BackTable Vascular & Interventional

We talk with Dr. Cullen Ruff about common misconceptions when it comes to IV contrast and issues with the "contrast allergy", including ways we can improve patient care and clinical workflows by clarifying the true source of these reactions.---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/16AayH---SHOW NOTESIn this episode, diagnostic radiologist Dr. Cullen Ruff and our host Dr. Chris Beck discuss the research and patient education surrounding contrast allergies.Dr. Cullen starts the episode by commenting on the history of contrast media, noting that the earlier ionic contrast agents are more allergenic than the more recent non-ionic ones. By knowing the time period during which many radiologists switched to non-ionic agents (around 1985), we can identify during a medical history which of these types caused a patient’s allergic reaction.The doctors discuss current research, which shows that substituting for a different contrast media is more effective than giving steroid premedication and using the allergy-inducing contrast media. Unfortunately, many patients are unable to recall the year when they experienced their allergy or the name of the contrast agent given. This lack of information makes it difficult to administer a substitute contrast media to the patient.To address these workflow inefficiencies, Dr. Cullen advocates for individualized patient education over specific contrast allergies. He believes that taking the time to discuss allergies and giving the patient the name of their allergen, in writing, is essential for future imaging studies. He advises against the use of the vague and nonsensical term of “iodine allergy”, noting that patients are never allergic to the iodine itself, but rather a different component in the iodinated contrast media.Finally, we discuss Dr. Cullen’s book, “Looking Within: Understanding Ourselves Through Human Imaging” in which he shares patient stories and introduces the general public to the retrospective and predictive values of diagnostic imaging.---RESOURCES“Patients Have a Very Limited Knowledge of Their Contrast Allergies”:https://www.clinicalimaging.org/article/S0899-7071(21)00324-7/fulltext“Prevention of Allergic-like Reactions at Repeat CT: Steroid Pretreatment versus Contrast Material Substitution”:https://pubmed.ncbi.nlm.nih.gov/34342504/“Iodine Allergy: Common Misperceptions”:https://academic.oup.com/ajhp/article-abstract/78/9/781/6129459American College of Radiology Manual on Contrast Media, 2021:https://www.acr.org/Clinical-Resources/Contrast-ManualDr. Cullen’s book, “Looking Within: Understanding Ourselves Through Human Imaging”:https://www.cullenruff.com/books“The Immunology of the Vermiform Appendix: A Review of the Literature”:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5011360/

We talk with Dr. Mary Costantino and Dr. Goke Akinwande about their experiences and advice on making equipment purchase decisions for OBLs and outpatient centers, including pitfalls to avoid.---CHECK OUT OUR SPONSORSiemens Healthineershttps://www.siemens-healthineers.com/---SHOW NOTESIn this episode, interventional radiologists Dr. Mary Constantino, Dr. Goke Akinwande, and Dr. Aaron Fritts discuss the process of choosing and financing equipment for office-based labs (OBLs). This episode focuses on three major types of equipment: C-arms or fixed units, disposables, and ultrasound machines.First, the doctors discuss the fundamental differences between mobile C-arms and fixed units. Drs. Constantino and Akinwande agree that while the fixed unit is more ergonomically advantageous, it carries significantly more cost. While a fixed unit must be incorporated into the architectural planning of the OBL, a C-arm can be adapted to an existing space. Both doctors emphasize the importance of vendor support and knowing that they have quick access to technicians in the area.Dr. Constantino provides her perspective on disposables and device partnerships, noting that an IR’s priority should be obtaining the equipment that allows them to operate to the best of their abilities. Dr. Akinwande obtains most of his disposables through consignment inventory in order to minimize waste.Finally, the doctors talk about ultrasound technology and situations where different types may be more appropriate than others. Overall, they emphasize that while the OBL model grants autonomy to IRs, this pursuit introduces a large financial risk that should be carefully considered.---RESOURCESMidwest Institute for Non-Surgical Therapy: https://www.mintstl.com/Advanced Vascular Centers: https://www.advancedvascularcenters.com/

