BackTable Vascular & Interventional

In this episode, host Dr. Michael Barraza interviews Dr. Kyle Cooper, interventional radiologist and Dr. Tahmeed Contractor, electrophysiologist about how IR and EP work together at their institution, including how they perform complex pacer lead removals, and how the have embraced collaboration over competition.---CHECK OUT OUR SPONSORInari Medicalhttps://www.inarimedical.com/---SHOW NOTESThe doctors begin by discussing how they began working together. It was somewhat by chance that they started to work so closely, because the EP and the IR labs are directly across from each other at Loma Linda, where they work. They both began finding patients that had overlapping problems requiring intervention by both specialties, such as someone who needed a pacer lead out who also had an occluded AV fistula on the same side.Their relationship developed further due to the nature of the complexity of some of the EP cases. They often have to remove multiple pacer leads that were placed in the patient over 30 years ago. When these devices were created, they were not designed to be removed, so it is often quite difficult to do. Furthermore, because they are mostly plastic, not metal, they often break during removal. When this happens, it is not uncommon to have to call IR to help retrieve the piece. Though a cardiothoracic surgeon is usually always scrubbed into EP cases, open heart surgery is only done if all else fails.The two discuss how this collaboration has allowed them both to learn new skills. Dr. Contractor now does many lead extractions and will only call Dr. Cooper if there is a complication. Similarly, Dr. Cooper says he has learned many techniques from Dr. Contractor such as how to use intracardiac echo (ICE), or more commonly called intravascular ultrasound (IVUS) in IR for many more procedures than he was previously able to. Some of the challenges they have encountered is reimbursement and scheduling. With EP, CT surgery and IR are all in the room and helping, it complicates who gets paid. In general, IR bills for any venoplasty done during the procedure, and EP and CT surgery bill for the rest.

Host Aparna Baheti interviews Barbara Hamilton and Aarti Luhar about navigating training and early career during a pregnancy. They discuss factors to consider such as scheduling, parental leave policies, radiation exposure risks, and childcare.---CHECK OUT OUR SPONSORSAthletic Greenshttps://www.athleticgreens.com/backtableviMedtronic Abre Venous Stenthttps://www.medtronic.com/abrevenous---SHOW NOTESOur guests start by sharing their paths to motherhood. Dr. Luhar was pregnant as a diagnostic radiology trainee, while Dr. Hamilton was pregnant as an attending. We talk about the benefits of being part of a large department or group during maternity leave, due to more flexibility of scheduling changes and availability of coverage. Both of our guests recommend that IRs reach out to their HR departments as soon as they feel comfortable sharing their pregnancy news. Establishing contact with the department is a helpful way to clarify parental leave policies, specifically if one qualifies for parental leave and how long the leave can be. Additionally, Dr. Luhar encourages listeners to reach out to colleagues who have been pregnant before, since they can be a valuable resource for insights on the granular details of practicing IR while pregnant.In terms of radiation as an occupational exposure, Dr. Hamilton did not change her caseload during pregnancy. She shares her preference to wear extra radiation protection around her waist. Dr. Luhar reached out to her hospital’s radiation physicist for guidance. She received the advice to use standard radiation protection and follow the principle of ALARA (as low as reasonably achievable). Additionally, we discuss the risks of pathogen exposure and needle sticks. Both doctors agree that having supportive staff and colleagues can make the pregnancy process more manageable.Additionally, we discuss unexpected challenges during pregnancy. Dr. Hamilton describes her experience with the risk of premature labor and bedrest. Dr. Luhar recounts the struggle of scheduling prenatal appointments and dealing with pregnancy complications while working a full caseload. We close the episode by giving advice for evaluating the culture of your work environment, relying on support systems that are in place, and not being afraid to ask important questions.---RESOURCESDr. Barbara Hamilton Twitter:@TSuperheroineDr. Barbara Hamilton Instagram:@TiredSuperheroineSIR Pregnancy Toolkit:https://www.sirweb.org/practice-resources/toolkits/pregnancy-toolkit/

