Before the advent of TIPS, mesocaval shunts were considered a less popular option for managing portal hypertension. But today, could they serve as a lifeline when no other choices remain? This week on BackTable, Drs. Omar Chohan and Harris Chengazi (Great Lakes Medical Imaging) join host Dr. Chris Beck to discuss the evolving role of endovascular mesocaval shunts, covering patient selection, clinical decision-making, and technical pearls.

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SYNPOSIS

In this episode, the hosts delve into the specialized procedure of meso-caval shunts, focusing on its applications for patients with portal hypertension who have no other viable options. This discussion includes detailed case studies, such as one involving a woman with autoimmune hepatitis and another with pancreatic cancer, showcasing the practical challenges and innovative solutions in creating these shunts. In each case, they detail the rationale for patient selection, difficult anatomy, procedural steps, and resolution of symptoms like recurrent ascites and variceal bleeding. The episode emphasizes the importance of pre-procedure planning, collaboration, and precise imaging, utilizing advanced tools like the 4D CT scanner. The conversation also highlights the compassionate motivation behind these complex procedures, aimed at improving patients' quality of life.

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TIMESTAMPS

00:00 - Introduction
03:07 - Historical Context and Indications
06:49 - Case 1: Patient with Refractory Ascites
34:00 - Case 2: Recurrent GI Bleeding
41:16 - Case 3: TIPS Consult - Pancreatic Cancer and Duodenal Varices
47:44 - Lessons, Pearls, and Tips
56:13 - Final Thoughts

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RESOURCES

A Case Series of Dr. Chengazi's Mesocaval Shunts on X:
https://x.com/chengazimd/status/1966337167879438571

Episode 573 Portal Hypertension Treatment Strategies:
https://www.backtable.com/shows/vi/podcasts/473/portal-hypertension-treatment-strategies-ir-hepatology-perspectives

TIPS University Freshman Year:
https://www.backtable.com/shows/vi/podcasts/123/tips-university-freshman-year-referrals-pre-op-workup

TIPS University Sophomore Year:
https://www.backtable.com/shows/vi/podcasts/124/tips-university-sophomore-year-basic-procedure-technique

TIPS University Junior Year:
https://www.backtable.com/shows/vi/podcasts/125/tips-university-junior-year-advanced-techniques-ice-splenic-access

TIPS University Senior Year:
https://www.backtable.com/shows/vi/podcasts/126/tips-university-senior-year-gunsight-technique-splenic-closure

What does it really take to break away from the hospital system and build your own interventional radiology practice?
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This podcast is supported by:
Medtronic Emprint
https://www.medtronic.com/emprint
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SYNPOSIS
In this episode, host Dr. Ally Baheti interviews Dr. Kartik Kansagra and Dr. Harout Dermendjian, independent interventional radiologists from California and founders of EVS LA. They share their journey in establishing and growing an independent IR practice, discussing their training at Kaiser Sunset, the steps they took to develop their own practice, and the challenges they faced along the way. Emphasizing the importance of training, clinician communication, and balancing inpatient and outpatient services, they offer valuable insights and advice for new IR professionals considering a similar path.
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TIMESTAMPS
00:00 – Introduction and opening remarks
01:23 – Early training and transition
08:54 – Clinical vs. non-clinical IR practice differences
13:05 – Achieving parity with other interventional specialties
17:47 – Building insurance contracts and following up with patients
24:31 – Setting boundaries and documenting clinical decisions
34:32 – Final advice and closing words from the guests

Below the knee atherectomy is a hot topic right now in the vascular community. Why is it so controversial? Dr. Anahita Dua, vascular surgeon at Mass General, joins host Dr. Sabeen Dhand to explore the utility of this technique and the pressing need for more Level I evidence in this space.
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This podcast is supported by:
AngioDynamic
https://www.auryon-system.com/
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SYNPOSIS
The conversation dives into the controversial role of below-the-knee atherectomy in limb salvage, an area where data has long been debated. Dr. Dua, principal investigator of the AMBITION BTK Trial—the first randomized controlled trial comparing below-the-knee atherectomy to angioplasty alone—introduces the trial and explains how it fits into the current body of literature.
Together, the doctors review past evidence, current practice, and the future outlook for tibial interventions. Dr. Dua outlines the wide range of techniques and clinical strategies used to manage PAD, and stresses the importance of physician engagement with the NIH and research community to establish stronger, evidence-based protocols. She also shares her candid thoughts on the most overrated and underrated devices in tibial intervention, highlighting atherectomy’s potential role in vessel preparation before below-the-knee treatment.
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TIMESTAMPS
00:00 - Introduction
04:55 - Current State of Evidence and Challenges
10:54 - Heterogeneity in PAD Treatment
14:26 - Need for National Metrics and Standardization
20:51 - AMBITION BTK Trial and Importance
27:23 - Potential Outcomes and Implications
30:18 - Trial Design
34:56 - Advice for Practitioners
37:36 - Underrated and Overrated Devices
41:50 - Conclusion
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RESOURCES
AMBITION BTK Trial:
https://www.angiodynamics.com/studies/ambition-btk/

From new techniques to evolving best practices–are you up to date with the latest developments in carotid artery stenting? In this episode, Dr. Wayne Olan, Interventional Neuroradiologist and the director of Minimally Invasive Neurosurgery at George Washington University joins Dr. Michael Barraza for a discussion on the latest innovations and evolving techniques in carotid artery stenting.

