BackTable Vascular & Interventional

In this episode, our host Dr. Ally Baheti interviews interventional radiologist Dr. Nikki Keefe about safety considerations for pregnant and breastfeeding IR patients.Dr. Keefe’s personal experience with pregnancy during her IR training sparked her interest in this topic. A lot of IR patients are pregnant or breastfeeding, so it is important to be cognizant of radiation and medication exposures and how they should be altered. She emphasizes the importance of establishing a protocol when these patients present.We review radiation doses of various IR procedures and risk stratification based on gestational age. At each stage of pregnancy, there are different risks of disruptions in organogenesis, effects on neural tube development, and predisposition to cancer. Elective procedures should usually be deferred until after delivery. The most common and necessary procedures performed in pregnant patients are PICC line placement, nephrostomy tube, and treatment of postpartum hemorrhage. Dr. Keefe also shares her tips for minimizing fluoroscopy time and deciding between different diagnostic imaging modalities that present both maternal and fetal radiation risks.Next, we discuss medication safety. Iodinated contrast is safe to give during pregnancy, while gadolinium is not. Sedation with opioids is generally safe, but their sustained use or administration around the perinatal period can cause neonatal withdrawal symptoms. Benzodiazepines can also be used for amnesia and anxiety reduction, and midazolam has a good safety profile and long half life. However, abnormally extended use of benzodiazepines can cause floppy infant syndrome (sedation, muscle laxity, failure to suckle). Dr. Keefe notes that pregnant patients have to start on higher doses than the standard, since they have higher blood volume and increased renal clearance of these medications. Lovenox is the safest known anticoagulant for pregnant women. Additionally, fetal heart monitoring should be performed before and after the procedure.Finally, we talk about specific cases of patient positioning when placing nephrostomy tubes, transhepatic access for gallbladder tubes, treatment of visceral artery aneurysms before pregnancy, and selection of  imaging modalities to detect pulmonary embolism.

In this episode, host Dr. Aaron Fritts interviews Dr. Jim Melton, vascular surgeon, and Dr. Blake Parsons, interventional radiologist, about progress in the OBL and ASC space, including reimbursement updates, partnering with a private equity firm, and value based care.---CHECK OUT OUR SPONSORSurmodics Pounce Thrombectomyhttps://pouncesystem.com/---SHOW NOTESWe begin by discussing new developments in Dr. Melton’s and Dr. Parson’s practice. Over the past year, they have partnered with a private equity firm, Assured Healthcare Partners to create Heart and Vascular Partners (HVP). They now cover Oklahoma City, Colorado Springs, Denver, Pueblo, and parts of Illinois and Indiana. They employ mostly hospital based physicians’ ready to start their own office based lab (OBL) or ambulatory surgery center (ASC). The physicians under HVP are cardiologists, vascular surgeons, and interventional radiologists.The two discuss the advantages of aligning with a private equity firm. For them, it provided the scale and capability to provide value-based care when it becomes widely adopted. Additionally, the payer has a much lower cost for the service in the outpatient space versus the hospital. All the physicians in HVP maintain local control over their practices, which was one of their main goals when they decided to partner with a firm.Next, we cover reimbursement cuts and the trends in OBLs and ASCs. On the arterial side of business, they are seeing that OBLs are down 10-15% in reimbursement rates, whereas ASCs are up 3-30%. For iliac interventions in the ASC, they have seen a 30-50% increase in balloon angioplasty and stenting, and up to a 60% increase for Shockwave. On the embolization side, arterial and venous reimbursement has dropped in the OBL by 7-8% and increased in the ASC by 3-30%. Alternatively, the CPT code for embolization for end organ ischemia (UFE, PAE) is still well reimbursed in the OBL. They caution listeners on genicular artery embolization and cryoneurolysis due to the risk of not getting it reimbursed and having to pay money back.---RESOURCESHeart and Vascular Partners:https://heartandvascularpartners.com