In this special crossover BackTable episode, Dr. Aaron Fritts and Dr. Julie Wei talk with Dr. Gerry Mattia, Chiropractor and Director of Rehabilitation of ViscoGen Clinic in Orlando, Florida.The CME experience for this Podcast is powered by CMEfy - click here to reflect and unlock credits & more: https://earnc.me/UmeBWU---CHECK OUT OUR SPONSORRADPAD® Radiation Protectionhttps://www.radpad.com/---SHOW NOTESFirst, Dr. Mattia recounts his journey to becoming a chiropractor, beginning with his medical history of aortic stenosis fixed by a chiropractor, his decision to enter chiropractic school, and starting his independent practice after graduation. Then, he explains how he deals with patients presenting with degenerative disc disease with spinal stenosis, which was the issue he resolved in Dr. Wei. A herniated disc is the most common cause of degenerative disc disease. The standard chiropractic treatment is cervical decompression to help the disc restore itself. Dr. Mattia also uses a level 4 laser to rehydrate the disc. For optimal results, he recommends that patients see him 4 times a week for 6 to 8 weeks in order to fully lift the pressure off of the brachial plexus. He notes that good chiropractors will use the correct formulas and appropriate technology while adjusting the patient gently.Next, the doctors delve into why many physicians are wary of chiropractors, which is rooted in a 1988 legal case that prohibited doctors from referring their patients to chiropractors. Dr. Mattia encourages physicians to seek therapy before medical issues develop into very severe conditions. Additionally, Dr. Wei notes that medical culture often encourages physicians to put the health of their patients before theirs.Then, Dr. Mattia discusses how younger people and surgeons can improve their neck health. He notes that excessive cell phone use can reverse the cervical curve, causing people to lose their normal lordotic curve, a structure which usually prevents compression. He also recommends strengthening the muscles in the neck and shoulders, sleeping with a cervical pillow, and going to a good chiropractor to get routine adjustments. Dr. Wei recommends avoiding slouching and adjusting screens to eye-level in OR. Both Dr. Wei and Dr. Mattia agree that maintaining a healthy body weight will have positive benefits on spinal health.Finally, Dr. Mattia recommends which qualities to focus on when finding a good chiropractor. He recommends looking for an experienced, passionate family practice chiropractor. As a word of caution, he warns listeners to never let a chiropractor adjust them without reviewing their X-ray imaging first.

Dr. Shamit Desai talks with Dr. Kavi Devulapalli and Dr. Vishal Kadakia about Locums work, including the current market and opportunities, different practice models, navigating finances and taxes, and how to organize your life around this unique practice style. Meet the locums chameleon!---CHECK OUT OUR SPONSORMedtronic Abre Venous Stenthttps://www.medtronic.com/abrevenous---SHOW NOTESTo start off, we discuss what locums means for each of these clinicians, including inpatient vs outpatient work. Most locums opportunities are in mid-sized cities and smaller cities, due to increased demand in these areas. Locums work is a way for IRs to take control of their practices, making it a very appealing work model. The ratio of IR to DR for each of these clinicians ranges from 70:30 up to 90:10. Employers need locums to prevent burnout of their FTE employees, and to reduce call in areas where IRs are overworked. Employers also look to locums to build service lines and bring in procedures that aren’t currently being done at their institutions. It is a rewarding opportunity for both employer and employee.Next, we review job expectations and the difference between inpatient and outpatient locums work. There are generally two types of clients, one needing someone to fill the role of a person who works at FTE, and another where the IR department is made up of a roster of rotating locums providers. Being in locums, you get exposure to so many different people, and practices and you get to expand your network. This opens up many opportunities that you would not get at one location. Some of the downsides are the need to constantly adapt, use equipment you are not as familiar with, and work with staff who do not know your preferences or even glove size. However, you get to build your schedule, and you have the power to work where you want when you want.Finally, we discuss some of the contracts, reimbursement, and insurance details. The three discuss the differences between being a W2 employee versus a 1099 employee, comparing what happens with health insurance and retirement. They also discuss the pros and cons of a 1099 versus owning an LLC versus starting an S corporation. All three physicians highly recommend researching these and speaking to a lawyer about your best options until you fully understand these concepts. They discuss licensure, credentialing and malpractice insurance, as well as whether they recommend using an agency for these as a locums. Lastly, they discuss reimbursement, including models such as a flat rate for a week versus a deconstructed model that consists of a daily rate, a call rate, and an overtime rate.---RESOURCESKavi Devulapalli ProfilesTwitter: @linemonkeymdBlog: https://linemonkeymd.comVishal Kadakia ProfilesLinkedIn: https://www.linkedin.com/in/theirdoc

