BackTable Vascular & Interventional

Interventional Radiologist Dr. Preston Smith and healthcare attorney Patrick Souter join us to discuss strategies for navigating the legal world of non-compete agreements and exclusive contracts.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/pAxIn5---SHOW NOTESFirst, we review the vocabulary and examples of each type of agreement. Mr. Souter emphasizes that contrary to popular misconceptions, non-compete agreements are enforceable, as long as they are reasonable in scope, geographic location, and time frame. Additionally, he calls attention to “backdoor noncompetes,” which are clauses that, while not officially called “noncompetes,” still restrict a physician’s ability to practice medicine in a certain location. These include non-circumvention and non-solicitation agreements. Dr. Smith advises listeners to be wary of any terms that seem far-reaching or unreasonable, and to have a legal professional review the terms of the agreement.Next, we discuss exclusive contracts between large radiology practices and hospitals. While they are legal, they cannot be entered into for antitrust purposes of trying to prevent others from entering the marketplace. Exclusive contracts can serve as a barrier for independently practicing IRs to gain hospital privileges. Mr. Souter advises independent IRs to speak with hospital CMOs and provide reasonable explanations for why their services would be efficient and necessary for quality patient care.

We talk with Interventional Radiologist Dr. Sandeep Bagla about the challenges of clinical research in private practice, and the inspiration behind building a new practice paradigm in collaboration with Urology colleagues.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/Ogw44h---SHOW NOTESIn this episode, interventional radiologist and entrepreneur Dr. Sandeep Bagla joins our host Dr. Aaron Fritts to discuss the founding and multispecialty focus of Prostate Centers USA, a rapidly expanding network of office based labs (OBLs).Dr. Bagla describes why he decided to shift away from his former private practice and embark on a new venture that would eventually become Prostate Centers USA. Dr. Bagla sought to focus on embolization, a novel area of interventional radiology. He recounts the process of conducting prostate artery embolization clinical trials in a private practice environment, including challenges encountered and lessons learned about changing FDA regulations.Dr. Bagla developed Prostate Centers USA from a vision of collaboration with urologists to provide comprehensive procedural and clinical care. He describes how he pitched his collaborative approach to urologists and how he dealt with pushback. He also describes why the centers’ ownership structures and focused training pathways are attractive to physicians. Finally, Dr. Bagla highlights technologies that allow for ease of communication between the team members, such as task management systems and centralized monitoring systems.---RESOURCESEp. 164 Collaborative Approach to Prostate Artery Embolization (PAE) for BPH:https://www.backtable.com/shows/vi/podcasts/164/collaborative-approach-to-prostate-artery-embolization-pae-for-bphProstate Centers USA: https://www.prostatecentersusa.com/Outpatient Endovascular and Interventional Society (OEIS) Annual Meeting: https://oeisociety.com/

Co-hosts Dr. Christopher Beck and Dr. Aaron Fritts discuss cholecystostomy tube placement for acute cholecystitis, including the pros and cons of different techniques, and pitfalls to avoid.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/QDepym---SHOW NOTESIn this episode, our hosts Dr. Aaron Fritts and Dr. Chris Beck compare their procedural techniques for placing cholecystostomy tubes.They start the conversation by discussing patient workup. Dr. Beck always obtains an ultrasound and sometimes a HIDA scan. He also orders coagulation tests and checks if the patient is on anticoagulation medication in order to stratify the risk of the procedure and counsel the patient accordingly.Next, the doctors discuss pros and cons of transhepatic and transperitoneal approaches. Dr. Fritts usually prefers a transhepatic approach because it minimizes the risk of biliary leaks. He also believes that it is easier to stick the gallbladder in an area where it is affixed to the liver.Dr. Beck emphasizes that the gallbladder is a dynamic organ, so doing this procedure under ultrasound with fluoroscopy will allow real-time visualization of the needle.Finally, they consider different needle and drainage options. There are a variety of needles that can be used, including AccuStick, Yueh, and spinal needles. With drainage, the doctors highlight the differences between drainage bags and JP bulbs, noting that the former relies on drainage of infected bile by gravity, and the latter provides additional vacuum suction.

In this episode, our host Dr. Eric Keller interviews his longtime mentor, interventional radiologist Dr. Bob Vogelzang about the evolution of their mentor mentee relationship overtime and ways to create benefits for both mentors and mentees.---CHECK OUT OUR SPONSORRADPAD® Radiation Protectionhttps://www.radpad.com/---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/3QPBiv---SHOW NOTESA common idea throughout this episode is that no single definition of mentorship exists. Dr. Vogelzang highlights the importance of a flat structure, in which the mentee and the mentor feel comfortable to ask questions and explore an area of shared interest. Dr. Keller emphasizes the reality that mentoring relationships will grow and change with career development and geographic relocation.Overall, both doctors agree that an effective mentoring relationship should be driven by feasible projects that motivate both parties.

