radiology/interventional-radiology-integrated-pathway-residency
University of Florida IR Residency: https://radiology.med.jax.ufl.edu/interventional-radiology-integrated-residency/
MedSchoolCoach: https://www.medschoolcoach.com/
We talk with IR Resident Dr. Jeff Bodner and Emory IR Program Director Dr. Bill Majdalany about the current IR training pathways and what it takes to get in these days!
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In this episode, interventional radiology (IR) program director Dr. Bill Majdalany, integrated IR resident Dr. Jeff Bodner, and our host Dr. Chris Beck continue the BackTable Trainee Series by discussing the IR residency application and interview process: different pathways to enter IR, applications that stand out, and interview day tips.
As a recent residency applicant, Dr. Bodner walks us through his journey through medical school, applications, and interviews. For students interested in pursuing IR, he recommends demonstrating interest in the field by participating in medical student committees, conferences, and volunteer opportunities. He also advises fourth-year students to apply broadly to both integrated interventional radiology and diagnostic radiology programs, emphasizing that there are multiple pathways to IR.
Dr. Majdalany elaborates on these pathways, describing the differences between the Early Specialization in Interventional Radiology (ESIR), the independent IR residency, and the integrated IR residency. He highlights key actions that applicants can take, which include performing well in all clerkships, taking advantage of research opportunities, and composing a personal statement that ties the whole application together.
We conclude the episode by offering advice for interview days. Overall, the best practices are to maintain professionalism and come prepared with knowledge about each program.
RESOURCES
Society of Interventional Radiologists (SIR) Online Education Resources: https://www.sirweb.org/learning-center/rfs-landing-page/medical-student-and-resident-educational-resources/
SIR Residents, Fellows, and Students (SIR RFS): http://rfs.sirweb.org/
Emory University IR Residency: https://med.emory.edu/departments/radiology/education/interventional-radiology-residency/index.html
We talk with Dr. Daryl Goldman, an IR resident at Mount Sinai Health System, about what it takes to "crush" your Interventional Radiology Rotation as a medical student, as well as what makes for a great educational experience from the resident and attending side.
SHOW NOTES
In this episode, interventional radiology resident Dr. Daryl Goldman and our host Dr. Aaron Fritts launch our BackTable Trainee Series by talking about how medical students can perform well on IR rotations, and more broadly, how they can best position themselves to apply for an integrated IR residency. They also discuss actions that program directors can take to ensure that their rotation is effective at teaching and recruiting trainees.
Dr. Goldman outlines her path to IR and offers advice to medical students for getting involved in research, networking, and away rotations. For students at sites without IR residency/fellowship programs, she suggests that they reach out to external programs for research opportunities and away rotations. Overall, she encourages interested students to learn how to be good mentees, attend conferences, and get involved with IR interest groups.
Dr. Goldman says that a major goal of an IR rotation should be showing students a broad view of the specialty: workups, procedures, inpatient management, clinic time, and follow-up care. She suggests that programs provide students with graduated responsibility, didactic time, and opportunities to give presentations.
The doctors advise students to use social media to get connected with their specialty networks. Specifically, they emphasize the collaborative and educational environment of the endovascular community on Twitter.
RESOURCES
BackTable’s Twitter: @_BackTable
Dr. Goldman’s Twitter: @Daryl_Goldman
SIR Residents, Fellows, and Students (SIR RFS): http://rfs.sirweb.org/
Mt. Sinai Integrated IR Residency: https://icahn.mssm.edu/education/residencies-fellowships/list/msh-interventional-diagnostic-radiology
“Five Ways to Be a Great Mentee” by Dr. Yasha Gupta: https://www.acr.org/Member-Resources/rfs/Resident-and-Fellow-News/2020MAR-Mentorship
We talk with Dr. Christopher Pittman to better understand Management Services Organizations (MSOs) and what they can do for your practice. We also get the 101 on Value-Based Care payment models.
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In this episode, interventional radiologist and vein treatment expert Dr. Chris Pittman and our host Dr. Aaron Fritts discuss the structure and benefits of management services organizations (MSOs).
As healthcare moves from a fee-for-service model to a fee-for-value model, MSOs have become increasingly popular. Dr. Pittman gives a brief overview of the services that these organizations can provide to independent physicians. These services can encompass billing, human resources, scheduling, contract negotiation, marketing, and any aspect of practice management outside of direct medical care. We discuss the benefits of joining an MSO, which include sharing resources within the network, offloading non-medical functions, controlling costs, learning best business practices, and ultimately, having more time and energy to deliver quality patient care. Additionally, having a network of practices allows each physician to have access to industry data and benchmark themself from operational, clinical, and patient satisfaction standpoints.
Dr. Pittman advises all physicians to have due diligence when deciding to join an MSO. He emphasizes the importance of determining the amount of physician autonomy that will be retained, evaluating the organization based on outcomes of past clients, and having an attorney look over agreements. In general, he believes that the most well-run MSO’s are the ones that focus on a single specialty and have physicians on their leadership teams.
RESOURCES
Health Performance Specialists (HSP): https://www.healthperformancespecialists.com/
Bryan Hartley talks with Neurosurgeon Dr. Chris Mansi about the origin story of Viz.ai, a company using Artificial Intelligence to Shorten Time to Treatment and Improve Access to Care for Stroke Patients.
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In this episode, neurosurgeon and co-founder/CEO of Viz.ai, Dr. Chris Mansi, and our host Dr. Bryan Hartley discuss the use of AI technology to detect large vessel occlusion (LVO) strokes and increase efficiency of workflow. Dr. Mansi describes his entrepreneurial journey, through the phases of idea formation, funding, growth, and expansion of his company.
We start by outlining key advantages that MBA and other graduate degree programs can provide for healthcare entrepreneurs. Both doctors emphasize the value of dedicating space and time, outside of clinical practice, to innovate and test new ideas. Dr. Mansi highlights his collaboration with other disciplines, such as engineering. He also discusses takeaways from his business education-- the importance of patient-centered innovation and having flexible technology that can meet the changing needs of the market.
Dr. Mansi gives an overview of Viz.ai’s origins, mission, and product offerings. The company addresses a clinical need for more consistent and efficient stroke care, and aims to move patients from stroke detection to stroke treatment more quickly. Viz.ai employs self-learning technology to provide high-quality imaging, automatic workflow triggers, and HIPAA-compliant communication channels for stroke teams to work together for the benefit of patients. We end this episode by talking about Viz.ai’s plan to expand to more disease states and medical specialties in the near future.
RESOURCES
Viz.ai Platform: https://www.viz.ai/
“Crossing the Chasm” by Geoffrey Moore: Dr. Mansi’s book recommendation for all tech entrepreneurs
Dr. Sabeen Dhand chats with Interventional Radiologist Shankar Rajeswaran from Lurie Children's Hospital in Chicago about a novel minimally invasive treatment of unicameral and aneurysmal bone cysts.
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In this episode, pediatric interventional radiologist Dr. Shankar Rajeswaran joins host Dr. Sabeen Dhand to discuss a novel minimally-invasive treatment for unicameral and aneurysmal bone cysts.
Pediatric interventional radiology is a rapidly growing field, and Dr. Rajeswaran describes how it has evolved in complexity and innovation over the course of his career. Dr. Rajeswaran says that there is a significant challenge that pediatric IRs must overcome-- treating children with IR devices that were originally designed to be used in adults. As a result, he emphasizes the need for creativity and flexibility in this field.
Next, we define and differentiate between unicameral and aneurysmal bone cysts. Both can be benign; however, they carry the risk of causing pain, bone fracture, and growth deformities. Dr. Rajeswaran outlines the current standard of care, which includes monitoring and curettage and bone grafting. Then, he describes a new method of treatment, which involves needle injection of doxycycline to burn the walls of the cyst and bone paste to help generate new bone. This method can be applied to unicameral bone cysts and aneurysmal bone cysts, and it leaves no scarring. He also discusses the recurrence rate for various treatment methods.
Overall, Dr. Rajeswaran encourages anyone interested in pediatric IR to reach out to doctors in the field for shadowing opportunities and guidance.
RESOURCES
Society for Pediatric Interventional Radiology: https://www.spir.org/
Lurie Children’s Hospital blog article over novel treatment of bone cysts: https://www.luriechildrens.org/en/blog/interventional-radiology-cutting-edge-procedure-puts-brooklyn-back-in-the-game/
We talk with radiologic technologists Andrew Struchen and Alisha Hawrylack about current training pathways for Vascular and Interventional Technologists, the importance of respect at work and in the lab, as well as key factors in recruiting and retaining top notch A-team technologists.
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In this episode, interventional radiologic technologists Alisha Hawrylack and Andrew Struchen join Dr. Aaron Fritts to discuss the important role of IR technologists in the lab and major factors that affect their recruitment, training, and retention.
To start, we discuss the current state of IR technologist training. Alisha describes two major educational pathways, structured training programs and on-the-job training. She says that while both modes of training can be effective, structured training programs are likely to provide deeper knowledge of anatomy and IR procedures. Andrew gives an overview of the yearlong IR technologist program at the University of Virginia, which offers a mix of didactic learning, clinical training, and mentorship. We also briefly outline the ARRT and RCIS certification requirements.
Next, we address job satisfaction and turnover of IR technologists. We discuss increasing workload, staffing concerns, and the need to feel engaged in cases. Andrew recognizes that if these problems are not addressed, technologists will start seeking other opportunities, such as careers within industry. Alisha emphasizes that technologists at academic institutions are excited about innovative procedures and seek ways to positively contribute to outcomes.
Finally, we discuss team culture and ways to cultivate respectful relationships between technologists and other clinicians. We talk about our experiences with giving team members the benefit of the doubt, learning how to work with other teammates, and resolving miscommunication.
RESOURCES
Charles J. Tegtmeyer Program of Interventional Radiology and Special Procedures at the University of Virginia Medical Center: med.virginia.edu/radiology/educat…ogist-education/ Alisha Hawrylack: ac4nf@hscmail.mcc.virginia.edu Andrew Struchen: ads6r@hscmail.mcc.virginia.edu Association of Vascular and Interventional Radiographers (AVIR): avir.org/ American Registry of Radiologic Technologists (ARRT): https://www.arrt.org/ Registered Cardiovascular Invasive Specialist (RCIS) Exam: cci-online.org/CCI/Certification…OrganizerCommon=2
We talk with Vascular Surgeon Jim Melton and Interventional Radiologist Blake Parsons about several key pieces to success in the Outpatient (OBL/ASC) setting, including partnerships, staffing, and case selection.