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This podcast is supported by:
RADPAD® Radiation Protection
https://www.radpad.com/

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SYNPOSIS

Dr. Olan opens the conversation with a historical perspective on the evolution of carotid stenting, tracing advancements from early techniques to modern devices. He then talks through referral patterns, noting that the majority originate from cardiologists. Dr. Olan emphasizes the importance of meticulous periprocedural planning and comprehensive post-procedural management. Central to this discussion is the critical role of antiplatelet therapy, including strategies for addressing Plavix non-responders, such as the use of Integrilin.

The discussions also covers advanced techniques in carotid artery stenting, including the utilization of the Aptus sheath and the Contego stent system. He underscores the importance of mastering the available tools, understanding patient-specific factors, meticulous procedural planning, and always maintaining a contingency plan. He concludes the discussion by exploring emerging trends and the future potential of outpatient carotid stenting.

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TIMESTAMPS

00:00 - Introduction
02:44 - The Importance of Stroke Intervention
07:16 - Carotid Stenting: Evolution and Techniques
13:29 - Challenges and Collaborations in Carotid Interventions
16:17 - Technical Insights and Best Practices
25:24 - Choosing the Right Wire for Carotid Procedures
25:53 - Anticoagulation and Filter Wire Techniques
28:30 - Managing Stent Placement and Distal Protection
30:54 - Handling Carotid Bifurcation and Skull Base Lesions
38:43 Dealing with Tandem Occlusions
42:06 - Future Trends in Outpatient Procedures
44:43 - Addressing Re-stenosis and Vertebral Lesions
45:44 - Conclusion and Final Thoughts

What does it really take to bring cutting-edge vascular care to the most underserved corners of the rural South? In this episode of the BackTable Podcast, host Dr. Ally Baheti welcomes interventional cardiologist Dr. Ash Sastry and interventional radiologist Dr. Sree Nair to discuss the financial and regulatory side of providing care to underserved rural populations in North Carolina, Virginia, and Georgia.

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SYNPOSIS

The doctors delve into the operations and challenges of running an office-based lab (OBL) and the potential transition to an ambulatory surgical center (ASC). This episode covers topics like certificate of need (CON) laws, reimbursement issues, and the importance of multidisciplinary collaboration. The conversation offers insights into the practical and regulatory hurdles faced in delivering high-quality vascular care in rural settings.

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TIMESTAMPS

00:00 - Introduction
02:14 - Challenges in Rural Healthcare
09:00 - Understanding Certificate of Need (CON) Laws
11:30 - The Financial Struggles of OBLs
19:58 - Advocacy and Legislative Efforts
27:53 - Future Prospects and Final Thoughts

What piques your clinical suspicion for biliary structure? And when is interventional endoscopy the preferred approach? Fine tune your diagnostic and treatment algorithm with Dr. Premal Trivedi from the University of Colorado and host Dr. Christopher Beck as they go in-depth on the management of biliary strictures.
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This podcast is supported by:
RADPAD® Radiation Protection
https://www.radpad.com/
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SYNPOSIS
The doctors first break down the signs and clinical picture that alert them to a possible biliary stricture. Dr. Trivedi then explains the steps of his workup and preferred imaging, and also describes his threshold to pursue percutaneous transhepatic cholangiography (PTC), especially in diffuse conditions like primary sclerosing cholangitis. Dr. Trivedi also walks through his procedural steps for PTC and drain placement, covering his best practices and typical intraoperative decision making.
Dr. Trivedi then explains the role of angioplasty over the course of longitudinal treatment, balloon choice, and his upper limit of catheter upsizing. The doctors also delve into the role of interventional endoscopy and tackling complications such as bleeding and tube leakage. The conversation offers valuable insights for trainees and practitioners alike, and highlights future advancements in biliary interventions.
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TIMESTAMPS
00:00 - Introduction
06:19 - Approach to Biliary Strictures
08:10 - Workup and Imaging for Biliary Strictures
20:41 - Accessing the Biliary System
27:14 - Crossing the Obstruction: Next Steps
33:22 - Endoscopic Evaluation and Its Role
47:14 - Complications and Pain Management
53:40 - Future of Biliary Management
54:55 - Conclusion and Final Thoughts