In this episode, our host Dr.Michael Barraza interviews Drs. Jawad Hussain and Alan Sag about how they implemented thyroid artery embolization into their respective private and academic practices.---CHECK OUT OUR SPONSORMedtronic Chocolate PTA Balloonhttps://www.medtronic.com/peripheral---EARN CMEReflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/GXgzcZ---SHOW NOTESDr. Hussain discusses how he started doing thyroid embolizations. It was born out of a need to replace thyroid RFA, since the thyroid RFA generator was not yet approved in his health system. At Duke, Dr. Sag collaborated with endocrinologists and endocrine surgeons to address a need to treat non-surgical candidates with bulk symptoms. These symptoms can include supine dyspnea, dysphagia, and aspiration risk. Together, they developed an institutional protocol for post-procedural management. Dr. Sag emphasizes that everything an IR needs to perform a goiter embolization is probably already available to them.Next, the doctors describe how they implemented thyroid embolization in their respective practices. Dr. Sag approached his institution’s weekly tumor board of endocrine specialists to introduce the concept. When talking to non-surgical patients, he offers thyroid embolization as a palliation alternative to tracheostomy and percutaneous gastrostomy as airway protection for patients with aspiration risks. Dr. Hussain describes patients with TR-3 and TR-4 nodules who require repeat FNA. Embolization can be a valuable option for them, since it is a quick outpatient procedure with minimal side effects. Additionally, he communicates to patients that IRs have experience with applying transcatheter embolizations in different spaces in the body and sets the expectation that shrinkage will be a gradual process. Both doctors emphasize the importance of informed consent in a relatively new palliative procedure. In terms of the research landscape for thyroid embolization, Dr. Hussain says that publishing a large retrospective multicenter study would revolutionize the procedure, since it could show efficacy and safety. Dr. Sag believes that RFA and embolization are complementary technologies that can be used in different scenarios.Dr. Hussain shares his treatment algorithm, which includes getting a CTA after each consultation, to map out variable anatomy and select hypertrophied vessels. Deep cannulation is key to preventing reflux and non-target embolization. Additionally, he does a two week follow up for post-procedural symptoms and a 2 month imaging appointment. Dr. Sag describes a joint clinic with endocrine surgeons. Every patient gets a visit from each service on the same day, and the doctors are able to convene and make joint decisions based on patient and goiter factors. He recommends getting a cone beam CTA to rule out anastamoses to aerodigestive structures and the cervical spinal cord. In his embolization, he uses 300-500 micron Embospheres and leaves at least one quadrant untreated to spare some thyroid and parathyroid glands. He also administers decadron and a medrol dose pack. Lab follow-up happens at day 7, when most thyroid hormone peaks occur. If patients are still experiencing symptoms after two months, Dr. Sag will consider repeating the embolization.---RESOURCESThyroid Embolization for Nonsurgical Treatment of Nodular Goiter: A Single-Center Experience in 56 Consecutive Patients (Yilmaz et al):https://pubmed.ncbi.nlm.nih.gov/34256121/ACR TI-RADS:https://www.acr.org/Clinical-Resources/Reporting-and-Data-Systems/TI-RADS2017 Thyroid Radiofrequency Ablation Guideline: Korean Society of Thyroid Radiology:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6005940/

In this episode, host Dr. Aparna Baheti interviews Dr. Merve Ozen, interventional radiologist, about how to integrate ICE for TIPS, including why she uses a vampire stick, her needle preference, and tips for single operators.---CHECK OUT OUR SPONSORMedtronic VenaSealhttps://www.medtronic.com/venaseal---EARN CMEReflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/nfh4bj---SHOW NOTESDr. Ozen begins by discussing the challenges she faced when introducing this new technique into her practice at the University of Kentucky. She faced pushback from administration about procedure time and anesthesia time. She now does all her TIPS with intracardiac echocardiography (ICE) guidance, but she keeps CO2 available in case of device malfunction, which would cause her to revert to the traditional method of CO2 angiography.It takes time to learn how to navigate the ICE probe, also called intravascular ultrasound (IVUS), but it helps with complicated cases like thrombosed portal veins and Budd-Chiari syndrome. She uses the “vampire stick” technique, which is a side by side internal jugular access technique for the TIPS needle and the US probe. She puts her TIPS access more medial, which makes it more stable, and places her ICE access more lateral.After getting access, she spends time understanding the anatomy in the liver. Prior CT is useful for getting information about patient specific anatomy. She then uses ICE to view the portal vein and hepatic vein on the same plane, then she advances the needle with one stick. Dr. Ozen prefers a Rösch-Uchida needle versus a Colapinto because she feels she can better visualize it with ICE. One thing she recommends spending time on is understanding where to start introducing your needle. If there is clot or liver stuck in the needle and preventing blood return, she recommends flushing the needle, or advancing it and then pulling back gently. She ends by stating that learning how to operate the ICE probe is a steep learning curve, but one that every IR should invest time in. It cuts down on anesthesia and fluoroscopy time, and provides a level of safety that is simply not achievable with traditional methods.---RESOURCESARRS 2022 Abstract on ICE TIPS:https://apps.arrs.org/AbstractsAM22Open/Main/Abstract/E2038

Dr. Daniel Lerman, an orthopedic oncologist, and Dr. Anthony Brown, an interventional radiologist, discuss their collaboration in a joint practice of MSK interventional oncology. They focus on improving minimally invasive fixation techniques for metastatic cancer patients, offering true joint reconstruction and stable fixation. Despite advances, MSK interventional oncology still has a long way to go, especially in treating pelvic fractures in the community. The speakers highlight the importance of interdisciplinary collaboration, the application of biomechanics, and educating the medical community about IR. They express excitement and optimism for the future of ortho/IR collaboration.

