BackTable Vascular & Interventional

Dr. Juan Gimenez and Dr. Tyler Sandow, experienced interventional radiologists, discuss the management of hepatocellular carcinoma (HCC). They cover topics such as building strong relations with transplant surgeons, working-up patients with HCC, effective interventional oncology services, and factors that guide their treatment plan using the Barcelona Clinic Liver Cancer (BCLC) staging algorithm. Stay tuned for Part 2 of this discussion.

In this episode, host Dr. Jacob Fleming interviews Dr. Dana Dunleavy about spinal tumor ablation and vertebral augmentation. Dana is an interventional radiologist and Director of Windsong Interventional & Vascular Services.---CHECK OUT OUR SPONSORStryker Interventional Spinehttps://www.strykerivs.com---SHOW NOTESDana begins the discussion by reflecting on his upbringing in a small country town. His parents, his mother a midwife and his father a contractor, shaped his early experiences. His exposure to medicine began through his mother, particularly in witnessing childbirths. As he navigated his way through medical school, he contemplated various specialties, including orthopedic surgery, interventional radiology, and neurosurgery. He discovered incredible mentors in radiology and ultimately found his place in the field of interventional radiology. During his residency at Johns Hopkins, he sought externships in interventional spine and had the opportunity to immerse himself in this field for one month.He underscores the significance of participating in tumor boards and being a valuable contributor to the team in terms of diagnosis and treatment. He also emphasizes the value of calling consults when performing biopsies and the importance of meeting with the patient face-to-face and engaging in a thorough discussion of the treatment plan.Next, Dana delves deeper into the topics of bone tumor ablation and mechanical augmentation. He notes the importance of having a comprehensive understanding of the patient's anatomy and being well-versed in interventional tools. Cement extravasation is a feared complication of vertebral augmentation, so Dana discusses the role of implants as a means to establish structural support and mitigate the risk of cement leakage. In addition, he talks about his approach in combining ablation with mechanical augmentation so that the augmentation provides a structure after the ablation.Lastly, he discusses the use of advanced technology such as cone beam CT in trajectory planning. He shares his hybrid approach to performing bone biopsies, utilizing fluoroscopy during access and cone beam CT to ascertain accurate trajectory.

In this episode, host Dr. Ally Baheti interviews Dr. Bill Julien about strategies to secure independent IR hospital privileges. Bill is an experienced vascular interventional physician at South Florida Vascular Associates.---CHECK OUT OUR SPONSORSBD Advance Clinical Training & Education Programhttps://page.bd.com/Advance-Training-Program_Homepage.htmlSiemens Healthineershttps://www.siemens-healthineers.com/Reflow Medicalhttps://www.reflowmedical.com/---SHOW NOTESBill starts the episode by telling us why it is crucial for vascular and interventional physicians to have hospital privileges. We learn about Bill’s career progression. He discusses the growing pains he faced, how he effectively tackled these challenges, and how he became staff at a number of hospitals.Bill and Ally then unfold Bill’s detailed roadmap for how IRs can join hospital staff. They explore different pathways, and Bill shares his anecdotes and advice throughout. The doctors discuss how many contracts leave little opportunity to build longitudinal care practice, since the majority of time can be dedicated to large volumes of diagnostic reading time and consults for non-complex cases.At the conclusion of this episode, Bill emphasizes the need for SIR and other societies to step in and usher change. He also shares his 13-point action list for what SIR can do to accomplish this and help IRs secure hospital privileges (linked in Resources section).---RESOURCESSIR Strategic Plan:https://tinyurl.com/SIRstrategicplanSIR Policy Statement:https://tinyurl.com/SIRpolicystatementDr. Bill Julien’s Clinical Practice Position:https://tinyurl.com/clinicalpracticeposition2ACR Policy Statement:https://tinyurl.com/ACRpolicystatement