As new graduates enter the workforce, what are the key differences between academic, private, and hybrid practice models? Dr. Oleksandra Kutsenko, Chief of Interventional Radiology at Red Rock Radiology Associates, joins host Dr. Ally Baheti to discuss her experiences working in a private equity group in Nevada.
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This podcast is supported by:
Medtronic Emprint
https://www.medtronic.com/emprint
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SYNPOSIS
Dr. Kanko discusses her career trajectory, her experiences with private equity, and the benefits and challenges of working in such a setting. She highlights the value of stepping into leadership roles, cultivating a versatile skill set, and navigating the complexities of working within a large, multifaceted organization like Radiology Partners. The conversation covers day-to-day operations, educational opportunities, and her perspective on balancing clinical work with administrative responsibilities. She emphasizes the importance of investing early in one’s career to build credibility and establish a lasting presence.
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TIMESTAMPS
00:00 - Introduction
01:50 - Career Journey and Challenges
03:15 - Private Practice vs. Academics
07:11 - Daily Life as an Interventional Radiologist
12:19 - Involvement with RAD Partners
13:42 - Educational Tools and AI in Radiology
24:08 - Clinic Operations and RVU Discussion
31:59 - Advice for Trainees and Career Insights
33:13 - Conclusion and Final Thoughts

Resorbable embolics are gaining traction in musculoskeletal interventions, but what are the key technical considerations? Dr. Keerthi Prasad, interventional radiologist at the Centers for Pain Control and Vein Care joins host Dr. Ally Baheti to share practical insights when using resorbable embolics in MSK interventions.
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This podcast is supported by:
OBL Marketing
https://www.oblmarketing.com
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SYNPOSIS
Dr. Prasad opens the conversation with an overview of embolic agents used in MSK interventions—including Imipenem, Lipiodol, and Nexsphere-F—and shares practical insights into technique selection. He explores the nuances of working with various resorbable embolics, highlighting clinical cases from his personal experience. The discussion also highlights Dr. Prasad’s innovative approach to establishing an outpatient-based lab (OBL) focused on musculoskeletal interventions. Additionally, Dr. Prasad also offers insight into the expanding role of resorbable embolics in treating conditions such as knee arthritis, plantar fasciitis, and adhesive capsulitis. The episode ends with a call to broaden access to this evolving treatment.
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TIMESTAMPS
00:00 - Introduction
01:55 - Outpatient Embolization and MSK Procedures
04:20 - Resorbable Embolics in Joint Embolization
04:52 - Available Resorbable Embolics in the US
07:57 - Technical Insights on Using Resorbable Embolics
15:18 - Patient Outcomes and Long-Term Durability
22:24 - Future of MSK Embolization Techniques
24:05 - Exploring New Applications for Resorbable Embolics
27:30 - Innovative Procedures and Techniques
37:00 - Final Thoughts and Advice for Practitioners

Can you manipulate blood flow in the tumor microenvironment to optimize drug delivery? In this episode of the BackTable Podcast, interventional oncologist Dr. Zachary Berman (UC San Diego) joins host Dr. Christopher Beck to discuss real-world applications of pressure-enabled drug delivery in locoregional liver-directed therapies like TACE and Y90.
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This podcast is supported by:
TriSalus Life Sciences
http://trinavinfusion.com/
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SYNPOSIS
The conversation begins with an overview of the tumor microvascular environment, focusing on the abnormal nature of the new vessels that feed tumors. They then discuss the genesis of pressure-enabled drug delivery and the theory behind its efficacy. Dr. Berman explains the TriNav catheter’s micro-valve design, its anti-reflux properties, and how these features enhance tumor drug delivery. He walks through his own procedure technique, comparing and contrasting it to standard embolization, and details the utility of pressure-enabled drug delivery in lobar radioembolization and larger tumors. They also explore the benefits of both balloon occlusion and microvalve catheters.
Real-world cases—including neuroendocrine tumors, segmental HCC, and more—illustrate the thought process around when to use specialized technologies. The episode wraps up with a discussion of the future implications for this technology in other pathologies, cost considerations, and the potential for enhancing drug delivery with innovative approaches.
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TIMESTAMPS
00:00 - Introduction
01:39 - The Tumor Microenvironment
06:59 - Pressure-Enabled Drug Delivery Explained
09:37 - Technical Aspects of Pressure-Enabled Catheters
21:48 - Case 1: Grade 3 Neuroendocrine Tumor
34:06 - Case 2: Hepatocellular Carcinoma with Tumor and Vein
36:01 - Case 3: TACE for Segmental HCC in Decompensated Cirrhosis
38:58 - Case 4: Large Heterogenous Cholangiocarcinoma
40:40 - Case 5: Lobar Neuroendocrine Tumor
42:38 - Case 6: Segmental HCC with Central Necrosis
47:52 - Best Practices and Technical Considerations
57:52 - Future Directions in Pressure-Directed Embolotherapy
59:48 - Conclusion and Final Thoughts
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RESOURCES
JVIR 2024 Jaroch et al.:
https://pubmed.ncbi.nlm.nih.gov/38969336/