In this episode, our guest host Dr. Vishal Kumar interviews medical anthropologist and social scientist Dr. Kelly Knight of UCSF. They discuss the meaning of structural competency, methods for incorporating this concept into medical education, and how it can be applied to alleviate physician burnout.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/4GAyUy---SHOW NOTESDr. Knight starts by defining structural competency as the recognition of the underlying policies, systems, and hierarchies that produce social determinants of health. While these structures may sometimes be invisible, they have a large impact on health outcomes. Examination of these factors allows us to think about interventions that can make healthcare more equitable.Next, we highlight effective ways to integrate structural competency into medical education. Dr. Knight shares information about national shared curricula that are designed with the flexibility for each institution to modify the content according to their community’s needs.Finally, we examine redlining as an example of structural violence, signifying intentional disinvestment in marginalized communities. Dr. Knight believes that change starts with an initial acknowledgement and recognition of policies that make populations vulnerable to illness. She also encourages individual healthcare providers to take action by developing interpersonal communication skills, strategizing ways to make the clinical space more focused on healing, and working with elected individuals to create equity at a policy level. All of these efforts may allow for healthcare providers to reconnect with their original motivation to help patients and have a protective effect against burnout.---RESOURCESStructural Competency Working Group:https://www.structcomp.org/Teaching Structure: A Qualitative Evaluation of a Structural Competency Training for Resident Physicians:https://pubmed.ncbi.nlm.nih.gov/27896692/Mountains Beyond Mountains: The Quest of Dr. Paul Farmer:https://www.amazon.com/Mountains-Beyond-Tracy-Kidder/dp/0812973011The REPAIR Project:https://repair.ucsf.edu/homeDo No Harm Coalition:https://www.donoharmcoalition.org/UCSF Health Equity Collaborative:https://thecollaborative.ucsf.edu/training-health-equity-collaborative

In this episode, host Dr. Mary Costantino interviews Dr. Kathy Krol, interventional radiologist and former SIR president about the evolution of interventional radiology, her various leadership roles, and the growth of women in IR.---CHECK OUT OUR SPONSORInari Medicalhttps://www.inarimedical.com/---SHOW NOTESWe begin by discussing how Dr. Krol entered the field of radiology and subsequently became involved in special procedures in radiology, before the beginning of interventional radiology. At the time, there was only a 7 French stiff wire, a J wire, or a straight wire. She recalls how the introduction of two key instruments, the glide wire, and the stent, changed the entire practice and scope of the types of interventions radiologists could do.Next, Dr. Krol talks about her involvement with SIR (Society of Interventional Radiology). She first joined a meeting at a hotel in San Francisco, where she was the only woman in the room, and repeatedly mistaken for a nurse. At the time, the society had recently allowed women to join, and since joining, she has never missed a SIR annual business meeting. During her time as the president of SIR, in 2006, some of the main issues were preserving IR as its own field among vascular surgery and interventional cardiology, forming an independent IR residency, and forming the idea of the outpatient-based lab (OBL) as a new space for IRs to work in.Dr. Krol shares stories of her struggles as a woman in IR as well as in leadership positions. She began in radiology, where she had to work hard to learn procedures, and then even harder to prove to colleagues that she was capable. She was often mistaken for a tech or a nurse and resorted to wearing suits instead of dresses while in the IR suite performing procedures. She often had to take whatever role was given, but she used this to her advantage. One such instance is when she wanted to volunteer for SIR, they put her in coding and billing which was not her interest. She turned this around and became so invested in it that she has now helped create nearly all the CPT codes that exist for IR today.

