BackTable Vascular & Interventional

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.

In this episode, host Dr. Michael Barraza interviews Dr. Stephen Hunt about building a pain practice, including his nerve ablation technique, how to obtain referrals, and why it is one of the most rewarding procedures that he does.---SHOW NOTESWe begin by discussing what caused Dr. Hunt to start building a pain service. He was treating many patients with lung cancer, and he saw so many patients toward the end of their life. What they wanted was to reduce their suffering due to pain. He saw what was being offered for them, which was opioids, but this caused them to be disconnected from their families at such an important time in their life. He knew he could offer nerve blocks and ablation, so he began educating himself. As he learned about different blocks, he adapted them to create his own technique.Pretty soon, word got out that he was doing this, and he started getting referrals from oncologists. Soon after this, thoracic surgeons and breast surgeons began referring to him for post-thoracotomy and post-mastectomy pain. Next, radiation oncologists referred their patients with radiation necrosis of the ribs, and orthopedic surgeons referred patients to him for pain from musculoskeletal metastases.For his technique, he often starts with a test block using bupivacaine and triamcinolone, which prolongs the effect of the bupivacaine and provides relief for around two weeks. For the ablation, he does the block in the same way, waits 15 minutes, and then injects ethanol to ablate the nerve. Some tips he has learned for celiac ablation are to ablate the retrocrural splanchnic nerves, because they feed into the celiac, and you will get a better result. Other areas he commonly ablates are intercostal nerves. For these, to avoid devastating paralysis from damage to the spinal cord, he always orients his needle lateral and stays at least two inches away from the spine. He advises those new in pain interventions to remember your anatomy. In radiology, we learn it all, and if you remember these nerves, you will be able to help a lot of people with their pain and decrease their suffering, making an enormous impact on someone’s quality of life.---RESOURCESPIGI Lab:https://www.med.upenn.edu/pigilab/Twitter:@PigiLab@md_rogue

In this episode, host Dr. Ally Baheti interviews vascular surgeon Dr. Anahita Dua on the importance of political advocacy in healthcare, including why she created a PAC, the importance of healthcare workers in Congress, and how you can get involved.---CHECK OUT OUR SPONSORSBoston Scientific Eluvia Drug-Eluting Stenthttps://www.bostonscientific.com/en-US/medical-specialties/vascular-surgery/drug-eluting-therapies/eluvia.html?utm_source=oth_site&utm_medium=native&utm_campaign=pi-at-us-de_portfolio-hci&utm_content=n-backtable-n-backtable_site_eluvia_1_2023&cid=n10012337Reflow Medicalhttps://www.reflowmedical.com/---SHOW NOTESDr. Dua is a vascular surgeon at Massachusetts General Hospital, associate professor of surgery at Harvard Medical School, co-director of the Peripheral Arterial Disease Center, Clinical Director of Research, the Director of the Vascular Lab and the Associate Director of the Wound Care Center. Her passion is limb salvage, and she performs open and endovascular techniques. She was born in Scotland, grew up in Wisconsin, completed medical school in the UK followed by general surgery residency at the Medical College of Wisconsin, vascular surgery fellowship at Stanford, a post-doctoral research fellowship at UT Houston, and finally an MBA and Masters in trauma sciences. She is also a wife, mom of two, and recently created a political action committee (PAC).Before creating a PAC, she initially considered running for Congress. She was tired of seeing injustices both on the healthcare side with her patients, as well as in her own family. She bought a bulletproof backpack for her daughter after a school shooting near where they live, and since that day, she has not stopped fighting for change. Instead of running for Congress herself, she decided to create a PAC with the goal of getting 10 people in Congress who shared her ideas about the change needed in this country. She raised money, surpassed her goal, and got two people in Congress in just one month.She knew she had to pick a side to get anywhere with the current state of politics in this country, so she decided to support someone only if they were a healthcare worker and a Democrat. She chose candidates based on their policies and their personality. She spoke with each one to get a sense of who they were, and she was looking for people who were intelligent, nimble, and who she would trust to babysit her kids. She then called a list of colleagues, informed them who she was supporting, and asked for their financial support. Dr. Dua hopes to have an impact on healthcare reform by creating advice specific to diseases such as diabetes. There is no standardization for limb problems, and this leads to disparities in care, with staggeringly unequal rates of amputations among different racial and socioeconomic groups. She aims to develop a standard of care that is implemented federally to improve limb care and reduce amputations.---RESOURCESHealthcare for Action:www.healthcareforaction.com