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In this episode, vascular surgeon Dr. Jim Melton and interventional radiologist Dr. Blake Parsons join our host Dr. Aaron Fritts to discuss how they set up the vision and structure of their Outpatient-Based Lab/Ambulatory Surgery Center (OBL/ASC).
Dr. Melton begins by describing how he saw a need to make the surgery experience more patient-centered, which ultimately led him to co-found CardioVascular Health Clinic in 2015. He highlights the importance of staffing his clinic with talented individuals and strategies for retaining talent. Dr. Melton also describes how the practice navigates partnerships, pay structures, and expenses.
Dr. Parsons shares his advice for marketing OBLs to referring physicians. This includes staying in touch with local providers, keeping them updated on their patients, and hosting educational events. He also covers their clinic’s process of updating and changing technology, which involves team meetings and potential vendor negotiation. Additionally, we cover virtual strategies for communicating with sales representatives during the COVID era.
Overall, the doctors emphasize that the OBL path is risky, but it can turn out to be very rewarding for both patients and providers.
RESOURCES
CardioVascular Health Clinic- https://cvhealthclinic.com/ CardioVascular Health Clinic Twitter- @CVHealthClinic Avail Software- https://www.avail.io/
We talk with Interventional Radiologist and Philips Chief Medical Officer Atul Gupta about his path from the interventional suite to the boardroom, and how physicians can work with device companies to innovate and make big impact changes in healthcare.
SHOW NOTES
In this episode, Dr. Bryan Hartley discusses the intersection of IR practice and medical device innovation with Dr. Atul Gupta, interventional radiologist and Chief Medical Officer of Philips’ Image-Guided Therapy division. Throughout the show, Dr. Gupta describes his path from medical student, to IR practice builder, to executive leader.
Dr. Gupta describes his philosophy of innovation, which stems from the identification of real clinical needs. He explains why interventional radiologists are well-positioned to be device innovators and cross-specialty collaborators (Hint: It has to do with our curiosity and cool technology!). He recalls innovative mentors, or “gadgeteers,” who have inspired him to work on research projects during residency and onwards. As a result, Dr. Gupta’s work with Philips grew into a partnership and, eventually, a formalized role within the company. In addition to serving as a CMO, Dr. Gupta maintains his clinical skills by continuing to practice IR when he can.
To close, we discuss exciting new topics that are on the horizon of image-guided therapy: augmented reality, artificial intelligence, and dielectric imaging. We also highlight tips for any physician who is wanting to get involved with device innovation, as well as any physician who is contemplating a new role.
RESOURCES
Philips Image Guided Therapy- https://www.usa.philips.com/healthcare/solutions/interventional-devices-and-therapies
“The Infinite Game” by Simon Sinek A book that Dr. Hartley recommends for anyone interested in learning how to motivate their teams to achieve long-term success.
Interventional Radiologist Christopher Beck talks with Hepatologist Parvez Mantry about the management of Portal Hypertension and Ascites, and the importance of multi-disciplinary collaborative care for these patients.
SHOW NOTES
In this episode, hepatologist Dr. Parvez Mantry joins our host Dr. Christopher Beck to discuss portal hypertension and ascites, two complications that arise from liver diseases and have a large effect on patients’ quality of life.
Dr. Mantry starts the episode by sharing statistics on Chronic Liver Disease (CLD) and specifically highlights the burden of CLD on the U.S. population. He discusses various causes of CLD, including Hepatitis C, Alcohol Liver Disease, and Non-Alcoholic Steatohepatitis.
Next, Dr. Mantry takes us through his diagnostic workup, including his physical examination, cross-sectional imaging, percutaneous and transjugular liver biopsies, and serological workup. He checks for complications such as portal hypertension, ascites, pedal edema, and hepatic encephalopathy. We also discuss the diagnosis of Hepatocellular Carcinoma (HCC).
Then, we transition to strategies for managing ascites and portal hypertension through diuretics, paracentesis, Transjugular Intrahepatic Portosystemic Shunts (TIPS), liver transplantation, and a few experimental treatments that he is currently researching. Overall, Dr. Mantry advocates for close monitoring of symptoms and making treatment modifications as needed.
Finally, when focusing on the patient experience, Dr. Mantry offers troubleshooting tips, especially for patients who struggle with leakage from the paracentesis site. To close, he gives insights on how physicians can best support chronically-ill patients who are awaiting transplantation.
RESOURCES
Methodist Transplant Specialists- https://www.theliverinstitutetx.com/ Information about Dr. Mantry’s transplant center and its satellite locations in the Dallas-Ft. Worth Community.
American Association for the Study of Liver Diseases (AASLD) Practice Guidelines- https://www.aasld.org/publications/practice-guidelines
Management of HCC- https://www.journal-of-hepatology.eu/article/S0168-8278(12)60009-9/pdf
The Management of Ascites in Cirrhosis- https://aasldpubs.onlinelibrary.wiley.com/doi/abs/10.1053/jhep.2003.50315 These are guidelines set by the International Ascites Club.
BackTable Pdcast Ep. 123 TIPS University Freshman Year: Referrals and Pre-Op Workup- https://www.backtable.com/shows/vi/podcasts/123/tips-university-freshman-year-referrals-pre-op-workup
It's Senior Year at TIPS University with Dr. Emmett Lynskey talking us through his Gunsight technique for TIPS placement, as well as how to perform a safe closure of splenic access. Don't miss the first three parts of the series as well!
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In this episode, Dr. Emmett Lynskey joins Dr. Chris Beck for the final edition of TIPS University to discuss the gunsight technique and splenic closure. We begin by discussing where to start once the catheter is in the portal vein and you have access, and Dr. Lynskey shares why he likes to use a 8mm balloon for the angioplasty.
We explain the details of the gunsight technique, how to line up the portal and hepatic snare, how to adjust the view, and how to get access to both veins using a 22 gauge chiba needle. We share why it is important to make sure that the cranial caudal difference between the portal and hepatic snare is not significant before you gunsight. We discuss how to work with wires to floss through the splenic vein. Dr. Lynskey tells us why he uses a microcatheter for an extra step instead of snaring the end of the wire. We review some situations where you can throw the snare up and stick it with a colapinto needle and some of the considerations for portal vein thrombosis when doing TIPS.
We discuss splenic access and why it is important to set up for good closure. We explain the different options for splenic access, using a combination of coils, plugs, and gelfoam, and Dr. Lynskey shares which combinations he prefers to use for splenic closure. We review the technique to get images using fluoro and ultrasound.
It's Junior Year at TIPS University with Dr. Emmett Lynskey walking through advanced techniques for TIPS, including using Intracardiac Echocardiography (ICE) for placement, as well as transsplenic access for portal reconstruction.
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In this episode, Dr. Emmett Lynskey joins Dr. Chris Beck for the third edition of TIPS University to discuss intracardiac echo (ICE) and splenic access in TIPS procedures. We discuss the learning curve associated with ICE and Dr. Lynskey tells us about the early challenges he faced when learning this technique.
We share why using ICE is helpful in TIPS and how to set up the procedure, depending on the type of access you want. We explain how to get a more medial throw by getting the catheter closer to the portal vein, and we discuss how to torque the needle for different throws. We discuss making throws using an ICE probe and why ICE is helpful for acutely thrombosed TIPS revisions. Dr. Lynskey tells us about some other good uses for the ICE catheter.
We discuss splenic access, and we review the conditions that allow for safe splenic access. We explain how to do the ultrasound evaluation anterior to the probe. Dr. Lynskey shares why he dedicates one hand for the wire and one hand for the ultrasound, and he tells us how he picks the sheaths and wires that he uses to get splenic access. We discuss how to know that you have opened up the splenic vein.
RESOURCES
Edward Jones Financial Advisor Yaphet Tadesse: https://www.edwardjones.com/us-en/financial-advisor/yaphet-tadesse
It's Sophomore Year at TIPS University with Dr. Emmett Lynskey and Dr. Christopher Beck discussing basic procedure technique for Transjugular Intrahepatic Portosystemic Shunts (TIPS).
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In this episode, Dr. Emmett Lynskey joins Dr. Chris Beck for the second edition of TIPS University to discuss basic TIPS procedure techniques. Dr. Lynskey starts us off by talking through the steps of getting access for a basic TIPS procedure, and he tells us how to check if there is a large difference between wedge pressure and the true portal pressure.
Next, we discuss doing a puff or a run of the vein to make sure that there is no obstruction of outflow. Dr Lynskey compares new and old techniques for getting the sheath into the vein, and he explains two different methods, bare back and over the wire, for getting the needle down for the TIPS procedure. We outline what you should expect to see after doing a puff of contrast, how to locate the central portal vein, and the differences between using CO2 and contrast.
Dr. Lynskey shares what factors he considers when choosing a wire for TIPS and how he uses a pigtail and a sheath to perform a dual run. We review the purpose of a dual run and discuss the details of opening the tip once the sheath is down. We then compare the final steps of the TIPS procedure based on whether or not you will embolize, and give a brief overview of embolizing using a fogarty balloon.
Dr. Lynskey goes over his goal frame rate for the final run of the TIPS, and he explains how to check the flow dynamic of blood going to the liver. He tells us about follow-up care and how it changes if a patient develops encephalopathy. We end the episode by discussing the importance of counseling patients and caretakers on medications.
We start our TIPS University series with Interventional Radiologist Dr. Emmett Lynskey discussing referral sources and pre-operative workup, including the importance of patient selection and MELD score.
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In this episode, Dr. Emmett Lynskey joins Dr. Chris Beck for the first edition of TIPS University to discuss referrals and pre-op for transjugular intrahepatic portosystemic shunts (TIPS). Dr. Lynskey begins by telling us about his fellowship at Georgetown, his current practice, and how he became interested in portal hypertension.
We talk through the most common indicators for a TIPS procedure, including refractory ascites, portal vein thrombosis, and acute bleeders. Dr. Lynskey explains how patients are referred to him, and he outlines what factors he considers before determining the eligibility for TIPS. We then discuss how useful cross sectional imaging is, and we break down the Model for End-Stage Liver Disease (MELD) score. Dr. Lynskey shares the components that make up the MELD score as well as the cutoffs and thresholds for a TIPS patient.
Next, we review diuretics and emphasize the importance of being honest with patients regarding expectations post-procedure. We explain how to phrase questions when working with cardiologists. Dr. Lynskey goes over what all he can determine from cross-sectional imaging prior to the procedure, and he tells us when he might consider an alternative to TIPS.
We discuss which labs should be done the day of the procedure and why Dr. Lynskey gets MELD labs again just before the TIPS. Dr. Lynskey tells us about blood typing, crossmatching, and fibrinogen levels. The episode wraps with Dr. Lynskey explaining the benefits of performing a paracentesis prior to TIPS.