In this episode, host Dr. Jacob Fleming interviews Dr. Luigi Manfrè, spine interventional neuroradiologist and chair of the European Society of Neuroradiology about treatment of spinal stenosis and spondylolisthesis using interspinous fusion spacers.---CHECK OUT OUR SPONSORRADPAD® Radiation Protectionhttps://www.radpad.com/---EARN CMEReflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/Dr9Ojz---SHOW NOTESDr. Manfrè reviews his technique for interspinous spacer placement. He uses local anesthesia which he administers with a spinal needle. He adjusts the angulation and entry point using CT, then inserts the guide wire. When he has it positioned between two spinous processes, and when the wire abuts the facet, this is the end point of the guide wire. He then uses soft tissue dilators through a 5mm incision before placing a spacer over the spacer delivery system. He usually places 8-12mm spacers, occasionally using 14mm spacers.One of the main pitfalls that happens when placing spacers is oversizing. Dr. Manfrè believes that this is a more common phenomenon in open surgical decompression due to patient placement in the operating room. Patients are often placed prone with a pillow beneath their abdomen to flex the lumbar spine and aid in exposure and insertion of spacers. However, this causes measurements to be greater than they are in natural spine mechanics.Next, we discuss the historical idea that interspinous spacers induce an unnatural lumbar kyphosis. New research suggests this is not the case. In fact, spacers restore the natural alignment of the spine without inducing kyphosis. Additionally, in patients with stenosis at multiple levels, the addition of a spacer at the worst level improves the morphology of the entire spine. He usually only places one spacer for his patients, and rarely will place two. New unpublished research by Dr. Manfrè on upright MRI shows that spacers placed for patients with spinal stenosis cause expansion of the dural sac by up to 70% by the next day. What’s more, in patients with both stenosis and listhesis, placement of a fusion spacer to correct both the stenosis and the instability result in disappearance of listhesis on MR the day after the procedure.---RESOURCESDr. Manfrè Website:https://www.manfreluigi.com/index.htmlManfrè Articles:https://jnis.bmj.com/content/12/7/673.abstracthttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC8511561/https://journals.sagepub.com/doi/abs/10.15274/INR-2014-10052ESNR Hands On Spine Course:https://www.esnr.org/en/spine-interventional-neuroradiology-full-hands-on-course/about-catania/New Procedures in Spinal Interventional Neuroradiology:https://www.springer.com/series/13394

In this episode, host Dr. Jacob Fleming interviews Dr. Luigi Manfrè, interventional radiologist and chair of the European Society of Neuroradiology about how he treats lumbar spinal stenosis using spinoplasty and minimally invasive placement of interspinous spacers.---CHECK OUT OUR SPONSORRADPAD® Radiation Protectionhttps://www.radpad.com/---EARN CMEReflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/Syf8sW---SHOW NOTESDr. Manfrè discusses his background and how he arrived at his current practice in Catania, Italy. His journey in medicine began with the intention of becoming an ophthalmologist. He then realized he didn’t want to pursue this path, and was told by a teacher he would be studying neuroradiology. He despised neuroradiology prior to this, but soon fell in love “at first sight”. He then went to Toronto to study under pioneers of pediatric neuroradiology. He dabbled in vascular IR before finally finding interventional spine. It began with injections for pain but he soon realized the potential of this field. At the time, surgery was becoming more minimally invasive, and as a radiologist, he knew he could leverage this momentum due to this unique background in radiology that his surgeon colleagues did not have.Dr. Manfrè believed he could apply the same treatments that conventional spine surgeons were doing in a faster, more precise and less aggressive manner. Spine surgeons were beginning to place interspinous spacers for spinal stenosis, and he was interested in placing these using CT and fluoroscopy guidance. He selects his patients very precisely, because it is important to him to not be using a device on the wrong patient. He endorses collaboration with neurosurgeons and orthopedic surgeons and practices this frequently, often referring patients within his network of collaborators. He selects patients for interspinous spacer placement who have genetic lumbar spinal stenosis causing ligamentous compression of nerves.His technique involves a combination of CT and fluoroscopy as it has been shown that using CT for procedural planning has been shown to reduce patient radiation exposure by 90%. He then uses fluoroscopy to insert the dilater over the guide wire, put in the spacer and open the spacer, which takes around 20 seconds of fluoro time. The interspinous spacer is a device that is placed in between two spinous processes to slow the progression of spinal stenosis and neurologic injury. The spacer cannot undo any prior neurologic injury, however, due to the progressive nature of this disease process. Surgical placement of a spacer is aggressive, involving general anesthesia in older patients with comorbidities, opening of the spinal canal, and laminectomy, which causes ligamentous instability that requires repair. It can be a three hour procedure, which involves extensive recovery and rehab. Dr. Manfrè places a spacer in 3 minutes, uses local anesthesia and midazolam, a 5mm incision, and no rehab. The primary reason for failure of the procedure is spinous process fracture and bone remodeling. He began performing spinoplasty, a procedure in which he injects 1cc of Polymethyl methacrylate (PMMA) in the adjacent posterior arch to determine if this would impact the success of the spacers. He now routinely performs spinoplasty 2 months prior to spacer placement and has enjoyed very low failure rates since implementation of this technique.---RESOURCESDr. Manfrè Website:https://www.manfreluigi.com/index.htmlManfrè Articles:https://jnis.bmj.com/content/12/7/673.abstracthttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC8511561/https://journals.sagepub.com/doi/abs/10.15274/INR-2014-10052