In this episode, host Dr. Ally Baheti interviews Dr. Deepak Sudheendra about obstacles that he has faced while practicing medicine, including dealing with a career-threatening injury, redefining boundaries between clinical and home responsibilities, and navigating a transition from a surgical to radiology residency.---CHECK OUT OUR SPONSORSMedtronic Ellipsys Vascular Access Systemhttps://www.medtronic.com/ellipsysRADPAD® Radiation Protectionhttps://www.radpad.com/---SHOW NOTESDr. Sudheendra has recently returned to his clinical IR practice. He had taken one year off to recover from a traumatic fall that resulted in multiple fractures and loss of function in his left hand and arm. The recovery process was physically arduous, requiring intensive physical and occupational therapy multiple times a week to re-learn basic functions. As an IR that was 100% procedural, Dr. Sudheendra faced a lot of uncertainty about whether he would ever be able to return to performing complex procedures. Additionally, he faced the stress of battling with insurance companies for his rightful disability insurance payments. The paperwork process required him to submit case logs and attestations from co-workers to prove his prior case volume.Through this experience, Dr. Sudheendra is able to give disability insurance advice for young physicians and graduating trainees. Buying an insurance plan before residency or fellowship ends will allow the trainee to pay a lower premium than if they were attendings. It is important to read the fine print in the contracts that are offered and consider buying both short-term and long-term insurance, since there is no way to predict the timing and severity of a future injury. Additionally, buying into multiple plans can lower the total annual premium, but it comes with the added stress of having to deal with multiple companies when an injury does occur.As Dr. Sudheendra returned to clinical practice, he started with locums in community hospitals. He found that easing back into simple IR procedures allowed him to not only gain his confidence back, but also invest more time into his family. His next endeavor is opening his own office-based lab (OBL) focused on vascular interventions.To end the episode, we discuss Dr. Sundheendra’s perspective on navigating his career. He originally started in a cardiothoracic surgery residency, but decided to leave the field to pursue interventional radiology. This switch was not simple, and it required years of researching and advocating for himself to different residency programs. On this journey, he was able to attain his diagnostic radiology residency and interventional radiology fellowship positions through persistence and networking. Overall, Dr. Sudheendra advises procedurally-oriented medical students and early trainees to expose themselves to all related subspecialty areas, think about new developments in those fields, and imagine how the field might change in the course of their careers.---RESOURCESDr. Deepak Sudheendra Website:https://www.gethealthyveins.com/Dr. Deepak Sudheendra Twitter:https://twitter.com/Dr_Sudi/with_repliesPhysician Moms Group on Facebook:https://www.facebook.com/groups/PhysicianMomsGroup/