Interventional Radiologist Dr. Chris Ingraham discusses his approach to treating solid organ and pelvic trauma, including embolization technique and IR's role in workflow efficiency for better trauma care.---CHECK OUT OUR SPONSORBoston Scientific IOEhttps://www.bostonscientific.com/ioe---SHOW NOTESIn this episode, interventional radiologist Dr. Chris Ingraham and our host Dr. Michael Barraza discuss the role of IR in the trauma setting and approaches to embolization for trauma to the spleen, liver, kidneys, and pelvis.Dr. Ingraham outlines Harborview Medical Center’s workup of trauma patients and describes the collaboration between the emergency, trauma surgery, and interventional radiology departments. Although CT provides more comprehensive imaging, Dr. Ingraham says that taking a patient directly to an angiogram could address the trauma quicker and prevent more complications. He also speaks about empiric embolization, noting that extravasation can be intermittent and not visible on imaging.Overall, Dr. Ingraham recommends over-sizing coils, since patients are usually hypotensive and vasoconstrictive during active bleeding. Vessel diameter will eventually increase as patients are resuscitated.When embolizing the spleen, Dr. Ingraham emphasizes that the goal is to prevent the need for splenectomy, especially in young patients, because of its role in immunologic responses. He advocates for proximal embolization in order to decrease the blood flow into the spleen and allow for splenic lacerations to clot and heal.In liver embolization, Dr. Ingraham notes that there could be a laceration to the liver’s venous system, and embolization of the arterial system could reduce the dual blood supply of the liver. In these patients, there can be a higher risk of necrosis and biliary injury.Finally, we discuss follow up care with pulse exams and monitoring of hemodynamic stability.---RESOURCESBalloons Up: Reduced Time to Angioembolization:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7903099/SIR Trauma Guidelines, 2020:https://www.jvir.org/article/S1051-0443(19)30952-2/fulltext

Dr. Aparna Baheti talks with Dr. Timothy Huber about performing thyroid nodule ablation procedures, including patient selection, technique pearls and pitfalls, and how to incorporate the procedure into your practice.---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/QZ9TpA---SHOW NOTESIn this episode, interventional radiologist Dr. Tim Huber and our host Dr. Ally Baheti discuss the process of thyroid nodule radiofrequency ablation, including patient selection, workup, procedural technique, and follow up.Dr. Huber describes the most common indication for ablation, which is the presence of benign thyroid nodules that cause compressive symptoms. These can affect quality of life when they restrict a patient’s ability to swallow, breathe, and speak. He recommends ablation for symptomatic nodules that are over 2 cm in diameter. Dr. Huber also mentions functional nodules as more challenging cases, but still treatable with ablation. Though ablation for thyroid malignancies is rare, it is a field of active and growing research.In his workup, Dr. Huber uses ultrasound to assess nodular composition, vasculature, size, and nearby enlarged lymph nodes. Next, he obtains two benign fine needle aspiration samples and checks TSH levels before proceeding with ablation. During the procedure, he anesthetizes the skin of the neck with lidocaine, and periodically checks in with patients about pain level. Dr. Huber describes his “trans-isthmic approach” that keeps the needle as stable as possible. He exercises caution when ablating near the “danger triangle” containing the recurrent laryngeal nerve which innervates the vocal cords. While ablating posterior to anterior, Dr. Huber tracks echogenic changes on ultrasound.After the procedure, patients are monitored for one hour and then followed up in one month, and then three months over the next year. Dr. Huber warns interventionalists that post-ablation zones may look disfigured on ultrasound, but this will revert back to normal within 3-6 months.---RESOURCESEuropean Thyroid Association Guidelines:https://www.eurothyroid.com/guidelines/eta_guidelines.htmlKorean Society of Thyroid Radiology Guidelines:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6005940/

Vascular Surgeon Dr. Mazin Foteh and our host Dr. Sabeen Dhand consider various factors that can influence the choice of treatment methods for calcified common femoral artery (CFA) disease, including discussing the pros and cons of an endovascular vs surgical approach.---CHECK OUT OUR SPONSORShockwave Medicalhttps://shockwavemedical.com/?utm_source=CFA-Backtable-Podcast&utm_campaign=Backtable-Podcast---SHOW NOTESIn this episode, vascular surgeon Dr. Mazin Foteh and our host Dr. Sabeen Dhand consider various factors that can influence the choice of treatment methods for common femoral artery (CFA) disease.To start, Dr. Foteh describes risk factors of common femoral disease, such as smoking, renal failure, and diabetes. He notes that CFA lesions are usually calcified and homogenous because they are composed of layers of calcium, lipid, and platelets deposited in fibrin sheaths. He further distinguishes between partially occluded and fully occluded CFA lesions.Dr. Foteh reviews key tips to minimize complications during an open endarterectomy. To maximize exposure, he recommends making a longitudinal incision rather than a medial groin incision. Before closing, he also ensures that he checks 3-4 cm proximal and distal to the CFA and stents the external iliac artery if needed. Dr. Foteh opts for general anesthesia over local anesthesia, in case of unforeseen complications.With an endovascular approach, Dr. Foteh finds that shock wave lithotripsy has been most effective at cracking calcium, changing vessel compliance, and ultimately increasing luminal gain. He uses this technique first, examines the results, and then uses a drug-coated balloon or stent as needed.---RESOURCESClinical Trial Investigating the Efficacy of the Supera Peripheral Stent System for the Treatment of the Common Femoral Artery: https://clinicaltrials.gov/ct2/show/NCT02804113