Dr. Donald Garbett interviews Dr. Joseph Couvillon about how he helped his group build an OBL practice in a rural setting, including the importance of hitting the pavement and phones to drive awareness with referring docs. Dr. Couvillon also raves about his recent trip to East Africa to help out the Road2IR team.---CHECK OUT OUR SPONSORSAccountable Revenue Cycle Solutionshttps://www.accountablerevcycle.com/Accountable Physician Advisorshttp://www.accountablephysicianadvisors.com/---SHOW NOTESIn this episode, interventional radiologist Dr. Joe Couvillon and our guest host Dr. Donald Garbett discuss the opportunities and obstacles that arise with building an OBL practice in the Shenandoah Valley and lessons learned from Dr. Couvillon’s trip to Tanzania with Road2IR.Dr. Couvillon recounts the process of building up his referral base for uterine fibroid embolizations (UFEs) in his practice, and shares his current experience in doing the same for peripheral arterial disease (PAD). He employs marketing strategies such as reading noninvasive studies and offering his services, as well as fostering a collaborative approach with cardiologists and vascular surgeons. He also speaks to the importance of reaching out to the referring doctors’ staff (NPs, PAs, and administrative assistants), since they can influence referral patterns.In addition, Dr. Couvillon updates us on his recent trip with Road2IR. He gives his perspective on teaching procedures to IR fellows in Tanzania and being inspired by their enthusiasm and resourcefulness.---RESOURCESBringing IR to East Africa: The Road2IR Story:https://www.backtable.com/shows/vi/podcasts/104/bringing-ir-to-east-africa-the-road2ir-storyRoad2IR: https://www.road2ir.org/

Interventional radiologist Michael Barraza talks with orthopedic spine surgeon Thomas Andreshak about his approach to vertebral augmentation for compression fractures, including unipedicular vs. bipedicular approach, technique pearls, and post-procedure care.---CHECK OUT OUR SPONSORMedtronic Kyphonhttps://www.medtronic.com/kyphoplasty---SHOW NOTESIn this episode, orthopedic surgeon Dr.Thomas Andreshak and our host Dr. Michael Barraza discuss kyphoplasty technique, including different methods of imaging, approaches, sedation, and follow-up.Dr. Andreshak starts with obtaining a standing X-ray because it allows him to better observe cases of spondylolisthesis. He describes both unipedicular and bipedicular approaches, noting that the unipedicular approach can allow for greater cost savings, less cement used, and lower radiation exposure.The doctors also review the stages of bone healing: hematoma formation, fibrocartilage formation, bony callus formation, and bone remodeling. Dr. Andreshak warns against overfilling the vertebra, which creates stiffness and puts stress on the adjacent endplate. Finally, they discuss follow-up and considerations for future treatment if pain persists.---RESOURCESConsulting Orthopedic Associates:https://consulting-ortho.com/Kyphon Assist:https://www.medtronic.com/us-en/healthcare-professionals/products/spinal-orthopaedic/vertebral-augmentation/kyphon-assist.html

Urologist Dr. Claus Roehrborn and Interventional Radiologist Dr. Sandeep Bagla discuss the pros and cons of Prostate Artery Embolization (PAE) compared to other Minimally Invasive Surgical Treatments (MISTS) for Benign Prostate Hyperplasia (BPH). They also discuss the importance of a collaborative, multidisciplinary approach when offering these treatment options, including agreeing on the best treatment for the patient.---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/Daw1w2---SHOW NOTESIn this episode, urologist Dr. Claus Roehrborn and interventional radiologist Dr. Sandeep Bagla discuss benign prostatic hyperplasia (BPH) and prostate artery embolization (PAE) in the context of counseling patients and cross-specialty collaboration.Dr. Roehrborn starts by reviewing the history of BPH treatment, from medications like alpha-blockers and anticholinergics, to minimally invasive options like UroLift, Rezum, and PAE. He emphasizes that the latter options are growing in popularity, since they provide treatment alternatives for patients who are concerned about side effects from medications, or have not experienced symptom relief from medications.Dr. Sandeep Bagla describes Prostate Cancer USA’s philosophy on IR/Urology partnership and how it can ultimately benefit patients. This model provides the patient with both an IR suite for the PAE procedure and a urology clinic for diagnostic assessment, determination of PAE candidacy, and follow-up assessment.Both doctors describe ideal patients for PAE. These are usually patients with a gland size above 60 g, confirmed bladder function, and a desire to preserve ejaculation function. Contraindications include urinary retention, chronic prostatitis, and heavily calcified glands.Finally, they describe how they manage minor short-term complications such as frequency and dysuria with medication. They track symptom relief using the International Prostate Symptom Score (IPSS), Dr. Bagla notes that the largest drop in IPSS usually occurs about 4-5 weeks post-procedure.