In this episode, our host Dr. Sabeen Dhand interviews Dr. Pascal Jabbour, Division Chief of Neurovascular Surgery & Endovascular Neurosurgery at Jefferson University. We discuss the current training landscape for vascular neurosurgery, the open versus endovascular debate, and Dr. Jabbour’s perspective on multispecialty collaboration in vascular neurology.---CHECK OUT OUR SPONSORSMicroVention FRED Xhttps://www.microvention.com/emea/product/fred-xRapidAIhttp://rapidai.com/?utm_campaign=Evergreen&utm_source=Online&utm_medium=podcast&utm_term=Backtable&utm_content=Sponsor---SHOW NOTESDr. Jabbour starts the episode by recounting his time in residency and how his mentor inspired him to pursue a vascular neurosurgery fellowship. It is becoming increasingly common for neurosurgery residency programs to require their trainees to complete a rotation in vascular neurosurgery. He also speaks more about the residency program at Jefferson and different community hospitals that Jefferson is affiliated with. Having affiliates across a wide geographic area helps his department better serve the community by saving time and reducing the need to transfer patients.Next, Dr. Jabbour describes his own practice, which incorporates both endovascular and open procedures. He emphasizes that there is little benefit from debating superiority between the two methods, since neurosurgeons should focus on the disease process and select the method that best serves each patient. Training in both methods is a necessity.Finally, we cover the topic of collaboration between neurosurgeons, interventional neuroradiologists, neuroradiologists, and neurologists. Each specialty brings something different to the table, whether it is procedural skill, knowledge of anatomy, or expertise in disease processes. Dr. Jabbour encourages physicians to look past turf wars and recognize the importance of cross training and building a strong overall vascular team.---RESOURCESTwitter:@PascalJabbourMDSociety of Neurointerventional Surgery (SNIS):https://www.snisonline.org/AANS/CNS Cerebrovascular (CV) Section:https://cvsection.org/---MicroVention Disclaimer: For complete indications, contraindications, potential complications, warnings, precautions, and instructions, see instructions for use provided in the device. FRED X is intended for healthcare professional use only and by prescription only. Federal law restricts this device to sale by or on the order of a physician.