In this episode, host Dr. Aaron Fritts and interventional radiologist Dr. Alex Pavidapha give a primer on the emerging field of hemorrhoidal artery embolization (HAE), including patient presentations and referrals, treatment algorithms, procedural steps, and follow up care.---CHECK OUT OUR SPONSORBoston 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 NOTESTo start. Dr. Pavidapha describes the typical patient presenting with hemorrhoids. This is a prevalent condition that peaks at the ages of 45-65 and in the pregnant population. There are a variety of treatment options ranging from banding, hemorrhoidectomy, and cryotherapy; however, many patients may experience recurrence after these treatments or they may not be suitable candidates for surgery. Next, we discuss the current landscape of HAE. This treatment is a good option for patients who have failed other treatment options. The majority of Dr. Pavidapha’s patients come from referrals by gastroenterologists, although some come based on their own research on the web. It is important that all patients have a colonoscopy before HAE, to rule out the possibility of colon cancer. Additionally, a full history and rectal exam should be performed, since the choice to treat can be guided by the patient’s symptom severity and the degree of internal hemorrhoid prolapse. It is also advisable to identify extremely painful external hemorrhoids, since these can be addressed with conservative measures. Dr. Pavidapha notes that patient counseling is extremely important, since hemorrhoids have a high risk of recurrence and bowel habits play a large part in this. In terms of procedural risks, he counsels patients about standard risks of bleeding and infection, recurrence, mild pain in the few days after the procedure, and although it is rare, non-target embolization of skin or other organs.During the procedure, Dr. Pavidapha prefers femoral access, since this is the easiest way to select the internal mesenteric artery. He does a base catheter run here to visualize the superior rectal arteries. These vessels are the most commonly involved in internal hemorrhoids, and if they are feeding the hemorrhoid, he will inject 500 micron beads and then follow with embolic coils. Next, he navigates through the internal iliac and pudendal arteries to arrive at the middle rectal arteries for another run. If they also supply the hemorrhoids, he will embolize them. The inferior rectal arteries are usually not involved in hemorrhoid formation, embolization of them carries a high risk of skin necrosis. Treatment of inferior rectal arteries is usually avoided. It is important to know typical anatomy very well so you can determine targets for embolization and recognize whether a patient has variant anatomy.Finally, Dr. Pavidapha sees his patients for follow-up at 1 month, 4 months, and 1 year to check for symptomatic improvement, primarily decreased bleeding. If bleeding has worsened, the patient most likely needs a repeat procedure to identify new blood vessels supplying the hemorrhoid.To IRs who are interested in starting an HAE service line, Dr. Pavidapha advises them to read the existing literature about hemorrhoids and HAE and be able to show clinical outcomes data to gastroenterologists. Overall, patients with recurrent hemorrhoids are typically an underserved population and have the potential to benefit from this novel procedure.---RESOURCESEp. 319 - How to Collaborate with GI on a New Outpatient Service Line:https://www.backtable.com/shows/vi/podcasts/319/how-to-collaborate-with-gi-on-a-new-outpatient-service-lineOutcomes of Hemorrhoidal Artery Embolization from a Multidisciplinary Outpatient Interventional Center:https://pubmed.ncbi.nlm.nih.gov/36736822/The STREAM Meeting:​​https://www.thestreammeeting.com/

En los confines de la medicina, a veces es necesario un espíritu intrépido para desafiar las prácticas establecidas y abrir nuevos horizontes. El reconocido doctor Francisco Carnevale, una figura emblemática en el campo de la radiologia intervencionista, personifica a la perfección esta audacia. Su historia es la epopeya de un hombre que tuvo la inquietud de explorar la embolización de la próstata, un enfoque innovador en el tratamiento de la hiperplasia prostática.---CHECK OUT OUR SPONSORRADPAD® Radiation Protectionhttps://www.radpad.com/---SHOW NOTESComo un faro de curiosidad intelectual, el Dr. Carnevale se aventuró en el mundo desconocido de la embolización de la próstata. Con pasión y determinación, navegó a través de los océanos de investigación médica, desafiando la ortodoxia y enfrentando el escepticismo. Fue un viaje lleno de obstáculos y dificultades, pero cada paso que dio fue impulsado por la convicción de que estaba abriendo puertas a nuevas posibilidades de tratamiento.Su dedicación inquebrantable dio frutos. El Dr. Carnevale no solo superó los desafíos técnicos asociados con la embolización de la próstata, sino que también cosechó resultados impresionantes. Sus intervenciones se convirtieron en un éxito rotundo, aliviando el sufrimiento de muchos pacientes y mejorando su calidad de vida. Sus habilidades quirúrgicas y su enfoque innovador se ganaron el reconocimiento de sus colegas, quienes lo consideran un líder en el campo de la urología.Además de sus logros clínicos, el Dr. Carnevale ha dejado una huella imborrable en la comunidad médica a través de sus numerosas investigaciones y publicaciones. Sus contribuciones han ayudado a sentar las bases científicas de la embolización de la próstata, inspirando a otros profesionales a seguir su ejemplo y continuar expandiendo los límites del conocimiento médico.En resumen, la historia del Dr. Francisco Carnevale es una historia de coraje, determinación y éxito. Su viaje desde la inquietud inicial hasta convertirse en un modelo a seguir en investigación y publicaciones es un testimonio de la pasión y el espíritu de vanguardia que impulsa la medicina moderna. Su legado perdurará, iluminando el camino para las generaciones futuras de profesionales de la salud y dejando un impacto duradero en la comunidad médica.

