BackTable Vascular & Interventional

In this episode, host Dr. Ally Baheti interviews interventional radiologist Dr. Brooke Spencer about management of pelvic venous disease, endovascular therapies for pelvic varices, and important considerations for treating patients with complex and chronic pain.---CHECK OUT OUR SPONSORBoston Scientific Drug Elutionhttps://www.bostonscientific.com/en-US/medical-specialties/vascular-surgery/drug-eluting-therapies.html?utm_source=oth_site&utm_medium=native&utm_campaign=pi-at-us-de_portfolio-hci&utm_content=n-backtable-n-backtable_site_portfolio_1_2023&cid=n10012334---SHOW NOTESDr. Spencer serves as the CEO and medical director of Minimally Invasive Procedure Specialists in Denver, CO. Her patients commonly get referred from OB/GYNs for chronic pelvic pain that is refractory to laparoscopic surgery and undiagnosed. She notes that collaborative relationships with women's health specialists and pelvic pain physical therapists are necessary for adequate patient outreach. Classifying cases by the location and nature of the vessel abnormality (i.e. compressive, obstructive, varicose, reflux, congenital) allows her to think about the best treatment for each patient. Targeting proximal veins can improve back and groin pain, dyspareunia, and heavy periods. Iliac vein stenting can improve compressive symptoms 50% of the time. On the other hand, isolated labial pain is best treated by directly targeting labial varices. Perineal ultrasound is a helpful way to locate some varicosities, but Dr. Spencer prefers MRI and digital subtraction venography to get a comprehensive venous picture and correlate symptoms with imaging.Next, the doctors discuss embolization and foam sclerotherapy. Through her experience, Dr. Spencer has seen sclerotherapy work better in varices with slower outflow and coil embolization work better for varices with more rapid flow. She prefers oversized floppy coils to minimize the risk of migration. With both treatments, there can be significant insurance barriers. It is important to utilize preauthorization specialists and be aware of what the patient’s insurance will cover, in order to better frame a conversation about treatment options.After the procedure, maximal pain relief can be achieved anywhere between 3 to 6 months. During this period, it is important to counsel patients over adjunct therapies such as pelvic floor therapy, steroids, and puncture aspiration to remove trapped blood. Overall, Dr. Spencer wants IRs to keep in mind that the chronic pain population has faced many misdiagnoses and insurance barriers, so they might harbor mistrust of the healthcare system. It is crucial to acknowledge their feelings and understand their anatomy in order to manage their expectations.---RESOURCESPelvic Guru:https://pelvicguru.com/Efficacy of Endovascular Treatment for Pelvic Congestion Syndrome:https://pubmed.ncbi.nlm.nih.gov/27318059/International Pelvic Pain Society:https://www.pelvicpain.org/“The Way Out” book:https://www.amazon.com/Way-Out-Revolutionary-Scientifically-Approach/dp/059308683X