RESOURCES
Edward Jones Financial Advisor Yaphet Tadesse: https://www.edwardjones.com/us-en/financial-advisor/yaphet-tadesse
Interventional Radiologist Peder Horner talks with Barry Uchida about the early days at The Dotter Institute, with stories about working alongside Josef Rösch on developing the first TIPS sets, as well as working with other legends in the field including Charles Dotter, Fred Keller, and Julio Palmaz.
Interventional Radiologist Dr. Mike Watts talks with us about which procedures are being safely performed in the OBL space, and the importance of patient selection.
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SHOW NOTES
In this episode, Dr. Mike Watts joins Dr. Michael Barraza to discuss Office Based Labs (OBLs). We begin by explaining what an OBL is and how OBLs are different from Ambulatory Surgery Centers (ASC’s). Dr. Watts tells us about some of the advantages of working in an OBL, including reimbursement rates, patient access, and scheduling, and we talk about how the general patient experience is different.
Next, we give an overview of how to work with referring doctors at nearby hospitals and build relationships with departments outside of interventional radiology, such as oncology and urology. Dr. Watts shares the advantages of being a full-service IR group, and he tells us how he coordinates patient care between the OBL and hospitals when needed.
We also discuss how to expand an OBL practice to become a full-service IR group, how to make yourself valuable within an OBL, and how to participate in ongoing clinical studies. We end the episode with Dr. Watts telling us what is on the horizon for OBLs and what he would like to see in the future.
RESOURCES
Interventional Radiologist Sabeen Dhand talks with Interventional Cardiologist Eric Secemsky about building a Pulmonary Embolism (PE) Response Team, and about the various techniques for treatment of PE used in his practice.
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In this episode, interventional cardiologist Dr. Eric Secemsky and our host Dr. Sabeen Dhand discuss pulmonary embolization and the coordination of Pulmonary Embolism Response Teams (PERTs).
Dr. Secemsky starts by introducing the diagnosis of pulmonary embolisms. He explains the classification of patients into the categories of massive, submassive, and low-risk embolisms, as well as echocardiogram and CT imaging. His workup includes not only checking for clot burden, but also checking for vital sign abnormalities, evidence of right ventricle dysfunction, and neurological deficits.
Then, we transition to talking about the structure, workflow, and communication technologies used in pulmonary embolism response teams. Dr. Secemsky describes his experience with building a response team and ensuring its adaptability for a variety of cases. He emphasizes the importance of multidisciplinary care and team members’ accountability for every patient.
Finally, we discuss treatment of pulmonary embolism, based on how emergent a case is. Dr. Secemsky describes factors to consider when employing different treatments: clot extraction devices, thrombolytics, and anticoagulants. Additionally, we cover the topics of catheter-directed thrombolysis, mechanical thrombectomy, and surgical embolectomy.
RESOURCES
Interventional Therapies for Acute Pulmonary Embolism: Current Status and Principles for the Development of Novel Evidence: A Scientific Statement From the American Heart Association- https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000707 AHA guidelines for the classification of massive, submassive, and low-risk pulmonary embolisms.
PERT Consortium- https://pertconsortium.org/
Diagnosis, Treatment and Follow Up of Acute Pulmonary Embolism: Consensus Practice from the PERT Consortium- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6714903/
SUNSET sPE study- https://vivaphysicians.org/news-article?id=88424
Interventional Radiologist Sabeen Dhand talks with Vascular Surgeon Bryan Fisher about the benefits of using Intravascular Ultrasound (IVUS) for endovascular treatment of peripheral arterial disease (PAD), as well as the potential for other emerging imaging modalities such as Optical Coherence Tomography (OCT).
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Interventional Radiologist Dr. Donald Garbett talks with Dr. Michael Barraza about how he approaches acute limb ischemia, including different endovascular techniques for removing acute arterial clot.
SHOW NOTES
In this episode, Dr. Donald Garbett joins Dr. Michael Barraza to discuss treating acute limb ischemia. We explain when to take a hospital patient to the OR instead of angio, and Dr. Garbett tells us why he prefers establishing severity of the limb ischemia using the Rutherford classification. We discuss the circumstances of needing to have an immediate procedure, and what challenges may occur in these patients.
We discuss the beginning of treating acute limb ischemia, including getting access, initial angions, and when to get an ACT. We review how to get femoral access, and we explain some cases where a different type of access is needed. We discuss which sheath size to use for diagnostics and when lysing overnight. Dr. Garbett tells us when he will lyse while treating acute limb ischemia and why he treats the underlying issue first.
We review the different kinds of grafts, and we discuss what guides the approach to re-vascularizing a graft. We talk through some challenging situations that can occur when working on a graft and the dangers of the lipstick effect. We discuss how to use balloons to treat an underlying stenosis and how to deal with an unexpected intraprocedural clot. We discuss follow-up care and working with vascular surgery to coordinate care.
Interventional Radiologist Christopher Beck talks with Interventional Nephrologist Neghae Mawla about how to perform successful Declot procedures for AV fistulae and grafts, including tips and tricks to make this procedure safe and efficient.
SHOW NOTES
In this episode, Dr. Neghae Mawla joins Dr. Christopher Beck and Dr. Aaron Fritts to discuss declots for AV access. We discuss what to include in a work up for a declot and how to assess the size of an aneurysm. Dr. Mawla tells us about the cases where he would not perform a declot, and he explains why he might choose to place catheter and dialyze first.
We discuss how to set up the room and how to prepare for the declot procedure. Dr. Mawla shares the reasons why he does not use an IV or ultrasound in pre-op. We explain the differences between using balloon maceration vs rotational thrombectomy device for treating outflow clot. We also touch on the back bleeding technique for declots.
We review the up-down technique, how to use ultrasound to your advantage, and how to avoid overlapping sheaths. We discuss clot burden and why declot procedure length may vary. We explain some different techniques for using multiple sheaths at a time, and Dr. Mawla tells us about troubleshooting during a recalcitrant stenosis. We discuss how to decide when to stent lesions and what follow-up care looks like. Dr. Beck and Dr. Fritts share some of their favorite things they have learned from Dr. Mawla about declots.
Dr. Ryan Trojan gives us a 101 on Evaluation and Management (E/M) Coding, including tips and tricks for capturing inpatient notes and practice building, as well as the updates for success in 2021.
SHOW NOTES
In this episode, Dr. Ryan Trojan joins Dr. Christopher Beck to discuss Evaluation and Management (E&M) coding in IR. We discuss what a practice that uses E&M looks like and the pros of integrating E&M into a practice while IR becomes more clinical. Dr. Trojan explains why he thinks relative value units (RVUs) are worth the bit of extra time. We clear up some of the misinformation about E&M, and we discuss global billing periods.
We discuss templates, Epic, and some important details about Modifier-25 for E&M. We explain medical decision making in terms of problem point, data points, and risk. We discuss the four levels of complexity and the subsets of risk. We talk through documenting history and why it is important to use straightforward language.
We discuss the most typical codes used in E&M and which codes to know for specific scenarios such as physical exams, consults, and admission. Dr. Trojan tells us some of the updates to E&M in 2021 for outpatient care. We talk about how E&M is useful when building relationships with referring doctors.
RESOURCES
Dr. Trojan’s Youtube Video https://tinyurl.com/b5pvbcer
Dr. Trojan’s Templates Progress Notes: https://tinyurl.com/2uzm6hua
Beck Outpatient Consultation: https://tinyurl.com/uaukf7vc
Beck Inpatient Consult Note: https://tinyurl.com/a7fupr67
Resident Time Phrases: https://tinyurl.com/5uvxattn
Inpatient Consult: https://tinyurl.com/2vebu7rz
SIR Toolkit https://tinyurl.com/3ctz27a8
E&M Coding Education https://emuniversity.com/
Financial Advising https://www.edwardjones.com/us-en/financial-advisor/yaphet-tadesse
Dr. Sabeen Dhand talks with Dr. John Moriarty about how he started removing "clot in transit" from the right heart, in addition to the PE and caval procedures, and how this service line has created a great collaboration with cardiology colleagues at UCLA Health.
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In this episode, Dr. John Moriarty joins Dr. Sabeen Dhand to discuss novel right heart interventions. Dr. Moriarty tells us how he started working on right heart interventions, and we describe what a clot in transit is and how often they occur.
We explain how to decide when to do a right heart intervention for various types of clots, and we discuss the difference between the European and US right heart registries. We talk through some of the common devices used for right heart interventions, such as the angiovac.
We compare cable work and right heart work, and we discuss how collaborating with cardiology and anesthesia can be helpful. Dr. Moriarty tells us how often he uses a transesophageal echocardiogram (TEE). We share some advice for those hoping to start performing right heart interventions and how to build confidence when starting this part of his practice.
RESOURCES
Edward Jones Financial Advisor Yaphet Tadesse: https://www.edwardjones.com/us-en/financial-advisor/yaphet-tadesse
Dr. Julio Palmaz talks with Dr. Bryan Hartley about where he got the idea for the first commercially-available vascular stent, how he developed it working in his garage, and persevered despite repeated rejections to take it to market. Don't miss this one!
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In this episode, Dr. Julio Palmaz joins Dr. Bryan Hartley to discuss the origin story of his invention, the Palmaz Stent. Dr. Palmaz tells us about how he got into IR and the difference between practicing in Argentina and the United States. We discuss how Dr. Palmaz became interested in innovation and how he got started in academia.
Dr. Palmaz talks about what inspired him to make the stent and what angioplasty looked like before he started working on the Palmaz Stent. We discuss how he began working on a prototype out of his garage, and we explain some of the challenges he faced in trying to get balloons to test out. We talk about welding and the cross points of the stent, and Dr. Palmaz tells us about the challenges of proposing his ideas to companies.
We discuss working with mentors, getting grants and investors, and approaching Johnson & Johnson. Dr. Palmaz shares some of the biggest challenges he faced during his innovation of the Palmaz Stent. He explains his newest projects and what he sees for the future of medical devices.
Dr. Sabeen Dhand and Dr. Kumar Madassery discuss the importance of below-ankle interventions in limb salvage, including patient selection, technique, and a patient-centered longitudinal care plan.
SHOW NOTES
In this episode, Dr. Kumar Madassery joins Dr. Sabeen Dhand to discuss below ankle interventions. We discuss how to approach tissue loss in patients with severe and multi-level disease in order to minimize below ankle interventions and how to optimize imaging to get a comprehensive view.
We explain the tips and tricks of performing a pedal loop, and we review the techniques for retrograde access. We review how to carefully manipulate wires during a pedal loop procedure. We discuss which devices can go through the pedal loop and what qualities are important in a wire for below ankle interventions.