Vascular Surgeon Daniel Han discusses management of persistent false lumen perfusion in chronic aortic dissection, including the Knickerbocker Technique.---CHECK OUT OUR SPONSORMedtronic IN.PACT Admiral Drug-Coated Balloonhttps://www.medtronic.com/5yeardcb---SHOW NOTESIn this episode, vascular surgeon Dr. Daniel Han and our host Dr. Sabeen Dhand discuss various techniques involved in repairing chronic aortic dissections, including Thoracic Endovascular Aortic Repair (TEVAR), Knickerbocker, and candy plug.Dr. Han starts by reviewing the differences between a true lumen and a false lumen. False lumens are usually formed by a dominant entry tear in the aortic wall with additional fenestrations present. Since the false lumen lacks the three walls of the aorta, it is more easily perfused and compresses the true lumen. He further subdivides aortic dissection into hyperacute, acute, subacute, and chronic dissections, all depending on the chronicity of the tear. With treatment, the goal is to achieve aortic remodeling and fuse the true and false lumens. Dr. Han notes that the more chronic the dissection, the harder it will be to remodel the aorta back to its original state, since it has already started remodeling in the dissected state.The doctors discuss TEVAR and follow-up results in which Dr. Han would choose to re-intervene. He explains the Knickerbocker technique, in which he uses a balloon to selectively rupture the dissected septum. This establishes contact between the stent graft and the other side of the aorta, effectively creating a physical barrier to retrograde flow in the thoracic aorta. Dr. Han also discusses the candy-plug technique, which results in immediate cessation of blood flow into the thoracic aorta.---RESOURCESBackTable VI Episode 142: Type B Aortic Dissections with Dr. Frank Arko:https://www.backtable.com/shows/vi/podcasts/142/type-b-aortic-dissectionsFavorable Impact of Thoracic Endovascular Aortic Repair on Survival of Patients with Acute Uncomplicated Type B Aortic Dissection: https://pubmed.ncbi.nlm.nih.gov/29914833/Outcomes of Thoracic Endovascular Aortic Repair for Chronic Aortic Dissections:https://pubmed.ncbi.nlm.nih.gov/29157682/

Interventional Cardiologist Behnam Tehrani and Interventional Radiologist Reha Butros from Inova Health System tell us about their team approach to endovascular treatment of chronic thromboembolic pulmonary hypertension (CTEPH) with Balloon Pulmonary Angioplasty (BPA).---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/TCTEY3---SHOW NOTESIn this episode, interventional radiologist Dr. Reha Butros, interventional cardiologist Dr. Behnam Tehrani, and our host Dr. Michael Barraza discuss chronic thromboembolic pulmonary hypertension (CTEPH) and medical, endovascular, and surgical treatment options for CTEPH.CTEPH affects patients of all different ages and medical histories. While it has been associated with prior pulmonary embolism, it can also arise in patients due to blood clotting disorders and infected pacemakers. Both Dr. Butros and Dr. Tehrani stress the importance of collaborating with pulmonary hypertension experts to identify CTEPH patients before right sided heart failure occurs. CTEPH is diagnosed with dual energy CT, which shows perfusion, and right heart catheterization, which measures blood pressure.The three treatment options discussed are medical management, balloon pulmonary angioplasty (BPA), and pulmonary thromboendarterectomy (PTE). Medical management is discussed as an initial treatment for CTEPH, while PTE can be appropriate for good surgical candidates. Finally, Dr. Butros and Dr. Tehrani present BPA as an appropriate treatment for patients of all ages. BPA over multiple sessions and increasing balloon size has been shown to be effective at promoting pulmonary artery remodeling and dilation. The doctors share their own experiences with learning BPA technique, noting that it has a learning curve, but it is ultimately rewarding when patients’ quality of life is improved.