In this episode, host Dr. Christopher Beck interviews Dr. Peter Soukas about his algorithm for below the knee (BTK) critical limb ischemia (CLI) interventions as well as his implementation of new evidence-based guidance.---CHECK OUT OUR SPONSORMedtronic HawkOne Directional Atherectomy Systemhttps://www.medtronic.com/hawkone---SHOW NOTESDr. Soukas serves as the director of vascular medicine, the interventional peripheral vascular lab, and the endovascular medicine fellowship at Brown University in Providence, RI. In addition, he holds the position of associate professor of medicine at The Warren Alpert Medical School at Brown University. Dr. Soukas began his career as an interventional cardiologist. Over the course of his 13-year tenure in Providence, he has dedicated his career to the treatment of CLI and BTK disease.Prior to any interventional work, Dr. Soukas follows a comprehensive work-up including an ankle-brachial index (ABI), arterial duplex, and evaluating kidney function for safe administration of contrast. For a majority of cases, he uses the common femoral artery as the access point, but prefers to prep multiple access sites in the event of needing both anterograde and retrograde, or pedal, access. He discusses the use of the chronic total occlusion crossing approach based on plaque cap morphology (CTOP) classification on angiogram in determining the need for a retrograde approach. The type I morphology is characterized by the convexity of the plaque pointing away and is often treated successfully by an anterograde approach alone, as CTOP types II, III, and IV benefited from the addition of retrograde tibiopedal access. Once access is gained and the plaque morphology is evaluated using angiography, it becomes crucial to address any issues with the inflow to the affected vessel. This step ensures proper blood flow and provides a stable foundation for further interventions. Intravascular ultrasound is then used to assess the size and extent of the plaque, and then depending on the amount of calcification, either intravascular lithotripsy or calcium modifying technology can be used. Scoring balloons with low pressure may also be used for vessels that are moderately calcified and have been shown to have low rates of recoil and dissection. The main initiative of the procedure is to provide blood flow to the target angiosome which is dependent on the location of the wound.During his last remarks, Dr. Soukas comments on the future of BTK interventions, including Paclitaxel vs Sirolimus eluting stents, the use of self-expanding stents, and LimFlow, a minimally invasive technology that creates a channel between an artery and vein allowing the vein to provide blood flow to the foot. With the increasing prevalence of critical limb-threatening ischemia (CLTI) and high 12-month mortality rates in patients with amputations, Dr. Soukas ends the discussion by emphasizing how revascularization should be the preferred initial approach in treating CLTI due to the potential benefits it offers in terms of limb preservation and mortality reduction, urging practitioners to educate patients in being aggressive in their care.---RESOURCESCTOP article:https://evtoday.com/articles/2018-may/using-plaque-cap-morphology-to-determine-cto-crossing-approachDisrupt PAD III Observational study:https://pubmed.ncbi.nlm.nih.gov/34380334/PRELUDE BTK Study:https://pubmed.ncbi.nlm.nih.gov/34802313/Intravascular Ultrasound study:https://www.jacc.org/doi/10.1016/j.jcin.2022.01.001Intravascular US in Medicare Beneficiaries:https://pubmed.ncbi.nlm.nih.gov/35998803/PROMISE II study:https://limflow.com/us/clinical-evidence/promise-ii-study-results/

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 NOTESDr. 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.---RESOURCESMRI–Guided Focused Ultrasound Thalamotomy for Essential Tremor:https://thejns.org/view/journals/j-neurosurg/138/4/article-p1028.xmlTrial of Globus Pallidus Focused Ultrasound Ablation in Parkinson’s Disease:https://www.nejm.org/doi/10.1056/NEJMoa2202721Long-term effects of bilateral subthalamic nucleus deep brain stimulation on gait disorders in Parkinson's disease: a clinical-instrumental studyhttps://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.---CHECK OUT OUR SPONSORCagent Vascular Serranatorhttps://www.cagentvascular.com---SHOW NOTESDr. 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).---RESOURCESCagentVascular.comProspective Study of Serration Angioplasty in the Infrapopliteal Arteries Using the Serranator Device: PRELUDE BTK StudyDOI: 10.1177/15266028211059917Standard 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 StudyDOI: 10.1177/15266028221134891PRELUDE Prospective Study of the Serranator Device in the Treatment of Atherosclerotic Lesions in the Superficial Femoral and Popliteal ArteriesDOI: 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.---CHECK OUT OUR SPONSORRADPAD® Radiation Protectionhttps://www.radpad.com/---SHOW NOTESPocketHealth 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.---RESOURCESPocketHealth:https://www.pockethealth.com/

En este episodio de BackTable, las Dras. Gina Landinez y Ana María Fernández Martínez hablan sobre el intervencionismo musculoesquelético y las técnicas para la embolización del hombre rígido.---SHOW NOTESLa Dra. Fernández Martínez explica su trayectoria en el campo de intervencionismo musculoesquelético y la oportunidad de entrenarse en Japón. Luego entra en detalles técnicos, describiendo cómo obtiene acceso usando su microcatéter para entrar a las articulaciones que quiere tratar. Explica que estas arterias son de un calibre muy pequeño, así que necesita herramientas diferentes para los procedimientos esqueléticos. También, ella describe el efecto que tiene la embolización en las fibras nerviosas y la inflamación para restaurar la vascular normal.Adicionalmente, las doctoras explican quienes son los pacientes ideales para la embolización de un hombro rígido. Dra. Fernández Martínez distingue síntomas de un hombro rígido, como la limitación de la vida diaria y la movilidad, y hace la distinción entre esta patología y la artritis. Habla también del tiempo ideal para la embolización para optimizar los resultados y la importancia de la rehabilitación con la fisioterapia. Próximo, la doctora explica los beneficios inmediatos y a largo plazo que ve en sus pacientes. Usualmente, se pueden ver los efectos de la embolización tres meses después del procedimiento si el paciente participa en la fisioterapia, y el máximo beneficio ocurre a los seis meses. Repetición del procedimiento es posible también.Finalmente, las doctoras hablan sobre las complicaciones de la embolización, que incluyen un hematoma en la zona de punción. Dra. Fernandez Martinez termina el episodio alentando a sus colegas radiólogos intervencionistas a explorar la embolización musculoesquelética.