We discuss why having lysing can lead to a successful below ankle intervention and how to know when it is appropriate to do a pedal loop. We talk about the impact social media has had on IR and give some advice for those wanting to try pedal interventions.
RESOURCES
Dr. Madassery’s Twitter: @kmadass
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In this special Innovation episode, Dr. Aravind Arepally tells us the stories behind what inspires him to shoot for big impact projects, how he built a startup device company with Jim Chomas, and the importance of working with people who give you energy and challenge you.
SHOW NOTES
In this episode, Dr. Aravind Arepally joins Dr. Bryan Hartley to discuss his development and innovation of medical devices. Dr. Arepally tells us how his childhood experiences influenced him to become a physician and how his mentors during fellowship inspired him to become an innovator. We discuss how a grant writing class opened up the world of research for Dr. Arepally and connected him with engineers.
We talk about how important it is to have collaborative partners and why not to ignore any of the crazy ideas. Dr. Arepally shares his experience working in Germany for four months and how he started focusing on obesity and minimally invasive procedures. We discuss some of the challenges of trying to innovate while working in a private practice.
We explain the origin story of Dr. Arepally’s company, SureFire and how he developed a business plan. We discuss fundraising, finding investors, and developing prototypes. Dr. Arepally tells us about his current projects, his future plans for innovation, and why he wants to focus on need based devices.
We talk with Dr. Chris Pittman, founder of Vein911 and LinkedIn Foam Sclerotherapy Experts, about Foam Sclerotherapy for the treatment of superficial venous disease, including technique, patient workup, and some of the reasons why foam is underutilized.
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In this episode, Dr. Chris Pittman joins Dr. Aaron Fritts to discuss the underutilization of foam sclerotherapy. Dr. Pittman tells us about how he started his vein treatment centers and about his upcoming reality TV show. We introduce the basics of foam sclerotherapy for varicose veins and how the procedure has been developed. Dr. Pittman shares some reasons why he thinks foam sclerotherapy is not as popular in the United States.
We review when to use the three types of sclerosants, hypertonic saline, sotradecol, and polidocanol as well as the difference between compounded and non-compounded sclerosants. Dr. Pittman tells us the best way to get foam sclerotherapy training. We discuss the four components for evaluating a patient who may have venous disease, and we explain how to do a hose trial and make the proper notes for insurance claims. We discuss the treatment process from when the patient arrives and some of the details of thermal ablation.
We discuss the importance of an effective treatment and why there should be at least two rounds of foam treatment. We explain some of the key points to discuss with patients to manage expectations prior to treatment. We discuss the fundamentals of foam sclerotherapy, what post-procedure follow-up looks like, and how long after to wear stockings after the treatment. We explain how the shift from fee-for-service to fee-for-value has changed some of the ways treatments are done.
RESOURCES
Contact Dr. Pittman: cpittman@vein911.com
Interventional Radiologists Dr. Michael Barraza and Dr. Aaron Fritts talk about their early careers coming out of specialty training and hard lessons learned from their first jobs.
SHOW NOTES
In this episode, Dr. Michael Barraza joins Dr. Aaron Fritts to discuss his career path and what he has learned through different job experiences. We discuss how to be proactive during a job search, and Dr. Barraza tells us about his unique experience of getting a job offer while completing his radiology training.
We discuss aspects of jobs that are not learned during training, such as partnership tracks and non-competes. We explain why partnership tracks may be long and what factors determine the intensity of a non-compete. We discuss how call responsibilities are different than during training and some of the advantages of working in a large group.
Dr. Barraza shares his first job experience, why it was not a good fit for him, and how he learned what to look for in his next job. We discuss how to adjust a job search once you have a better idea of where you will fit in and the importance of networking and maintaining relationships with referring doctors. We give some advice to current trainees about how to continue working when you are not getting the opportunities you want and how to know when to switch jobs.
We check back in with Dr. Tim Yates one year after his transition into the OBL to discuss the pros and cons of practicing in the OBL setting.
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In this episode, Dr. Tim Yates joins Dr. Lincoln Patel again, after one year, to discuss his life in the outpatient based lab (OBL). Dr. Yates shares how his OBL practice has been going and how the COVID-19 pandemic affected the beginning of his transition. Dr. Yates gives an update on the expansion of OBL offices, and he explains the importance of building connections with other physicians and companies.
We discuss how to meet partners in the community and build relationships within the market in some unique ways, and we mention how to adapt marketing methods during a pandemic. We talk about some challenges the OBL has faced while trying to grow in the endovascular and oncology world and while trying to incorporate Y90 into the practice. We discuss why having a fixed floor unit is helpful and how equipment limitations may change how the interventionist approaches some cases.
We discuss the differences between working in a hospital and an OBL, and Dr. Yates shares what part of his new job has been the most fulfilling. We talk about the importance of learning to coach and manage personnel. Dr. Patel tells us about how he changed his career path and some lessons he learned along the way. We discuss which skills have been useful in the OBL setting, and we give some advice to those considering a transition to OBL.
RESOURCES
Dr. Tim Yates Interview from February 2020 https://www.backtable.com/shows/vi/podcasts/55/transitioning-from-hospital-to-obl-practice-part-i https://www.backtable.com/shows/vi/podcasts/56/transitioning-from-hospital-to-obl-practice-part-ii
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We talk with Interventional Radiologists Dr. Robbie Morrison and Dr. Srini Tummala about the pros and cons of adding a wound care services to your endovascular practice.
SHOW NOTES
In this episode, Dr. Robbie Morrison and Dr. Srini Tummala join Dr. Aaron Fritts to discuss adding wound care to a practice. Dr. Morrison and Dr. Tummala tell us about their work and why they, as endovascular specialists, wanted to include wound care at their practice. We discuss some examples of the benefits of wound care, and Dr. Tummala shares why he thinks wound care is the future of the vascular speciality.
We explain how the referral process works and how it may vary from practice to practice. We discuss why it is important to be well-rounded in wound care and how a background in IR can help with this. Dr. Morrison tells us how he collaborates with a nurse practitioner to elevate his care and we explain why it can be difficult to differentiate patients at the referral level.
We discuss how to get wound care training and certification and Dr. Morrison talks about the learning curve during training. We review some of the pearls of wound care and give some advice on how to present yourself to other physicians when getting started.
RESOURCES
BackTable Podcast Episode 86: Building a PAD Practice with Dr. Srini Tumala https://www.backtable.com/shows/vi/podcasts/86/building-a-pad-practice
Dr. Tummala’s Vascular Channel https://www.youtube.com/channel/UCAbrKSywIzcobBpp0FUo34w
Dr. Tummala’s Twitter @srinitummala
Medtronic Abre Stent https://www.medtronic.com/us-en/healthcare-professionals/products/cardiovascular/deep-venous/abre-venous-stent.html
Dr. Theresa Caridi, Section Chief of Interventional Radiology at UAB School of Medicine, discusses the pathophysiology and treatment of Pulmonary AVM's, as well as the importance of multidisciplinary management of patients with Hereditary Hemorrhagic Telangiectasia (HHT).
SHOW NOTES
In this episode, Dr. Theresa Caridi joins Dr. Christopher Beck to discuss management and treatment of pulmonary arterial venous malformations (AVMs). We explain what pulmonary AVMs are, why they can be dangerous, and how patients are referred to Hereditary Hemorrhagic Telangiectasia (HHT) Centers of Excellence. We discuss the clinical manifestations of HHT and why it is important to screen for HHT when diagnosing a patient with a pulmonary AVM.
Dr. Caridi tells us about the imaging and how to plan treatments for different types of pulmonary AVM patients. We review the pre-procedural steps and the intricacies of using anesthesia for PAVM treatment. We discuss catheters, access sites, and how to get the images needed. Dr. Caridi shares her advice on working closely to the feeding artery and some of the challenges when using coils.
We discuss what care looks like post-procedure and when to follow up patients. We talk about some of the common side effects that occur after pulmonary AVM treatment. We explain how to decide the number of lesions to treat at one time, and Dr. Caridi gives some advice for those who do not work at an HHT Center of Excellence, but want to perform this procedure.
RESOURCES
Image Guided Interventions: Expert Radiology Series (IR Textbook by Matthew A. Mauro) https://www.elsevier.com/books/image-guided-interventions/mauro/978-0-323-61204-3 https://www.amazon.com/Image-Guided-Interventions-Matthew-Mauro-FACR/dp/0323612040/ref=sr_1_1?dchild=1&keywords=Image-Guided+Interventions%3A+Expert+Radiology+Series&qid=1612320492&s=books&sr=1-1
PAVM Embolization: An Update https://www.ajronline.org/doi/10.2214/AJR.10.5230
Treated pulmonary arteriovenous malformations: patterns of persistence and associated retreatment success https://pubmed.ncbi.nlm.nih.gov/23912618/
Medtronic Peripheral Embolization Products https://www.medtronic.com/us-en/healthcare-professionals/products/cardiovascular/peripheral-embolization.html
Dr. Steven Yevich from MD Anderson Cancer Center talks with us about his approach to Treatment and Management of Painful Extra-spinal Bony Metastases.
SHOW NOTES
In this episode, Dr. Steve Yevich joins Dr. Michael Barraza to discuss treatment of extraspinal painful bony metastases. Dr. Yevich tells us about his training in interventional oncology at Gustave Roussy Cancer Campus in Paris, and we discuss how he adjusted to identify the individual needs of the hospital when he came back to the US.
We explain how to go into a case with either curative or palliative intent. Dr. Yevich shares when he would do soft tissue ablation around nerves and the location of the metastases he commonly treats. We emphasize the anatomic considerations to determine if ablation for the extraspinal bony metastases is feasible.
We discuss some of the advanced techniques Dr. Yevich learned in Paris and the two types of cases that may need pre-ablation embolization. We discuss advancements in technologies and devices that have allowed for more creative solutions in IR.
Society of Interventional Radiology (SIR) President Dr. Michael Dake tells us stories of the Aortic and Endovascular Innovations he participated in throughout various stages in his career.
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In this episode, Dr. Michael Dake joins Dr. Bryan Hartley to discuss his career of innovation as a clinician, teacher, and researcher. Dr. Dake tells us how he shifted from working in internal medicine to interventional radiology with the help of his mentors.
We discuss the challenges of starting a new residency, and Dr. Dake shares how he knew he wanted to follow a different career path in vascular work. We review the different types of cases that came up from working with cardiac surgeons and other specialties outside of IR. We discuss some lessons learned from working on the clinical side and the industry side of IR.
Dr. Dake explains which failures have stuck with him and touches on why relationships and collaboration are so important. We discuss his current work on a liquid embolic and how involvement in innovative opportunities has shaped Dr. Dake’s career.