In this episode, host Dr. Dana Dunleavy engages in a thought-provoking discussion about independent interventional radiology practice with two esteemed IRs, Dr. Kavi Devulapalli and Dr. Ian Wilson. Together, they discuss the complexities and opportunities in the ever-evolving landscape of IR.---CHECK OUT OUR SPONSORPhilips SymphonySuitehttps://www.philips.com/symphonysuite---SHOW NOTESWe start off the discussion with Kavi expanding on early experiences in working a standard DR / IR split that most IRs tend to work in. He elaborates on how this split was not what he, as well as most IRs, intended to practice in when they entered the field. Thus, he then shifted over to the OBL space, a gratifying journey, but one he notes was difficult to navigate due to the intricacies. As Kavi finally transitioned to locum tenens work, he reflects on its appeal, despite the scarcity of opportunities. He notes that locum tenens work is usually in areas with an extreme dearth of IRs, such as rural areas. This conversation also explores the topic of exclusive contracts. Their impact on independent IR practices' access to hospital privileges is also explored, shedding light on the challenges faced by IRs seeking to expand their reach.Ian then notes that his locum tenens work was also in a rural setting, and how he had served this location for an extended period of time due to their lack of retention of IRs. The discussion then reveals a growing trend among physicians, as more and more are turning to locum work due to its exclusive focus on the IR aspect of the job that initially attracted them to this field. It's a mutual demand, as physicians seeking to specialize in IR find locum work to be a well-suited avenue, while areas of healthcare dearth are equally eager to tap into the expertise of these specialists.Both guests emphasize the urgent need for sustainable solutions to address this growing public health crisis in rural areas. This is precisely where organizations like Travelier come into play. Travelier was established by IRs, one of whom is Kavi, with a mission to bridge this critical gap by offering world-class IR services to communities with unmet needs. Their approach involves assembling dedicated physician teams and creating interventional radiology practices that generate revenue while providing viable work solutions for radiologists. This discussion is a testament to the adaptability and innovation that drive the field of IR, characterized by the commitment to improving healthcare access in areas where it is needed the most. It's also a testament to the increasing mutual demand for specialized IR services and the unique opportunities that come with it.---RESOURCESTravelier:https://travelierir.com

Dr. Marcelo Guimaraes discusses the use of radiofrequency wires for sharp recanalization, including indications, workup, and alternative options. He also talks about the evolution of the Sniper technique, importance of cone-beam CT, application of IVUS, and future non-vascular applications. Tips for avoiding unfavorable outcomes and caution against using the Sniper technique in the office-based lab are shared.

In this episode, host Christopher Beck discusses the current landscape of IR training with Dr. Neil Jain, a fourth-year IR/DR resident at Georgetown University. Neil, who attended medical school in New Jersey, discusses his early desire for a diverse medical career encompassing clinical work, innovation, and mentorship.---CHECK OUT OUR SPONSORRADPAD® Radiation Protectionhttps://www.radpad.com/---SHOW NOTESTo start the episode off, Neil offers valuable advice on when to decide on interventional radiology as a career path. He emphasizes that the ideal timing varies based on one's portfolio, but he personally found his passion for IR during his first year of medical school, which facilitated building meaningful connections early on.The conversation then explores the different pathways to entering the field of interventional radiology, including integrated, ESIR, and classic routes. Neil provides insights into the pros and cons of each pathway, shedding light on the evolving landscape of residency applications.We then delve into the changing dynamics of application processes, as Neil discusses the nuances of the recent changes and how students can strategically navigate them. He introduces the concept of "signaling" features, gold and silver star preferences, and the importance of proper program selection when applying to IR residency.Neil also offers guidance on away rotations, emphasizing their significance for students aspiring to match into competitive IR programs. He underscores the dedication to IR as a crucial factor in securing a match. Another key factor is mentorship, and Neil highlights how peer and attending mentors as well as the resources provided by the Society of Interventional Radiology (SIR) can play an enormous role in matching into IR.The discussion then shifts to the virtual residency application process, with Neil offering valuable do's and don'ts for applicants. He underscores the importance of creating a proper environment and engaging in hobbies during virtual interviews. He also provides valuable advice on preparing for common interview questions, encouraging applicants to build compelling stories that showcase their clinical understanding.As the field of interventional radiology continues to evolve, Neil emphasizes the importance of staying informed and maintaining close connections with mentors and resources like SIR.

The podcast discusses transverse sinus stenting for idiopathic intracranial hypertension. Topics covered include patient population, meticulous preparation imaging, diagnostic angiogram, pressure measurements, Plavix usage, treatment options, managing pain post-procedure.

Dr. Minhaj Khaja, Clinical Professor of Radiology and Cardiac Surgery, discusses topics such as deep venous disease, complex cases, anticoagulation, types of stents, crossing devices, and treating inflow. He also talks about using arterial re-entry devices and radiofrequency wires for crossing occluded stents, as well as the new RevCore mechanical thrombectomy device. The episode concludes by highlighting components of good patient follow-up.