In this episode, host Dr. Ally Baheti interviews Jill Sommerset and Dr. Fadi Saab about EVUS and IVUS in peripheral arterial cases, including when to use each, how to train an interventional sonographer, and what adding ultrasound in a case can do for patient safety.---CHECK OUT OUR SPONSORSPhilips Image Guided Therapy Devices Academyhttps://resource.philipseliiteacademy.comPhilips SymphonySuitehttps://www.philips.com/symphonysuite---SHOW NOTESJill Sommerset is the director of ultrasound at Advanced Vascular in Portland, OR and Hope Clinical Innovation Center in Houston, TX, and chair of the SVU annual conference. Dr. Fadi Saab is an interventional cardiologist and associate professor at Michigan State University. He begins by introducing what intravascular ultrasound (IVUS) and extravascular ultrasound (EVUS) are. EVUS is looking from the outside in, and can be used to measure vessel width, hemodynamics, and cross chronic total occlusions (CTOs). IVUS is looking from inside a vessel towards the outside of the body, and can be helpful for viewing the extent of arterial disease and discerning the exact plaque anatomy.Dr. Saab always has a specially trained interventional sonographer involved in the case and in the room for critical limb ischemia (CLI) cases. He values them not only for obtaining access, but also to provide greater safety to the patient. He considers them a core member of the team. He notes the importance of training an ultrasonographer who is good when working under pressure, can interact with multiple personality types, and most importantly, someone willing to learn, be engaged in the case, and willing to put themselves out there in this foreign environment. Jill says it took her around 4 months to feel comfortable working in the cath lab, and for other members of the team to get used to her presence during cases. She describes her work as a dance with the physician. When a wire or catheter is being exchanged, Jill is always scanning and thinking ahead, and she is always ready to check for dissections after balloon angioplasty.Most arterial cases can benefit from the addition of EVUS. Jill says the only time EVUS is not as helpful is when the CTO cap morphology shows a rock hard plaque that casts shadows on the screen. Dr. Saab says he uses EVUS for crossing CTOs, patient safety, and looking at complications. He usually introduces IVUS after he crosses a lesion to look at plaque in a more granular way and understand it’s anatomy. Jill adds that she uses IVUS to help the physician cross a CTO sometimes, but notes that it is important for the tech to hold the probe still and not move in this scenario. The two end by restating the value that EVUS and IVUS add to the procedure, especially because angiography misses a lot of plaque burden that can be seen with IVUS. They recommend finding ultrasonographers interested in working in the cath lab, and taking the responsibility as physicians to mentor them and make them feel like an invaluable member of the treatment team.---RESOURCESCTOP Paper:https://assets.bmctoday.net/evtoday/pdfs/et0518_F5_Saab.pdf

In this episode, guest host Dr. Isabel Newton interviews Dr. Richard Saxon about his innovative approach of using stent grafts for transjugular intrahepatic portosystemic shunting (TIPS), the creation of the Viatorr endoprosthesis, and medical ethics of experimental technology.---CHECK OUT OUR SPONSORSPhilips Image Guided Therapy Devices Academyhttps://resource.philipseliiteacademy.comBoston Scientific Nextlabhttps://www.bostonscientific.com/en-US/nextlab.html?utm_source=oth_site&utm_medium=native&utm_campaign=pi-at-us-nextlab-hci&utm_content=n-backtable-n-backtable_site_nextlab_1_2023&cid=n10013202---SHOW NOTESAs an IR fellow, Dr. Saxon was surrounded by constant innovation at the Dotter Institute. He saw the takeoff of TIPS as a last treatment option for patients with liver failure, who were suffering from major variceal bleeding. He recounts the early days of TIPS as extremely technically challenging and arduous, since the methods and devices had not yet been refined. Dr. Saxon spent a significant amount of time performing TIPS revision procedures, which led him to explore the underlying pathology of biliary duct injury and subsequent stent thrombosis. These experiences led him to develop a stent graft for TIPS, which was first tested in swine models and eventually became the Viatorr endoprosthesis. Dr. Saxon highlights the supportive people and environment at the Dotter Institute as a major factor in fueling TIPS improvement. Additionally, during this era, innovative ideas were able to flourish with less influence of medical-legal or intellectual property disputes.In today’s clinical setting, TIPS has become a good option for patients with intractable variceal bleeding, but it is no longer the only option. Dr. Newton emphasizes that patient selection is a crucial part of ensuring that IRs continue to practice safely and effectively. The doctors discuss hepatic encephalopathy, another complication of TIPS that requires careful patient screening, adequate follow up, and collaboration with the medicine side of liver disease treatment.Finally, Dr. Saxon reflects on his career in translational research. A large part of his success has come from recognizing where his passions lie, what his current work environment can support, and maintaining a constant drive to improve procedures and clinical care.---RESOURCESGore Viatorr TIPS Endoprosthesis:https://www.goremedical.com/products/viatorr/resource-libraryStent-Grafts for Revision of TIPS Stenoses and Occlusions: A Clinical Pilot Study:https://www.jvir.org/article/S1051-0443(97)70606-7/fulltextBarry Uchida on the BackTable Podcast:https://www.backtable.com/shows/vi/podcasts/122/history-of-the-tips-procedure-an-interview-with-barry-uchida