RESOURCES
ISET; use discount code: BACKTABLE https://www.iset.org
Dr. Fabian Laage Gaupp tells us the origin story of Road2IR.org, an initiative to build self-sustaining IR training programs in East Africa. In collaboration with Yale and Emory Departments of Radiology, Road2IR has helped establish East Africa’s first accredited IR training program in Tanzania!
SHOW NOTES
In this episode, Dr. Fabian Laage Gaupp joins Dr. Aaron Fritts to discuss his work in The Road2IR training program. We discuss the beginnings of the program and how they worked to build the first generation of interventional radiologists as well as nurses and technologists in Tanzania. We discuss the types of procedures that the program offers and how they have adapted to the needs of the communities they work with.
We explain how the training measures have changed during the COVID-19 pandemic, and we examine the importance of having a certain mindset while working in this program. Dr. Laage Gaupp tells us about the sedation certificate nurses can train for and their plans for expanding the program to Rwanda.
We discuss some of the challenges of shipping imaging equipment and other disposable equipment. Dr. Laage Gaupp explains why he thinks IR will gain popularity in Africa, and we talk about how to get involved in the Road2IR program.
RESOURCES
Tanzania IR Initiative, Training the First Generation of Interventional Radiologists https://www.clinicalkey.com/service/content/pdf/watermarked/1-s2.0-S1051044319306876.pdf?locale=en_US&searchIndex=
Road2IR website https://www.road2ir.org/
Social Media Accounts Instagram: @road2ir Twitter: @Road2IR Facebook: https://www.facebook.com/road2IR/
Dr. Mary Costantino interviews the BackTable Team in honor of hitting the 100th episode mark. We had a great time telling the origin story of BackTable, reminiscing the early days of the podcast, and where we hope to go in 2021. It doesn't happen without all the amazing guests and guest hosts along the way.
SHOW NOTES
In this special episode, Dr. Mary Constantino interviews Dr. Aaron Fritts, Dr. Christopher Beck, and Dr. Michael Barraza to discuss the journey of the BackTable Podcast. Co-founder Dr. Aaron Fritts tells us why he wanted to start BackTable and how it transformed from an app to a podcast. Dr. Beck and Dr. Barraza share their experiences getting involved in the podcast.
We discuss some of the early challenges they faced while trying to get started, and we explain the lessons learned from these experiences. We discuss plans to expand to ENT and urology topics as well as other plans for 2021. Dr. Fritts touches on the learning process of editing audio and creating a podcast. Dr. Fritts, Dr. Beck, and Dr. Barraza share their goals and hopes for the BackTable podcast. We discuss the work that goes on behind the scenes and the team that makes it all possible.
Dr. Ezana Azene M.D., Ph.D. talks with us about how he found his side gig reviewing insurance claims, and shares tips on how to avoid insurance claim denials for procedures.
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SHOW NOTES
In this episode, Dr. Ezana Azene joins Dr. Christopher Beck to discuss reviewing medical cases for insurance claims. Dr. Azene tells us how often he reviews insurance claims for IR procedures, and he explains what the step-by-step process looks like once he gets a case to review.
We discuss how to search for information to show a procedure was done in extenuating circumstances by looking at clinic notes and labs, in addition to previous reviews from other physicians. We review some mistakes that physicians make that could keep an insurance claim from being approved, and we discuss why documenting all previous interventions is important.
We explain why it is helpful to understand the patient’s insurance policy and how citing articles and references can support an insurance claim. Dr. Azene shares how reviewing medical cases has improved his documentation, and we give some advice on how to get involved in this process.
RESOURCES
IR Quarterly article featuring Dr. Azene https://connect.sirweb.org/e-irq/participate/viewirqarticle?DocumentKey=ec2b47d8-e067-4628-a40a-ab19021ab36a
In Part 2 of their Pelvic Congestion Syndrome discussion, Dr. Mark Meissner and Dr. Michael Cumming get into their specific techniques, tips and tricks for embolization, and follow up care.
SHOW NOTES
In this episode, Dr. Mark Meissner and Dr. Michael Cumming join Dr. Michael Barraza to discuss techniques for treating Pelvic Congestion Syndrome. We examine their goals for therapy and why to approach the internal iliac veins first. We discuss which catheters they use and how to approach venograms in a therapeutic way, rather than diagnostic.
We share a new technique for coiling that reduces procedure time and pain for the Pelvic Congestion Syndrome patient. We discuss the challenges of embolization and why we often rely on the sclerosant when using an occlusion balloon. Dr. Meissner and Dr. Cumming tells us about the post-procedure management, why to follow-up after the first menstrual period, and why to make foam using CO2 when a patient has a history of migraines.
We examine the verbiage of the name “Pelvic Congestion Syndrome” and how it leads to misconceptions about its etiology. Dr. Meissner shares his process for treating Nutcracker Syndrome, and we discuss the potential problems of renal vein stenting.
Vascular Surgeon Dr. Mark Meissner and Interventional Radiologist Dr. Michael Cumming discuss diagnosis and treatment planning for Pelvic Congestion Syndrome. This is Part 1 of 2 on Pelvic Congestion Syndrome.
SHOW NOTES
In this episode, Dr. Mark Meissner and Dr. Michael Cumming join Dr. Michael Barraza to discuss Pelvic Congestion Syndrome. We discuss the pathophysiology of Pelvic Congestion Syndrome and the fundamentals of pelvic venous hypertension. Dr. Meissner and Dr. Cumming tell us how patients end up in their clinic.
We discuss why it is important to distinguish primary and secondary causes of Pelvic Congestion Syndrome and the dangers of an incomplete embolization. We review some techniques for ultrasounds, why not to rely on cross-sectional imaging, and the advantages of getting a CT for the Pelvic Congestion Syndrome patient.
We discuss how to adapt treatment plans for women that have never been pregnant or women that are post-menopausal. Dr. Meissner and Dr. Cumming explain how they frame their goals and expectations for each patient’s treatment process, and we examine when it is appropriate to use a multi-modality approach to treat Pelvic Congestion Syndrome.
RESOURCES
Check out our other episode featuring Dr. Michael Cumming: https://www.backtable.com/shows/vi/podcasts/52/ivus-for-iliac-vein-compression
Bryan Hartley talks with Lawrence "Rusty" Hofmann MD about his experiences in device and digital health innovation, including the inspiring story behind building Grand Rounds, a digital health company helping patients get better access to expert healthcare.
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In this episode, Dr. Randy Hofmann joins Dr. Bryan Hartley to discuss his path to creating an innovative digital health company. Dr. Hofmann tells us how he became an IR and discusses his start in medical devices. We share some advice on how to get started on a new project.
We discuss Dr. Hofmann’s health technology company, Grand Rounds, which offers clinical and financial guidance. Dr. Hofmann explains why he came up with the idea for a digital health company and how his experiences as a father and husband influenced his advocacy for patient education.
In this episode, Dr. Jason Levy and Dr. Amir Lavaf join Dr. Michael Barraza to discuss their multidisciplinary approach to treating spinal metastases. We examine the collaborative efforts between IR and radiation oncologists, and we break down the indications for treating spinal metastases. We discuss pain control and local control rates, and how doctors are working to improve them. Dr. Levy and Dr. Lavaf tell us why they are able to get better survival numbers when they approach the primary and metastatic disease at the same time. We explain how to work with tumor boards and different groups of doctors to make spinal metastases treatment easier. We discuss how to reduce risk of delayed skeletal events and radiation failure after spinal metastases treatment. We go over some of the challenges of working with the tumor board, and why it is important to develop relationships with medical oncologists and the importance of continuing systemic therapies. RESOURCES MENTIONED: BackTable Podcast Episode 68: RF Ablation Therapy for Bone Metastases https://www.backtable.com/podcast/68/rf-ablation-therapy-for-bone-metastases
In this episode, Dr. Ameer Hassan joins Dr. Sabeen Dhand to discuss the use of artificial intelligence (AI) to improve stroke care. We explain the hub and spoke model and how the primary stroke centers communicate in the hub. Dr. Hassan describes how the system determines which center a stroke patient will go to. We discuss how the system optimizes the transfer from spoke to hub and how comparing trends in stroke patients allowed them to speed up the process. We explain how AI is used in stroke care using decision trees and deep learning. We discuss the benefits of using AI to remove steps and sending push notifications to phones, allowing radiologists to review imaging quicker.
Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs here: https://earnc.me/IhN6NW
RESOURCES MENTIONED: SAGE journals; Interventional Neuroradiology https://journals.sagepub.com/doi/full/10.1177/1591019920953055 Early experience utilizing artificial intelligence shows significant reduction in transfer times and length of stay in a hub and spoke model
In this episode, Dr. David Field joins Dr. Aaron Fritts to discuss nephrostomy tube placement. We talk about the most common indications for this procedure, and Dr. Field explains why he prefers the single stick technique over the double stick technique. We discuss why it is important to scan the patient with ultrasound before preparing them for the nephrostomy tube placement. We give some tips for trainees on the process of inserting the needle, and we review the dangers of over-pressurizing. We discuss how much blood in the urine is worrisome, managing anticoagulation meds, and which labs to run prior to the nephrostomy tube placement. Dr. Field tells us about using guidance software and how to properly direct the needle, once inside the patient. We discuss why you might inject air rather than contrast. We emphasize the importance of working with urology ahead of time and what post-op care looks like for different types of patients. Dr. Field gives some advice when dealing with the challenges of nephrostomy tube placement, and we give trainees some general advice on this procedure.
Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs here: https://earnc.me/r2AlYc RESOURCES MENTIONED: Nephrostomy Tube Placement Procedure https://www.backtable.com/app-procedure/nephrostomy-tube-placement
In this episode, Dr. Matt Raynor and Dr. Ari Isaacson join Dr. Michael Barraza to discuss their prostatic artery embolization (PAE) program. They tell us about their new book and how they worked with IR and urology to build their program. We discuss how they got started with their first patient and explain when to follow up with PAE patients. We talk about the initial challenges of starting the PAE program, and we discuss what type of patients would be good candidates for the procedure. Dr. Raynor and Dr. Isaacson give us some advice on how to make a pitch to Urology practices that treat benign prostatic hyperplasia (BPH) patients. We discuss how IR and urology departments can collaborate and how to work with physicians who are skeptical. We examine how they approach the market for this procedure and why word-of-mouth from previous patients is so important. We emphasize learning the technique of the prostatic artery embolization, but also why interventional radiologists should learn about BPH disease process in detail. RESOURCES MENTIONED: Prostatic Artery Embolization https://www.amazon.com/Prostatic-Artery-Embolization-Ari-Isaacson/dp/3030234703/ref=sr_1_1?dchild=1&keywords=prostatic+artery+embolization&qid=1606166571&sr=8-1 This is the book by Dr. Raynor and Dr. Isaacson about PAE in IR. BackTable Podcast episode 17: Prostate Artery Embolization with Dr. Ari Isaacson and Dr. Sandeep Bagla https://www.backtable.com/podcast/17/prostate-artery-embolization Check out another episode about PAE with Dr. Isaacson!