In this episode, host Dr. Aaron Fritts interviews Dr. Maureen Kohi and Dr. Niten Singh on the VIVA Foundation’s multidisciplinary approach to advancing vascular medicine.---CHECK OUT OUR SPONSORSMedtronic ClosureFasthttps://www.medtronic.com/closurefast6fPhilips Image Guided Therapy Devices Academyhttps://resource.philipseliiteacademy.com---EARN CMEReflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/PO5TFV---SHOW NOTESMaureen is an interventional radiologist and Professor and Chair of the Department of Radiology at University of North Carolina - Chapel Hill. Niten is a vascular surgeon and Associate Chief of Vascular Surgery at University of Washington. Both serve on the board of directors at VIVA.We begin with how Maureen and Niten became involved at VIVA. They discuss the history and foundations of VIVA. The duo goes on to describe how VIVA has evolved throughout the years. Maureen speaks on how VEINS has become a comprehensive educational meeting for all things venous disease and interventions, which complements VIVA’s arterial focus.Niten and Maureen then explain how VIVA and VEINS have become more than just meetings. They are conglomerates of multiple initiatives for all things vascular driven by the central question of “What is best for the patient?” The duo also sheds light on the unique inner-workings of VIVA, highlighting the foundation’s speedy, nimble, and inclusive approach to the rapidly advancing landscape of vascular and endovascular surgery.We get a special look of what to expect at VIVA & VEINS Annual 2023 Conference at Wynn Las Vegas (October 28th - November 2nd) from Niten and Maureen. We conclude this episode with Maureen and Niten’s thoughts on how we can improve vascular care for our underserved patient populations and what role OBLs will play in this equation going forward.---RESOURCESVIVA 2023 Annual Conference Registration:https://viva-foundation.org/viva-programmingVEINS 2023 Annual Conference Registration:https://viva-foundation.org/veins-programmingVIVA Vascular Leaders Forum on Paclitaxel Safety (2019):https://evtoday.com/articles/2019-mar/highlights-from-the-viva-vascular-leaders-forum-on-paclitaxel-safety

In this episode, host Dr. Aaron Fritts and Dr. Krishna Mannava engage in a discussion with Dr. Bret Wiechmann about a concerning trend in the field—insurance denials for critical limb ischemia (CLI) interventions.---CHECK OUT OUR SPONSORPhilips SymphonySuitehttps://www.philips.com/symphonysuite---SHOW NOTESBret is an IR in Gainesville, Florida with over 26 years of experience and is one of the founders of the Outpatient Endovascular & Interventional Society (OEIS). OEIS was started 10 years ago to advocate for the viability of non-hospital IR services.We start the episode with Bret sharing his staff’s firsthand encounters with pre-authorization challenges for atherectomy procedures.The panel discusses how the recent inflammatory NY Times article regarding the use of atherectomy to treat peripheral artery disease has exacerbated these challenges. The doctors delve into the perplexing use of non-scientific articles as evidence by insurance companies, which are often influenced by third-party recommendations. The disconnect between insurance decisions and patients' actual needs becomes evident, as peer-to-peer reviews usually involve physicians unfamiliar with the specific medical speciality.Next, we explore strategies for navigating the intricacies of insurance approvals, a particularly challenging task as each insurance company has its unique set of requirements for procedure coverage. Evaluating these requirements for each patient not only limits the capabilities of the physician, but also decreases the quality of the patient's care. One strategy that is discussed is compiling a list of different payers and their specific requirements for each procedure, but this takes away valuable time away from a patient’s care. Another strategy includes the intriguing notion of physicians noting the names of insurance companies and peer reviewers on medical records as reasons for denying certain procedures. While promising, the effectiveness of this approach remains uncertain. Furthermore, the episode contemplates the possibility of refusing to work with insurance companies that consistently denying coverage— a bold strategy that warrants careful consideration as it may drop patient volumes.To combat the rising tide of insurance denials, the discussion emphasizes the pivotal role played by organizations like OEIS. It highlights the importance of involving referring physicians in various specialties, patients themselves as well as industry stakeholders manufacturing relevant devices to bring about meaningful change in the insurance approval process.---RESOURCESNew York Times Article:https://www.nytimes.com/2023/07/15/health/atherectomy-peripheral-artery-disease.htmlOEIS:https://oeisweb.com