In this episode, our host Dr. Chris Beck interviews interventional radiologist Dr. Riad Salem about indications, technique, and cross-specialty collaboration in portal vein recanalization in the cirrhotic patient population.The CME experience for this Podcast is powered by CMEfy - click here to reflect and unlock credits & more: https://earnc.me/M2xtKL

In this episode, host Dr. Chris Beck interviews interventional radiologist Dr. George Behrens about how he built a robust multidisciplinary portal hypertension clinic in a community hospital, tips for common challenges during a TIPS, and post-TIPS management.---CHECK OUT OUR SPONSORArgon Medical Scorpion Portal Vein Access Serieshttps://www.argonmedical.com/scorpion---SHOW NOTESWe begin by discussing Dr. Behrens portal hypertension practice. He sees patients in conjunction with hepatology and transplant surgery. The model of his clinic is the opposite of the standard practice. The specialists come to the community hospital, and their clinic gets referrals from tertiary hospitals in Chicago. This took years to build, and they received enormous pushback. This model encompasses patient-centered care because it removes many of the barriers that patients face to travel into Chicago for the workup and management plan of portal hypertension. In this clinic, they also evaluate the underlying cause of cirrhosis including more uncommon causes such as hemochromatosis, Wilson disease, and alpha 1 antitrypsin deficiency.Next, Dr. Behrens details the typical procedure and provides tips for commonly encountered challenges during a TIPS (transjugular intrahepatic portosystemic shunt). He does all TIPS under general anesthesia. He drains ascites, then uses a multipurpose catheter to enter the hepatic vein, without a preference for which hepatic vein he is in. He uses a Launcher AL 11 1 ½ or 2 if he is having difficulty entering a hepatic vein. He then does a CO2 portogram. Next, he advances the cannula into the hepatic veins, unsheathes the cannula, then brings it back to about 2cm from the pedicle, close to the ostium of the hepatic vein. He discusses the differences in technique between the Rösch-Uchida and the Scorpion. He likes to place his stent with the proximal portion where the diaphragm crosses the right atrium and the distal part at the entry site of the portal vein. He uses a VIATORR stent, and always dilates to 8mmHg first, then re-measures pressures. His general rule for dilation is less than 12mmHg for bleeding and less than 8mmHg for ascites.Dr. Behrens discusses follow-up for patients and post-procedure care. All patients are started on rifaximin 2 weeks prior to TIPS. If ascites drained was 4L or more, he gives 100g albumin and 20mg Lasix. He measures pressures via a right heart cath before and after the procedure. Depending on the MELD, he may send patients to the floor or home same day, while others go to the ICU. He starts all patients on lactulose and zinc 220mg BID the day of the procedure. He advises all patients against using PPIs due to the increased risk of encephalopathy. He maintains pre-procedure Lasix and spironolactone dosing for the first 3 months. At one month, patients get a TIPS US with velocities, CMP, CBC, and INR. At 3 months they get cross-sectional imaging and repeat labs. He starts managing diuretics at 3 months. After this, he sees patients every 6 months and screens for hepatocellular carcinoma.---RESOURCESArgon Scorpion:https://www.argonmedical.com/products/scorpionCook Rösch-Uchida:https://www.cookmedical.com/products/ir_rups_webds/Gore VIATORR:https://www.goremedical.com/products/viatorrMedtronic Launcher:https://www.medtronic.com/us-en/healthcare-professionals/products/cardiovascular/catheters/launcher.htmlMELD score:https://www.mdcalc.com/calc/78/meld-score-model-end-stage-liver-disease-12-older