In this episode, host Dr. Chris Beck interviews Dr. Nima Kokabi about renal trauma embolizations, including imaging workup, embolization technique, and a warning on renal biopsies.---CHECK OUT OUR SPONSORBoston Scientific Embold Fibered Coilshttps://www.bostonscientific.com/en-US/products/embolization/embold-detachable-coil-system.html---SHOW NOTESDr. Kokabi was born in Iran, then moved to Canada where he grew up. He attended medical school in Australia due to the shortage of English speaking medical schools in Canada. After his medical training, he was interested in IR, and came to Yale for a fellowship. He then joined Emory as an attending, where he serves one of the largest trauma hospitals in the country. IR and trauma surgery have a close relationship at Emory, and Dr. Kokabi notes they rely more and more on IR for trauma management, even for things such as penetrating trauma, which is traditionally handled by surgery.Most IR consults for kidney injury are iatrogenic from non-target renal biopsies in a nephrology office. The rules for getting access to a kidney that IRs are trained in are generally not followed by nephrology, and only some have ultrasound guidance for their biopsies. Other consults for bleeding from kidney injury are post-op from a partial nephrectomy or from blunt trauma. To work it up, he gets a 2 phase arterial and venous CT. All kidney injuries are evaluated and reported using the American Association for the Surgery of Trauma (AAST) grading scale. If there is an active bleed, they will go to IR for embolization. If the injury is severe, and there is no parenchymal enhancement, this indicates either the artery or both the artery and vein were transected, and this patient requires surgery. In cases where there is only a small pseudo-aneurysm or a perinephric hematoma, these patients can be monitored with repeat imaging.For the embolization, Dr. Kokabi uses radial access. For his microcatheter, he likes the True Select. He always uses coils in the kidney, while in the liver, he uses gel foam. Some of his colleagues use glue for the kidney. He prefers detachable Embold coils, which are fiber coils with a nitinol pusher, so they don’t kink when being pushed very fast, and can be adjusted if positioning is unsatisfactory. When he is finished, he injects first through the microcatheter and then again through the base catheter to ensure he hasn’t missed any bleeding. He generally follows patients in the hospital for 1-2 days, before signing off. His parting advice to trainees and anyone doing kidney biopsies is to exercise caution, because although it is just a biopsy, it can cause life-threatening bleeding.---RESOURCESAAST Kidney Injury Scale:https://radiopaedia.org/articles/aast-kidney-injury-scale