In this episode, host Dr. Michael Barraza interviews interventional radiologist Dr. Samdeep Mouli about controversies in prostate artery embolization, including technique, durability, and how we can leverage the data to unite IRs and establish PAE as standard of care.---CHECK OUT OUR SPONSORBoston Scientific Embold Fibered Coilshttps://www.bostonscientific.com/en-US/products/embolization/embold-detachable-coil-system.html---SHOW NOTESDr. Mouli discusses his role as director of translational research in interventional radiology at Northwestern. He reviews the most recent major data on PAE. There have been two major papers, one from a Portuguese group and another from a Brazilian group. The take home points from these papers are regarding the durability of symptoms and the safety profile of PAE. The biggest positive of PAE is that it is the safest among all minimally invasive surgeries. Dr. Mouli argues that PAE should be pursued as first line treatment for benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTs). Another upside of PAE is that it doesn’t prevent patients from undergoing any other medical or surgical intervention in the future.One of the barriers to PAE becoming first line therapy is that there is currently no standardization among operators. Everyone still does it differently, whether by using different microcatheters, particle sizes, or other technical factors. This gives urologists ground to stand on when they argue against PAE. Dr. Mouli feels IRs should approach BPH with the same rigor that urologists do. He believes we need to use the long-term data to prove that PAE is safe, durable and yields better sexual outcomes than TURP or other minimally invasive surgical procedures. This can be accomplished via publishing guidelines for IRs. He believes a good starting place is to only use 300-500 micron particles for de-novo PAE cases. It has been proven this size is safe and results in very low non-target embolization compared to the 100-300 micron size, which more commonly causes this complication and results in more sexual dysfunction.Dr. Mouli says urologists are pushing for surgical intervention before exhausting medical management and argues that IRs should do the same. He believes offering PAE early is in the best interest of patients, because waiting to fail medical management can cause further complications. Dr. Mouli does not get pre-procedure vascular imaging or MRI. This is because he uses intra-procedure cone beam CT. He does this as part of his procedure to map out collaterals and other blood supply to the prostate. He then targets these arteries with coils before using particle embolization on the prostate gland itself. He does this because his goal is to match the 5 year success rate demonstrated in recent studies of over 80 percent, with a less than 20% recurrence rate. He ends by stating that the long-term data show a 10-30% re-treatment rate across all treatment modalities. Knowing this, he feels even stronger that PAE should be the first line therapy, considering it is the least invasive option, it is safe and has the lowest rates of sexual dysfunction. If patients prefer more invasive procedures in the future, they can still go that route, or they can elect for repeat PAE as needed.---RESOURCESTriago Bilhim Paper:https://link.springer.com/article/10.1007/s00270-022-03199-8Francisco Carnevale Paper:https://pubmed.ncbi.nlm.nih.gov/33308534/UK-ROPE Study:https://pubmed.ncbi.nlm.nih.gov/29645352/

In this episode, host Ally Baheti interviews interventional cardiologist Dr. Hady Lichaa of Ascension St. Thomas Heart about wire senses, including ways to build tactile and visual skills, selection of workhorse and specialty wires, and the do’s and don’ts of crossing lesions.---CHECK OUT OUR SPONSORSSurmodics Pounce Thrombectomyhttps://pouncesystem.com/Reflow Medicalhttps://www.reflowmedical.com/---SHOW NOTESDr. Lichaa starts by outlining four different components of wire senses: visual sense, tactile sense, IVUS, and the digital subtraction angiography (DSA) roadmap. First, visual aspects are a combination of 2D wire sliding and looping, 3D rotation, and the course of the wire relative to the vessel architecture. By combining these visual cues, the operator can determine if the wire is inside the true lumen, within the vessel wall, or entirely outside of the vessel.The next factor is tactile sense. Each type of wire strikes a balance between resistance to rotation / advancement and torque transmission. This balance is determined by wire characteristics such as core material, tapers, tip design, and coating. Dr. Lichaa encourages operators to test out different wires and focus on mastering their favorite workhorse wires. Additionally, there are specialty wires that can be employed in certain cases, such as CTO wires with heavy tip, tapered tip wires to enter microchannels, and supportive wires for the use of other equipment.Additionally, we discuss how intravascular ultrasound (IVUS) leads to safer outcomes because it allows the operator to confirm that they are in the true lumen and measure vessel size before deploying stents or balloons. DSA can also help determine location and help map out different strategies if a first option fails.Finally, Dr. Lichaa lists some helpful tips for new operators. We highlight the importance of mastering your favorite wires, having backup plans, communicating with staff, and keeping calm in the angio suite.---RESOURCESAbbott Command Wire:https://www.cardiovascular.abbott/us/en/hcp/products/peripheral-intervention/guide-wires/workhorse/hi-torque-command.htmlASAHI Gladius Wire:https://asahi-inteccusa-medical.com/product/asahi-gladius-014/ASAHI CONFIANZA Pro:https://asahi-inteccusa-medical.com/product/confianza-pro-series/Terumo NAVICROSS Support Catheter:https://www.terumois.com/products/catheters/navicross.htmlTeleplex Turnpike Catheter:https://www.teleflex.com/usa/en/product-areas/interventional/coronary-interventions/turnpike-catheters/index.htmlACT ONE Technology:https://medical.asahi-intecc.com/en/technologiesPhilips Pioneer Reentry Catheter:https://www.usa.philips.com/healthcare/product/HCIGTDPPLUS/pioneer-plus-ivus-guided-re-entry-catheterCordis OUTBACK Reentry Catheter:https://cordis.com/na/products/cross/endovascular/outback-elite-re-entry-catheter