In this episode, Dr. Brinton tells us how he started as a biomedical engineer and why he eventually went to medical school. We discuss how important mentorship can be, and we talk about how he was able to balance residency with building a company. Dr. Brinton shares some of the biggest lessons he has learned while being an innovator, and he discusses the goals of his company, Shockwave. We talk about the importance of understanding the patient population and some of the technical challenges of creating solutions to healthcare problems. We speak about Dr. Brinton’s position as the Fellowship Director of BioDesign at Stanford, and how he worked to train the next generation of innovators. We review the importance of needs driven innovation in medicine and how to keep the patient at the center of the innovation process. We discuss the importance of having a creative, multidisciplinary team behind an invention. We share some advice for physicians wanting to get started in needs driven innovation and explain when to file for intellectual property. Dr. Brinton explains why it can be important to “fail often and fail fast.”
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In this episode, Dr. Douglas Beall joins Dr. Michael Barraza to discuss innovation in spine interventions. Dr. Beall tells us how he got his training in spine interventions and shifted to a more clinical approach. We talk about how following patients longitudinally can help determine the true source of pain, and the benefit of implementing new methods into a practice. We discuss what the term interventional radiologist really means and the importance of diagnostic input. We discuss an example of an out of the box spine intervention that helped a patient. Dr. Beall speaks about his new book that came out earlier this year and how it is different from other textbooks and how he has been using Twitter to give tips and tricks. We talk about how this inspired Dr. Beall to re-start a fellowship training program for spine intervention. We discuss studies and trials that were done on vertebral augmentation, and we examine the relationship between the name and value of interventional radiology. We touch on some goals for AI use in spine interventions and its impact on diagnosis and treatment.
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RESOURCES MENTIONED: Book by Dr. Beall: Vertebral Augmentation: The Comprehensive Guide to Vertebroplasty, Kyphoplasty, and Implant Augmentation https://www.amazon.com/gp/product/B0856PWC7G/ref=dbs_a_def_rwt_hsch_vapi_tkin_p1_i0 Check out Dr. Beall on Twitter @dougbeall
In this episode, Dr. Fadi Saab joins Dr. Sabeen Dhand to discuss deep venous arterialization for critical limb ischemia. Dr. Saab explains how gained experience in this procedure and the changes in treatment of CLI that have occurred over the past few years. We discuss the concept of deep venous arterialization and some common patient concerns.
We talk about working as a team with podiatrists and wound care specialists, who the best candidates for deep venous arterialization are, and Dr. Saab explains the term “white stop sign.” We discuss the setting of these procedures and why having the right support staff throughout the case is so important.
We examine the technique and steps of the deep venous arterialization procedure, as well as potential pitfalls to avoid. Dr. Saab describes his protocol for post-procedure care, and we discuss how technology has impacted this field in recent years.
RESOURCES MENTIONED:
https://www.iset.org/ Use the discount code (BACKTABLE) to register for ISET.
CLI Fighters Global Society https://www.cliglobalsociety.org/
In this episode, Dr. Justin Lee joins Dr. Christopher Beck to discuss hepatocellular carcinoma (HCC) and interventional oncology in private practice. Dr. Lee tells us how he frames his HCC patients and works with medical oncologists for treatment plans and procedures.
We talk about the importance of IR bringing cases to the tumor board, the evolution of cases involving ablation, and why Dr. Lee started moving towards radioembolization (Y90). We review how to approach HCC cases while working with medical oncologists.
We examine the differences between using resin and glass for radioembolization and when they should be used. Dr. Lee shares why IR should start looking into arterial drug delivery for immunotherapies.
RESOURCES MENTIONED:
NEJM: Atezolizumab plus Bevacizumab in Unresectable Hepatocellular Carcinoma https://www.nejm.org/doi/10.1056/NEJMoa1915745 This paper, mentioned by Dr. Lee, discusses the third phase of an HCC trial.
In this episode, Dr. Justin Lee joins Dr. Christopher Beck to discuss interventional oncology in private practice. We talk about challenges that come with developing a private practice, the transition from academics to community hospitals, and how to be comfortable speaking the language of oncologists.
Dr. Lee emphasizes why it is important to come out of a fellowship knowing the latest information in the field, and we cover some important details regarding scheduling oncology patients.
We discuss ways to build physician-physician relationships when it comes to referrals and why it is important to remember that not everyone knows what an interventional radiologist is or the services they might offer. Dr. Lee mentions how he made adjustments at his private practice to maintaining a healthy conversation between diagnostic and interventional radiology.
In this episode, Jill Sommerset joins Dr. Mary Costantino to discuss how she developed Pedal Acceleration Time (PAT) for limb salvage. She begins by talking about what got her into vascular ultrasound and the importance of vascular techs, especially for pre-operative planning.
We discuss how she invented the pedal acceleration time technique by tracking data from foot scans. Jill speaks about PAT classifications and how they correlate to ABI (Ankle-Brachial Index) numbers. We talk through how they use pedal acceleration time on a typical day and for some different types of patients.
We go over some of the limitations of PAT and some of the cases where it is extremely helpful. Jill discusses her role in the cath lab, how she is developing a platform for pedal acceleration time training, and why it is important for both the physician and vascular tech to learn about PAT.
RESOURCES MENTIONED:
International Symposium on Endovascular Therapy www.iset.org Use the discount code (backtable) to register for ISET.
In this episode, Dr. Theodosios Bisdas joins Dr. Aaron Fritts to discuss online education and his e-learning platform, Vascupedia. Dr. Bisdas talks about how he started the platform and the three main parts of the website: main arena, polling station, and exhibition area. We talk about how social media has helped expand his platform to American audiences and how to collaborate with companies and medical societies to present new devices. We go over some of the main challenges of e-learning and why it is important for physicians to have time to watch webinars. Dr. Bisdas emphasizes the value of virtual learning, having forums for international conversation, and he speaks about his hopes for the future of Vascupedia. We discuss the benefits of on-demand, high quality online content and the importance of platforms created by physicians for physicians.
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RESOURCES MENTIONED: Vascupedia https://vascupedia.com/ This website contains the online learning platform mentioned by Dr. Bisdas.
In this episode, Dr. Rajeev Narayan joins Dr. Achal Sahai to discuss structural heart disease and the (Transcatheter aortic valve replacement) TAVR procedure. Dr. Narayan talks us through what an average working week looks like and speaks to the importance of having a great referral network. We define structural heart disease and discuss the development of the TAVR procedure for high risk patients and how the process is different from a regular cardiac surgery. We examine what can make a patient with structural heart disease high risk and eligible for TAVR. We talk through how access has changed over the years and some of the more technical aspects of these procedures. Dr. Narayan gives some advice to trainees and emphasizes the importance of learning to face complications on your own.
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In this episode, Dr. Rajeev Suri joins Dr. Christopher Beck to discuss ascites and paracentesis. Dr. Suri touches on what a potential paracentesis candidate might present with and speaks about why no lab values or blood tests are needed prior to the procedure. We discuss the basic steps for removing ascites, how to find the side with the biggest pocket, and preventing leakage by using a Z pattern. He speaks to the circumstances for using direct US guidance rather than intermittent and when, if ever, to use glue or stitches after paracentesis. We mention the benefits of utilizing the Renova Pump for fluid removal and discuss why Dr. Suri might use a vacuum container bottle rather than a wall suction. Lastly, we examine some methods for managing recurring patients in the ascites clinic. Dr. Suri also discusses how his practice has incorporated a paracentesis clinic to reduce the number of emergency room visits for ascites and how this practice has improved workflow and patient access to an interventional radiologist. RESOURCES MENTIONED: RenovaRP® Paracentesis Management System www.rethinkparas.com This website allows you to download the case study mentioned by Dr. Beck and check out other products from GI Supply. AASLD Guidelines https://www.aasld.org/publications/practice-guidelines This website includes the 2013 guidelines for ascites management. SIR Coagulation Guidelines https://www.jvir.org/article/S1051-0443(19)30407-5/pdf This pdf has recommendations for periprocedural management of thrombotic and bleeding risks in patients. Denver Shunts https://www.ajronline.org/doi/full/10.2214/AJR.12.9203 This article, mentioned by Dr. Suri, discusses the placement and management of Denver shunts for portal hypertensice ascites.
In this episode, Dr. Jafar Golzarian joins Dr. Michael Barraza to discuss genicular artery embolization for osteoarthritis. Dr. Golzarian describes how he worked and collaborated with orthopedic surgeons to offer this procedure for his patients. He also speaks about some potential underlying causes and aggravating factors for osteoarthritis.
Dr. Golzarian provides useful tips on taking an academic approach to setting up trials and what makes his trials different from previous studies on genicular artery embolization. We discuss why patients with osteoarthritis can be a challenge for family practitioners and how collaboration with IR can benefit these patients.
We go into the differences in the procedure for hemarthrosis and osteoarthritis. We review some ways to find the best angle to identify an arterial origin for embolization, and we discuss some of the challenges in the embolization procedure and how to adapt to different types of patients.
In this episode, Dr. Eric Monroe joins Dr. Christopher Beck to discuss using intra-arterial chemotherapy (IAC) as a treatment for retinoblastoma. Dr. Monroe touches on how he has been using telemedicine during this time and the process of considering a patient for IAC. We go over the details of the intra-arterial chemotherapy procedure and we mention some challenges that may arise in dealing with equipment for pediatric patients, specifically how to have a successful procedure while maintaining a low radiation dose. Dr. Monroe speaks about post procedural care including follow-up intervals and what those visits entail. We discuss some of the common complications that can occur during intra-arterial chemotherapy. Dr. Monroe gives some advice about the mental preparation and learning curve that comes with developing skills for IAC.
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RESOURCES MENTIONED: A Review of the Literature for Intra-Arterial Chemotherapy used to Treat Retinoblastoma https://pubmed.ncbi.nlm.nih.gov/26886915/ This is the article mentioned by Dr. Monroe which gives an overview of retinoblastoma.
Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs here: https://earnc.me/gpvwSB In this episode, Dr. Eric Keller joins Dr. Christopher Beck to discuss medical ethics within IR. He speaks about using a bottom-up approach of applied ethics, and we examine why a combination of casuistry and virtue ethics may be helpful rather than principlism. We dig deeper into medical futility and the challenge of prospectively determining if a procedure is futile. Dr. Keller describes how to design a study that can explore medical ethics as well as methods of collecting and presenting data in an ethical way. We discuss advanced care planning, managing bias, and the role that unbounded ethicality plays in research. We talk through some benefits and drawbacks of ethics boards as well as how using decision support aides may improve informed consent and allow patients to become advocates for themselves. RESOURCES MENTIONED: Journal of the American Geriatrics Society https://onlinelibrary.wiley.com/action/doSearch?AllField=futility&SeriesKey=15325415 This website presents all the papers in the journal that are related to futility. Journal of the American Geriatrics Society (Medical Futility: Where Do We Go from Here?) https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1532-5415.1994.tb06570.x This article discusses various perspectives on medical futility. Decision Aids to Help People who are Facing Health Treatment of Screening Decisions https://www.cochrane.org/CD001431/COMMUN_decision-aids-help-people-who-are-facing-health-treatment-or-screening-decisions This article evaluates the effects of decision aids on health outcomes. Prevalence of Unprofessional Social Media Content Among Young Vascular Surgeons https://pubmed.ncbi.nlm.nih.gov/31882313/ American Geriatrics Society Feeding Tubes in Advanced Dementia Position Statements https://onlinelibrary.wiley.com/doi/full/10.1111/jgs.12924 This article discusses feeding tubes and how to handle feeding for patients with advanced dementia. The Impact of Advance Care Planning on End of Life Care in Elderly Patients https://www.bmj.com/content/bmj/340/bmj.c1345.full.pdf This article describes a randomized controlled trial that examines advanced care planning. Does Facilitated Advance Care Planning Reduce the Costs of Care Near the End of Life? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4838173/ This paper discusses the ethical conflicts in advanced care planning. Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units https://www.atsjournals.org/doi/full/10.1164/rccm.201505-0924ST This article describes how to handle treatment disagreements in the ICU. Research Ethics in IR: The Intersection Between Care and Progress https://pubmed.ncbi.nlm.nih.gov/32359529/ This paper mentions the ethical issues in collecting and presenting data. It also discusses the role IR plays in conflict of interest and bias. Understanding Bias: A Look at Conflicts of Interest in IR https://www.researchgate.net/publication/332750177_Understanding_Bias_A_Look_at_Conflicts_of_Interest_in_IR This article examines conflicts of interest and how they affect the field of IR. Reflect and Remember: The Ethics of Complications in Interventional Radiology https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6531013/ This paper discusses the ethics behind the relationship between IR and complications. Informed Consent: Beating a Dead Horse or an Opportunity for Quality Improvement? https://www.researchgate.net/publication/338303598_Informed_Consent_Beating_a_Dead_Horse_or_an_Opportunity_for_Quality_Improvement This paper examines the ethical implications of informed consent and its complexities. Reconsidering Requests - Futility in IR https://www.jvir.org/article/S1051-0443(19)30069-7/fulltext This article discusses the ethics in challenging healthcare situations.
Interventional Radiologist Dr. Jeffrey Chick tells us about his deep venous practice at UW Medicine including tips on growing a collaborative, multidisciplinary venous program.
Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs here: https://earnc.me/xI8Csf Interventional Radiologists Dr. Sam Mouli from Northwestern University and Dr. Sandeep Bagla discuss new research examining Y-90 Radioembolization as a novel therapeutic option for treating prostate cancer.
In this episode, Dr. Neghae Mawla joins Dr. Chris Beck to discuss endovascular AV fistula creation. The episode begins by discussing the advantages of fistulas versus catheters and grafts and how guidelines have changed from “Fistula First” to the most appropriate type of access for the patient. Dr. Mawla explains the details of how he determines candidates for the EndoAVF using ultrasound for vein mapping. We then review patient preparation for EndoAVF including anticoagulation, antibiotics, and anesthesia. We share the two main systems for EndoAVF, Avenu Ellipsys and the WavelinQ device and discuss the similarities and differences between these two approaches for fistula creation. Dr. Mawla walks through his ultrasound-guided techniques and the need for dual venous and arterial access with the WavelinQ device. They review some potential complications with using these devices, including hematomas and uncontrolled arterial bleeds, and post-procedural management. Dr. Mawla discusses timelines for evaluating venous maturation in patients and when a fistula is typically ready for use. He explains the differences between EndoAVF and surgically created fistulas, including several advantages of endo-anastomosis. The episode ends by talking about EndoAVF education in dialysis centers and collaborating with nursing staff, clinics, and both device companies to re-educate staff and patients on differences in cannulation.
Interventional Radiologist Terence Gade from Penn Medicine, University of Pennsylvania Health System tells us about emerging research and therapies targeting the tumor microenvironment in Hepatocellular carcinoma (HCC).
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Dr. Martin Radvany and Dr. David Sacks discuss the role of Interventional Radiologists in the treatment of acute ischemic stroke, including training requirements, the multidisciplinary team approach, and ways to improve patient access to high quality care.
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Interventional Radiologist Dr. Gerry O'Sullivan shares his experiences with Iliocaval stenting in post-thrombotic patients, including pearls and pitfalls and the "Aiming for the bottom corner" technique.
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John Lipman, MD discusses UFE practice building, patient workup, and embolization technique in his dedicated Women's interventional practice, Atlanta Interventional Institute.
We talk with Interventional Radiologist Sarel Gaur about what inspired his #medEd #YouTube channel, where his topics come from, and tips for success for others.
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In this episode, Dr. James Caridi joins Dr. Christopher Beck to discuss the benefits of using CO2 for an angiography as well as some important tips for proper use. Dr. Caridi mentions some of the reasons for choosing CO2 rather than contrast, including its solubility, low viscosity, and buoyancy. He also speaks about CO2 angiography approaches for imaging difficult to access vasculature. Dr. Caridi also speaks to specific uses of CO2 angiography for use for mesenteric angiography and how CO2 angiography can improve the sensitivity for detection and localization of GI bleeds. Dr. Caridi and Dr. Beck also discuss some non-vascular uses for CO2 angiography as well as a technique for imaging with CO2 without having to give up wire access. We talk through safely preparing a delivery system and gently injecting CO2 to prevent/reduce reflux in the patient if needed. Finally, we go into some notes concerning dialysis, contrast induced nephropathy, and some instances when CO2 angiography should not be used.
Resources mentioned: CO2 Angiography Society http://www.co2angio.org/index.php This website features over 100 pieces of literature related to CO2 angiography, information about the newest developments, and access to membership in the society. Dr. Jim Caridi explains CO2mmander and AngiAssist
https://www.youtube.com/watch?v=MjsnHWmRZQI This video explains the portable delivery system and the gas management system.
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Dr. Jim Melton and Dr. Blake Parsons discuss the benefits of retrograde pedal access in the treatment of PAD, as well as the team approach of their outpatient CardioVascular Health Clinic , which includes Vascular Surgery, Interventional Radiology, and Interventional Cardiology working together as partners for better patient care.
Dr. Jason Levy and Dr. Sandeep Bagla discuss palliative treatment of bone metastases with radiofrequency ablation, as well as recent results from the OPuS One trial.
Interventional Radiologist Dr. Alex Kim and Dr. Christopher Beck discuss the utility of different locoregional liver therapies in bridging HCC patients to transplant.
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Dr. Sabeen Dhand and Dr. Saher Sabri discuss their various approaches to treating Type 2 Endoleaks.
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Dr. Sabeen Dhand talks with Dr. Saher Sabri about diagnosis and treatment of Endoleaks after EVAR placement. This is part one of a two part series on Endoleaks.
Transplant Surgeon Dr. Jennifer Berumen and Interventional Radiologist Dr. Isabel Newton discuss the treatment of HCC and the importance of multi-specialty collaboration in bridging these patients to successful liver transplantation. Special discussion was given around this HCC consortium article in Annals of Surgery: https://pubmed.ncbi.nlm.nih.gov/30870180/
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Dr. Eric J. Keller from Stanford Medicine Department of Radiology provides insight from his studies on the IR Identity, as well as his research on perceived turf wars between specialties.
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Special guest Dr. Mina Makary from The Ohio State University Wexner Medical Center discusses the need for better awareness and protection from the serious harmful effects of chronic low dose radiation, which can sometimes require change in institutional culture. An extremely important occupational health issue!
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Dr. Jeffrey Chick and Dr. Jacob Bundy discuss the results of their recent study in April JVIR on rates and major contributors to Physician Burnout in IR, how they compare to other specialties, and how to prevent it in your own career.
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CLI fighters Sabeen Dhand and Jihad A. Mustapha discuss the essentials of building a successful Limb Salvage program, including the importance of a multidisciplinary approach, broadening skill sets such as pedal access, and meticulous patient follow up.
Dr. Stephen Hunt of Penn Medicine at University of Pennsylvania Health System discusses ways in which his IR practice has changed in the setting of the COVID 19 pandemic, including case selection and lessons learned from colleagues in Singapore and China.
Vascular Surgeons David Dexter and Steven Abramowitz discuss endovascular treatment of lower extremity DVT, including patient selection and risks and benefits of catheter-directed therapy (CDT), mechanical thrombectomy, and pharmaco-mechanical thrombolysis.
Interventional Cardiologist Thomas Tu, MD and Interventional Radiologist Venkat Tummala MD discuss their respective approach to the treatment of Pulmonary Embolism, including risk stratification, treatment options, and endovascular technique.
Dr. Christopher Beck talks with Dr. Gregory Makris of Guy's and St. Thomas' NHS Foundation Trust in London about IR education and practice in the UK, as well as his involvement with CIRSE and the European Trainee Forum.
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In Part 2 of this 2-part series, Dr. Tim yates and Dr. Lincoln Patel provide insight on marketing strategies, as well as the importance of experience and partners in an outpatient based endovascular practice.
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In Part 1 of this 2-part series, Dr. Tim yates and Dr. Lincoln Patel provide insight on how they made their career change decisions, as well as the advantages and disadvantages of a hospital-based vs. outpatient-based endovascular practice.
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Dr. Barbara Hamilton and Dr. Mary Costantino, MD discuss inclusivity in IR, including the importance of mentorship and diversity in medicine.
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Dr. Stephen Hunt shares his international volunteer experiences traveling with IR4Nigeria and RAD-AID International. Get involved at www.rad-aid.org.
Dr. Michael Cumming and Dr. Mark Lessne discuss the utility of Intravascular Ultrasound (IVUS) in the diagnosis and treatment of Deep Venous Disease, including patient selection, appropriate assessment of stenoses and assistance with stent placement.
Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs here: https://earnc.me/ySM6hy
Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs here: https://earnc.me/zGhYib
Austin Bourgeois and Dr. Christopher Beck discuss ways you can improve your Cone Beam imaging for liver directed therapy, prostate artery embolization and how it can be used to improve safety of other procedures, such as G-tube placement.
Dr. Deepa Shree tells us about the challenges she faced building her IR practice in Chennai, and how she is spreading awareness of the specialty and training new IRs to help serve the need throughout India.
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Director of IR Innovation Dr. John Racadio and Pediatric Surgeon-in-Chief Dr. Daniel von Allmen of Cincinnati Children’s Hospital discuss their experiences in the Hybrid OR, how they built it, and how cross-specialty collaboration with pulmonary, urology, and orthopedic surgeons has greatly improved patient care.
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In this episode, Dr. Ashley Agan and Dr. Sabeen Dhand join Dr. Gopi Shah to discuss IR and ENT treatment of epistaxis. We cover the differences in how epistaxis presents for ENT and IR as well as how epistaxis presents in children and older patients. Dr. Agan tells us about the types of nosebleeds that are common and the general treatment algorithm she follows. We discuss nasal packing and decongestant sprays for treatment and how to know when to take the patient to the OR. Dr. Agan talks about isolating the bleeding spot, how to use a foley for posterior nosebleeds, and SPA litigation. We discuss why ENT might consult IR for an embolization. Dr. Dhand tells us about the contraindications for embolization and the procedure for treating the epistaxis. We review the materials that should be used and why it is important to look out for artery connections and pseudoaneurysms. We discuss the pearls and pitfalls of ENT and IR treatment of epistaxis and how to avoid the risk of stroke.
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Special Guest Dr. Luke Wilkins of University of Virginia VIR discusses BRTO and PARTO techniques for treatment of gastric variceal bleeding.
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Interventional Cardiologist (IC) Dr. Achal Sahai and Interventional Radiologist (IR) Dr. Christopher Beck discuss ways these two specialties collaborate on complex cases, share endovascular techniques, and avoid the "turf war" trap.
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Dr. Maureen Kohi from UCSF Medical Center and Dr. Sandeep Bagla from Vascular Institute of Virginia discuss the challenges of dealing with procedural complications, and the importance of talking with colleagues and mentors in effective coping.
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East Coast "McBreamy" and "Western Peder" discuss their Colapinto vs. Uchida needle preference, advantages of the ICE catheter, and other great pearls and pitfalls for the TIPS Procedure. Special thanks to our sponsor RADPAD® Radiation Protection. Protect yourself and your patients during those lengthy TIPS cases.
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Urologist Dr. Arthur Caire and IR Dr. Shelby Bennett return to the BackTable Podcast to discuss their approaches to urosepsis, stent vs. nephrostomy for a variety of presentations, and the middle-of-the-night patient.
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Dr. Mary Costantino and her contract lawyer Courtney Angeli discuss the essentials of physician contract negotiation: finding the right lawyer, partnerships, non-competes, and critical pitfalls to avoid.
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Urologist Dr. Arthur Caire and IR Dr. Shelby Bennett discuss their approaches to treating renal masses, including ways in which IR and Urology collaborate, laparoscopic versus percutaneous ablation, follow-up imaging, and more.
Dr. Arun Jagannathan and Dr. Jeffrey Chick discuss their approach to the Difficult IV access (DiVA) patient. Special thanks to sponsor Access Vascular Inc. for lending their booth at #SIR19ATX.
Dr. Thor Johnson discusses his experience with the Argon BioPince biopsy needle for liver, renal and soft tissue biopsies, including tips and tricks for obtaining better biopsy samples with fewer passes. Recorded at SIR 2019 in ATX.
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Physician on FIRE (PoF) founder Dr. Leif Dahleen discusses financial independence for physicians. Leif created his platform to inform and inspire physicians with insightful writing after he attained financial independence and the freedom to retire early. More information at physicianonfire.com
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Special guests Dr. Mike Watts and Dr. Omar Saleh discussing the ins and outs of treating PAD in the Outpatient Based Lab (OBL) setting. Includes great info on practice building, patient safety, and essential equipment. #irad #miips
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Dr. Mary Costantino tells us the story of how she built her OBL practice in Portland and discusses the advantages of performing UFE and other procedures in the outpatient setting.
Dr. David Mobley of Columbia University VIR describes his over-the-wire technique to prevent tilting in IVC filter placement. Special thanks to our sponsor Argon Medical.
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Our second podcast recorded live from Western Angiographic (WAIS) conference in Maui 2018! Dr. Sabeen Dhand interviews Dr. Peder Horner on how he built a spinal tumor ablation practice in Denver, CO, including tips/tricks on equipment and patient selection.
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Dr. Brooke Spencer gets into the pearls and pitfalls of building a comprehensive vein practice, including a detailed discussion on the treatment of May-Thurner and Pelvic Congestion syndrome.
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Interventional Radiologist Dr. Julie Zaetta and Oncologist Dr. Julie Stanton discuss the essentials of building a successful Interventional Oncology program, including the importance of a multidisciplinary approach.
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Dr. Aaron Shiloh of PA Vascular Institute discusses his experiences adding Cosmetic IR procedures to his practice, as well as some essential online marketing strategies for IRs.
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Our interventional radiologist guest Dr. Aaron Fischman gets into the details of his technique, equipment and tips/tricks for transradial access, as well as its advantages in a variety of IR interventions.
An interview with Interventional Initiative founders Isabel Newton and Susan Jackson taking us through the journey behind the awe-inspiring Without A Scalpel documentaries, including some funny stories and more exciting things to come.
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Dr. Jeffrey Chick and Dr. Ravi Srinivasa discuss what inspired them to start IRAD Lab, their advanced enteral access techniques, as well as a new technique for closing EC fistulas with laser!
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Our latest BackTable podcast on an exciting new therapy for osteoarthritis of the knee- Geniculate Artery Embolization! Our guests Dr. Ari Isaacson and Dr. Sandeep Bagla discuss their experiences and the immense potential this trans-arterial treatment has for management of people suffering from OA.
Dr. Christopher Beck and Dr. Jason Iannuccilli discuss radial vs femoral access in IO procedures, including the pros and cons of both, and a very informative "how I do it" for radial access by Dr. Iannuccilli.
In this episode, Dr. Sabeen Dhand joins Dr. Christopher Beck to discuss arteriovenous access declot procedure with the Argon Cleaner device. We review the routine declot procedure and the different methods to get access. Dr. Dhand explains why he starts out using the Argon Cleaner device and what his endpoint is. We discuss the nuances of the device in addition to tips and tricks for using the device with declots, including external massaging the fistula and an unsheathing trick.
Jeffrey Chick and Ravi Srinivasa of University of Michigan VIR. In Episode 24 they explain the advantages of using simple to learn endoscopic techniques in gallbladder, biliary and genitourinary cases.
The procedure that everyone gets excited about! In this week's BackTable podcast Mike Devane talks us through adrenal vein sampling technique, including equipment/imaging tips and tricks, as well as pitfalls to avoid. Whether looking to build an AVS service, or just preparing for that once in a blue moon case, you're certain to take away a few pearls!
Central and Upper Extremity Venous Interventions with Dr. Mark Lessne of Charlotte Radiology and Dr. Sabeen Dhand of PIH Health. In this episode our docs discuss central recanalizations, ballooning versus stents, declot techniques, and get into a ton of tips and tricks!
Vertebral augmentation can be accomplished through various techniques - Dr. Venu Vadlamudi and Dr. Kumar Madassery shed light on the utility of kyphoplasty versus vertebroplasty when treating compression fractures of the spine.
Our 20th BackTable podcast episode featuring special guests Dr. Justin Lee of Florida Interventional Specialists, and Dr. Terence Gade of Hospital of University of Pennsylvania. They discuss experiences and utility of pressure-directed, antireflux infusion for TACE treatments.
Our holiday episode featuring Dr. Jeffrey Chick and Dr. Ravi Srinivasa of University of Michigan. They sit fireside with our host J. Michael Barraza Jr. to discuss lymphatic interventions in IR.
Dr. Jeffrey Chick and Dr. Ravi Srinivasa discussing complex lower extremity venous interventions at University of Michigan VIR.
Special guests Dr. Ari Isaacson and Dr. Sandeep Bagla sharing their experiences with prostate artery embolization, including a candid discussion on practice building, equipment, and a brief intro on what to expect at the upcoming STREAM PAE course Jan 13 in Washington DC.
In our first podcast on pressure directed therapy, Dr. Charles Nutting and Dr. Nainesh Parikh discuss some of the first principles of Y90 radioembolization delivery, and the potential advantages of pressure directed devices over end-hole catheters in the treatment of HCC.
Podcast episode 14 with J. David Prologo and J. Michael Barraza Jr. discussing Novel Bariatric and Pain Interventions.
Our docs discuss integrating neurovascular interventions (part 2) into your IR practice with Venu Vadlamudi and Sabeen Dhand.
Our docs discuss integrating neurovascular interventions (part 1) into your IR practice with Venu Vadlamudi and Sabeen Dhand.
On Episode 11 of the BackTable Podcast Robert Ryu and AJ Gunn discuss building a filter retrieval practice, equipment preferences, and challenging cases.
Dr. Keith Pereira and Dr. Chris Beck discuss building their UFE practice and transradial versus transfemoral approaches.
There are numerous modalities available to characterize and treat peripheral arterial disease (PAD). Dr. Kumar Madassery and Dr. Sabeen Dhand highlight their preferred techniques - covering imaging, atherectomy, drug coated balloons, and stenting.
Dr. Aaron Fritts talks with Dr. Abdulaziz AlHarbi about his IR practice in the Kingdom of Saudi Arabia.
In Episode 7 we discuss Lung tumor ablation therapies with Dr. Stephen Hunt, MD, PhD, including practice building and devices.
Episode 6 with Dr. Aaron Shiloh, MD FSIR discussing pearls and pitfalls of starting an outpatient vein clinic, including the importance of marketing.
In Episode 5 of the BackTable podcast: Aaron Fritts MD and Chris Beck MD discuss the Angioseal and Mynx closure devices.
Dr. Bryan Hartley and Dr. Aaron Fritts discuss the pros and cons of using coils and/or vascular plugs for splenic trauma.
Special guests Peter Bream MD and Aaron Brandis MD discuss the pros and cons of antegrade versus retrograde tunneled dialysis catheter placement.
Special guests Peter Bream MD and Aaron Brandis MD discuss the Balloon-Assisted (BAG) and Per-oral (POG) techniques for the gastrostomy procedure.
Listen to New Orleans IR Christopher Beck MD and Dallas IR Aaron Fritts MD discuss preferences in bone biopsy needles.