Interventional Radiologist Dr. Jonathan Gross and host Dr. Aaron Fritts discuss the results from his recent JVIR Media article on the quantifiable environmental impact of operating an interventional radiology practice for one week. Guess how many road trips around the world it equates to!?---CHECK OUT OUR SPONSORRADPAD® Radiation Protectionhttps://www.radpad.com/---EARN CMEReflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/Wg2OuX---SHOW NOTESIn this episode, interventional radiologist Dr. Jonathan Gross and our host Dr. Aaron Fritts discuss the results from Dr. Gross’s recent JVIR article on the quantifiable environmental impact of operating an IR practice for one week.Dr. Gross begins by describing his lifelong interest in environmental sustainability. He developed the idea for this study because he recognized the discordance between his conscientious practices at home and his less sustainable practices in the IR suite. Dr. Gross acclimates us to vocabulary that is used in the article and defines the measurements of “life cycle assessment” and “volume of greenhouse gases.”Many listeners will be surprised to find out that material waste makes up less than 2% of all greenhouse gas emissions in an IR suite. The majority of emissions is actually produced by air conditioning and air exchange systems, which frequently and unnecessarily run when IR suites are not being used.Finally, Dr. Gross shares ways to reduce the environmental impacts of IR, such as installing motion-sensor lights, using re-processed equipment instead of single-use equipment, and streamlining procedure packs.---RESOURCESThe Environmental Impact of Interventional Radiology: An Evaluation of Greenhouse Gas Emissions from an Academic Interventional Radiology Practice: https://pubmed.ncbi.nlm.nih.gov/33794372/Environmental Impacts of Abdominal Imaging: A Pilot Investigation:https://pubmed.ncbi.nlm.nih.gov/30158086/

Dr. Donald Garbett, an Interventional Radiologist at Radiology Associates in Oregon, shares insights on tackling gastrointestinal bleeds. He discusses the essential role of triple phase CT angiography to differentiate between arterial bleeds and varices. The conversation includes his preference for transradial access and the use of various embolic agents like glue and coils. Dr. Garbett also highlights innovative techniques for emergency interventions, the challenge of ambiguous imaging, and how music can positively influence the medical environment.

Interventional Neuroradiologist Dr. Hannes Nordmeyer and Biomedical Engineer Dr. Matt Gounis discuss compositions of tough clots, approaches to stroke thrombectomy, and bailout stenting.---CHECK OUT OUR SPONSORCERENOVUShttps://www.jnjmedicaldevices.com/en-US/companies/cerenovus---SHOW NOTESIn this episode, interventional neuroradiologist Dr. Hannes Nordmeyer, biomedical engineering professor Dr. Matt Gounis, and our host Dr. Michael Barraza discuss compositions of tough clots, approaches for stroke thrombectomy, and bailout stenting.Dr. Nordmeyer believes that interventionalists are still struggling to find the most effective method for pulling clots. He says that the use of double stent retrievers has shown high success rates, but it would be ideal to have one retriever that can work on its own. He describes his equipment setup for a standard large vessel occlusion. Dr. Nordmeyer notes clot location and behavior within the first two passes determines whether or not the operator should continue with the stent retrieval approach or change the approach.Dr. Gounis evaluates various devices by defining “success” as achievement of TICI 3 with the first pass. He comments on the current development of very large bore aspiration catheters, such as the 088 Millipede catheter and the Tenzing catheter. He also emphasizes that the success of the procedure relies largely on the composition of the embolus. Fibrin-rich clots are less likely to integrate with the stent retriever. We discuss Dr. Nordmeyer’s technique, which utilizes a microcatheter and the NIMBUS device to pin and retrieve the challenging clot.We also cover bailout stenting and the benefits of recanalization when clot removal is not possible.---RESOURCESSWIFT DIRECT Trial:https://www.swift-direct.ch/the-swift-direct-trial/Preclinical Evaluation of Millipede 088 Intracranial Aspiration Catheter:https://pubmed.ncbi.nlm.nih.gov/32606100/The Novel Tenzing 7 Delivery Catheter Designed to Deliver Intermediate Catheters to the Face of Embolus Without Crossing:https://jnis.bmj.com/content/13/8/722Factors Influencing Recanalization After Mechanical Thrombectomy With First-Pass Effect for Acute Ischemic Stroke: https://www.frontiersin.org/articles/10.3389/fneur.2021.628523/fullNIMBUS Geometric Clot Extractor:https://www.jnjmedicaldevices.com/en-EMEA/news-events/cerenovus-launches-nimbustm-geometric-clot-extractor-remove-tough-clots