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.---CHECK OUT OUR SPONSORSBoston Scientific Ranger DCBhttps://www.bostonscientific.com/en-US/medical-specialties/vascular-surgery/drug-eluting-therapies/ranger.html?utm_source=oth_site&utm_medium=native&utm_campaign=pi-at-us-de_portfolio-hci&utm_content=n-backtable-n-backtable_site_ranger_1_2023&cid=n10012340Philips SymphonySuitehttps://www.philips.com/symphonysuite---SHOW NOTESDr. 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.---RESOURCESSouth 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.pdfACR Position Statement on Exclusive Contracts:https://www.acr.org/-/media/ACR/Files/About-ACR/2022-2023-Digest-of-Council-Actions.pdfLine 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. Aparna Baheti interviews Dr. Fritz Angle about adrenal vein sampling, including indications, workup, and his technique for accessing the right adrenal vein.---CHECK OUT OUR SPONSORRADPAD® Radiation Protectionhttps://www.radpad.com/---SHOW NOTESDr. Fritz Angle is the Director of Interventional Radiology at the University of Virginia. He frequently performs adrenal vein sampling for primary hyperaldosteronism, and has developed a specific technique. The patient is usually referred from an endocrinologist or primary care doctor. The IR should review the labs to verify the aldosterone-to-renin ratio is greater than 20. Additionally, it is important to review medications and stop all potassium sparing diuretics at least two weeks before the procedure. If they haven’t had a CT scan, the IR should order one to assess the position of the right adrenal vein, the hardest to access due to its variable anatomy. The morning of the procedure, Dr. Angle always checks a potassium level to know whether to give potassium supplements. He gets dual femoral access, so that he can obtain both non-stimulated and ACTH-stimulated samples. He obtains the sample from the left adrenal vein first. For the right side, he starts with a C2 catheter, to which he adds side holes using a biopsy needle. The left adrenal vein is almost always one vertebral body above the right renal vein, so he begins here, with the catheter pointing directly posterior. He searches around the entire back wall of the IVC by puffing contrast and rotating the catheter. He moves up and down by half a vertebral level. If he still cannot locate it, he begins looking to the left and right. When injecting, it is important to be gentle. To do this, he inserts an 014 wire through his catheter, then does a dry scan to see if the vein is pointing toward the liver or the right adrenal gland. If the vein is injected too hard, it can cause a venous infarct and adrenal insufficiency. The right adrenal vein forms an upside down Y shape. Dr. Angle draws two sets each from the right and left adrenal veins and two peripheral samples. To interpret results, look for a cortisol of 2-3x greater (3-4x greater in stimulated samples) compared to the peripheral blood to confirm correct placement in the adrenal veins. Once you correct aldosterone levels to cortisol levels, the aldosterone-to-cortisol ratio should be about 5x greater on one side (compared to the other side) to confirm the diagnosis and lateralize the hyperaldosteronism to one side. About 2 ⁄ 3 cases lateralize, but Dr. Angle has found many patients’ symptoms are actually due to bilateral adrenal hyperplasia. Finally, Dr. Angle emphasizes that this is an easy, safe procedure that all IRs should offer.