Neurosurgeon Dr. Nam Tran from Moffitt Cancer Center talks with us about RF ablation for painful spinal metastases, including patient selection and the importance of a multidisciplinary approach.---CHECK OUT OUR SPONSORMedtronic OsteoCoolhttps://www.medtronic.com/us-en/healthcare-professionals/products/spinal-orthopaedic/tumor-management/osteocool-ablation-system-rf.html---SHOW NOTESIn this episode, neurosurgeon Dr. Nam Tran and our host Dr. Michael Barraza discuss minimally invasive procedures to treat both primary spine tumors and spine metastases.Dr. Tran describes the flexibility that kyphoplasty and spinal ablation can grant patients who are not suitable candidates for open surgical decompression. These minimally invasive procedures can reduce hospital stays from 4-5 days to just one night.Dr. Tran views ablation not only from a palliative pain reduction perspective, but also from an oncologic perspective that aims to reduce tumor burden. Dr. Tran says the ideal candidate for ablation is a patient who has isolated disease to the anterior column of the spine. With larger lesions, Dr. Tran relies on his neurosurgical background to take an aggressive approach in treating the entire vertebra.The doctors also discuss research studies that have made ablation more widely accepted and available (all articles are linked below).---RESOURCESOPuS One Study: https://pubmed.ncbi.nlm.nih.gov/33129427/CAFE Study: https://www.clinicaltrials.gov/ct2/show/study/NCT00211237

Dr. Aparna Baheti talks with Dr. Saher Sabri from MedStar Georgetown University Hospital about his approach to Balloon-occluded retrograde transvenous obliteration (BRTO) for portal hypertension, including advanced tips and tricks.---CHECK OUT OUR SPONSORMedtronic Embolizationhttps://www.medtronic.com/embolization---SHOW NOTESIn this episode, Dr. Saher Sabri and our host Dr. Aparna Baheti discuss PARTO, BRTO, and combined TIPS and BRTO procedures.First, they discuss differences between PARTO (Plug-Assisted Retrograde Transvenous Obliteration) and BRTO (Balloon-Occluded Retrograde Transvenous Obliteration). Dr. Sabri walks us through the steps of both, noting that it is important to study the shunt before the procedure to identify its narrowest part. He also emphasizes the need to confirm successful balloon occlusion before starting embolization. This can require minor adjustments to balloon size and positioning.To identify the endpoint for injection, Dr. Sabri tracks sclerosant movement up to the diaphragm and then down to the gastric varix. He confirms that the shunt has been obliterated and prevented from recruiting other outflows in the future.When considering combined TIPS and BRTO procedure, Dr. Sabri focuses on key indications such as bleeding gastric varices, high-risk esophageal varices, and ascites. He prefers to do the TIPS procedure first, then the BRTO, then re-measuring the gradient and deciding if more ballooning of the TIPS is needed.Finally, the doctors discuss post-procedural follow up and imaging. Dr. Sabri aims to have CT imaging within 2-4 weeks after BRTO and an ultrasound within 2 weeks after TIPS.

Dr. Nainesh Parikh from Moffitt Cancer Center discusses his approach to ablation of small renal masses, including workup, technique, and device selection. He also tells us why he has the best job ever!---CHECK OUT OUR SPONSORMedtronic FlowMethttps://www.medtronic.com/flowmet---SHOW NOTESIn this episode, Dr. Nainesh Parikh and our host Dr. Michael Barraza discuss tips for renal ablation and multispecialty care for kidney cancers.First, they delve into the decision-making process for choosing between cryoablation and microwave ablation. Dr. Parikh believes that cryoablation is relatively safe to use in lesions near the collection system; however, it can cause a large inflammatory response in surrounding tissues. On the other hand, he prefers to use microwave ablation on exophytic lesions. Both doctors share their experiences with tricky lesions near the spine and various nerves. They also discuss the usage of pre-ablation embolization lesions larger than 5 cm.Throughout the episode, the doctors emphasize the importance of constant communication with urologists, since embolization and ablation can provide significant benefits for patients who are poor surgical candidates. Collaboration can help the medical team better manage recurrences as they arise. Dr. Parikh notes that follow up care for image-guided procedures should occur around four weeks, which is sooner than the conventional urology follow up period.Finally, Dr. Parikh gives pearls of wisdom regarding the advantages of hydrodissection, pneumodissection, and CT fluoroscopy for a safer and more efficient procedure.---RESOURCESMoffitt Cancer Center IR Page:https://moffitt.org/for-healthcare-professionals/clinical-programs-and-services/radiology-diagnostic-imaging-and-interventional-radiology-program/