In this episode, host Dr. Aaron Fritts and interventional radiologist Dr. Kevin Henseler discuss his treatment algorithm and new technologies for embolization of GI bleeds.---CHECK OUT OUR SPONSORBoston Scientific Obsidio Embolichttps://www.bostonscientific.com/obsidio---SHOW NOTESDr. Henseler starts by differentiating between lower and upper GI bleeds. Upper GI bleeds tend to be more life-threatening and are most commonly caused by esophageal varices or duodenal ulcers, and many of these consults come from the endoscopy suite. These upper GI bleeds also have a higher risk of recurrence. On the other hand, lower GI bleeds can be more indolent. CTA is the most efficient way to assess the source of GI bleeding. It provides valuable information about the vascular territory, including localization of bleeding, planning where to inject during angiography, and variant anatomy. If CTA is negative for bleeding, Dr. Henseler does not move onto angiography. He monitors the patient for further signs of intermittent bleeding and may re-image or intervene the following day.If CTA does show bleeding, Dr. Henseler moves onto angiography and embolization. He finds that there are few contraindications to angiography. Relative contraindications include renal insufficiency, which is a small tradeoff for a lifesaving procedure, and contrast allergy, which can be addressed with a preprocedural steroid dose.When it comes to methods of embolization, detachable coils have been a mainstay. While they are more expensive than pushable coils, detachable coils allow for more exact placement and increased safety and more IRs are being trained to use these now. Dr. Henseler also discusses the use of embolic particles, which carry risks of end-organ damage and ischemia, as well as embolic glue, which can be difficult to use if the operator does not have sufficient training. Then, we shift gears to discuss Obsidio, a new injectable solid that is soon to be commercially available. It exists as a liquid when it is in its pressurized form within the microcatheter; however, it immediately solidifies in the vessel as soon as the injection ceases. Obsidio is made of radio-opaque tantalum so it is visible on CT, stays permanently in the vessel, and can be used in conjunction with coils if desired. Additionally, its cohesive properties decrease the risk of abdominal extravasation and it can be used with any catheter.---RESOURCESDr. Kevin Henseler LinkedIn:https://www.linkedin.com/in/kevin-henseler-364832231/CTA for Lower GI Bleeds:https://www.youtube.com/watch?v=UWEf_sAUGKUEp. 179- Happiness is a Warm Coil: Treating GI Bleeds:https://www.backtable.com/shows/vi/podcasts/179/happiness-is-a-warm-coil-treating-gi-bleedsEp. 216- Stick It: Glue Embo:https://www.backtable.com/shows/vi/podcasts/216/stick-it-glue-embo

In this episode, host Dr. Sabeen Dhand interviews interventional cardiologist Dr. Eric Secemsky about the role of intravascular ultrasound in lower extremity interventions, and how he published a consensus document to standardize its use across specialties and provide a framework for new users.---CHECK OUT OUR SPONSORSPhilips Image Guided Therapy Devices Academyhttps://resource.philipseliiteacademy.comPhilips SymphonySuitehttps://www.philips.com/symphonysuite---SHOW NOTESDr. Secemsky practices at BIDMC in Boston. His passions are pulmonary embolism intervention and intravascular ultrasound (IVUS) for peripheral vascular disease. He began using IVUS for coronary interventions, and then began incorporating it in arterial and venous peripheral interventions. The goal is to make procedures durable in the endovascular world, and IVUS is key for that.In the coronaries, there is a standardized way that all cardiologists use IVUS for. First, they cross the lesion with the wire, then use IVUS to measure lesion length and vessel diameter for stent sizing. They also evaluate plaque composition, which informs whether to use a plaque modifying device before stenting. They then balloon, stent, and use IVUS again to evaluate stent position and check for dissections. Dr. Secemsky measures an arterial lumen by identifying the 3 layers of the vessel wall, and finding the black stripe behind the intima, which corresponds to the elastic membrane.Dr. Secemsky tells us about a consensus article he published in the Journal of the American College of Cardiology. He collaborated with some colleagues to form a 12 person steering committee composed of interventional cardiology, interventional radiology, vascular surgery and vascular medicine specialists. The goal was to consolidate information from all these specialties to provide a single standardized document. This document can be used for those wanting to incorporate IVUS into their practice, but don’t know where to begin. They established levels of evidence regarding where IVUS is most appropriate. They found that tibial arterial intervention has the highest support for use of IVUS across specialties. Furthermore, they established that the best practice for IVUS is to use it three times per case, for pre-intervention, middle-run and post-run. Using IVUS is safe, and offers so much information to make case a more efficient. In addition, you cut down on device utilization, contrast use and radiation exposure, while improving patient outcomes by getting better luminal gain and improved durability of your intervention.---RESOURCESJACC Consensus Article:https://pubmed.ncbi.nlm.nih.gov/35926922/