Dr. Jacob Fleming talks with Dr. Alan Alper Sag about building a musculoskeletal (MSK) interventions practice at Duke University Medical Center, collaborating with other specialists, and future predictions for MSK IR.The CME experience for this Podcast is powered by CMEfy - click here to reflect and unlock credits & more: https://earnc.me/o00BlF---CHECK OUT OUR SPONSORRADPAD® Radiation Protectionhttps://www.radpad.com/---SHOW NOTESIn this episode, our host Dr. Jacob Fleming interviews Dr. Alan Sag about building a musculoskeletal (MSK) interventions practice at Duke University Medical Center, collaborating with other specialists, and future predictions for MSK IR.Dr. Sag starts the episode by sharing his unique experience abroad. His first job was centered around helping to build an IR practice at a teaching hospital in Istanbul. This process helped him discover that the key to practice building was forming foundational cross-specialty relationships. These eventually led to more patient referrals and a higher level of care coordination.When he transitioned to an academic position, Dr. Sag first saw an unmet need in bone cryoablation. He recognized that IR procedures could be powerful alternatives to opioid escalation. A key turning point for his department came when a local TV station covered one of his patient’s stories, and he saw a large increase in referrals. Dr. Sag emphasizes that it was important to ensure that the practice was set up with enough resources to accomodate a large volume of patients. Additionally, it was crucial to recognize when to say “no” to patients when a procedure was contraindicated for them. This patient-first approach also showed referring doctors that he was independently and objectively assessing patients, which helps with trust-building.As we move onto discussing multidisciplinary care, Dr. Sag says that learning another specialty’s vocabulary can greatly enhance your communication and show your desire to collaborate. He encourages IRs to be flexible and learn which conditions are important to the referring doctors. When working with anesthesiology and PM&R, IRs can offer their services to enhance their pain palliation efforts. When working with oncologists, this pain palliation can allow cancer patients to continue participating in clinical trials.Finally, we discuss the next frontiers of MSK interventions. Dr Sag is excited by the prospect of standardization of MSK training, internally cemented screws, and vertebral body stents.---RESOURCESDr. Alan Sag Twitter:https://twitter.com/AlanAlperMD?s=20&t=8RGQsroHPZ9Vyc-0lpkiVQBone Cryoablation Media Coverage:https://www.wral.com/komen-s-kohl-tries-tumor-freezing-therapy-in-ongoing-cancer-fight/18974441/Duke Center for Brain & Spine Metastasis:http://dukecancerinstitute.org/DCBSMSpineJack System:https://strykerivs.com/products/families/spinejack-systemSociety of Interventional Oncology (SIO):http://www.sio-central.org/SIO’s “Language of Oncology” Course:http://www.sio-central.org/p/cm/ld/fid=385Visible Body Anatomy Atlas:https://www.visiblebody.com/anatomy-and-physiology-apps/human-anatomy-atlase-Anatomy Atlas:https://www.imaios.com/en/e-AnatomyEp. 199- Advanced Minimally Invasive Pain Interventions:https://www.backtable.com/shows/vi/podcasts/199/advanced-minimally-invasive-pain-interventions

STREAM Meeting Founders Ari Isaacson and Sandeep Bagla tell us about what to expect at the next meeting in September, including PAE and GAE practice building tips, as well learn about new embolization procedures such as adhesive capsulitis and thyroid arterial embolization.The CME experience for this Podcast is powered by CMEfy - click here to reflect and unlock credits & more: https://earnc.me/CIj1ey---SHOW NOTESIn this episode, host Dr. Aaron Fritts and interventional radiologists Drs. Ari Isaacson and Sandeep Bagla discuss new programming for their upcoming STREAM Conference in September 2022.See our “Resources” section below for a special promotion code for BackTable listeners!As they enter their fifth year of hosting the STREAM, the doctors describe the conference’s evolution beyond procedural teaching of prostate artery embolization (PAE). This year, they will focus more programming on practical factors such as decision-making strategies, malpractice considerations (with both plaintiff and defense attorneys), and new frontiers of embolization. They highlight the increased efforts for cross-specialty collaboration, since the conference will include sessions on genicular artery, shoulder, and hemorrhoid embolization.Finally, we share more ways to learn about PAE. Our guests describe opportunities to shadow at Prostate Centers USA and request to be proctored for initial cases.---RESOURCESThe STREAM Meeting:https://www.thestreammeeting.com/Promotion Code for 25% off registration for the STREAM Meeting: BACKTABLE22Prostate Centers USA:https://www.prostatecentersusa.com/