BackTable Vascular & Interventional

Given the challenges that our dialysis patients face, how can we as providers stay sharp with the latest access techniques to help ensure the best possible outcomes? Dr. Omar Davis (interventional nephrologist) and Dr. Ari Kramer (general surgeon) join host Dr. Chris Beck to discuss advanced approaches to AV access and share their experiences with the FLEX Vessel Prep device.

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This podcast is supported by:

VentureMed FLEX Vessel Prep

https://www.venturemedgroup.com/

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SYNPOSIS

The doctors begin by describing how they create dialysis access and what they account for during the procedure. They then focus on the role of the FLEX VP system, its benefits, and how they use it in practice, touching on the latest clinical data. Dr. Kramer and Dr. Davis also stress the importance of mental health in dialysis care and share ways that we can better support our patients through difficult diagnoses and treatments. In fact, one of their patients, Fred Hill, authored the book “Dialysis Is Not Your Life,” which offers a unique perspective for patients feeling overburdened by dialysis, and the healthcare providers who treat them. The episode concludes with case presentations and practical guidance on when to use the FLEX Vessel Prep system.

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TIMESTAMPS

00:00 - Introduction

07:00 - AV Access and Procedures

10:58 - Case Walkthrough

14:19 - Balloon Angioplasty and IVUS

24:43 - Flex VP Device and Vessel Prep

35:03 - Algorithm and Reimbursement Challenges

39:51 - Device Usage and Techniques

46:58 - Clinical Data and Outcomes

01:01:59 - Case Studies

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RESOURCES

Fred Hill, “Dialysis Is Not Your Life” Founder and Author:

https://www.dialysisisnotyourlife.com/meet-founder.php

“Dialysis Is Not Your Life” Book:

https://www.amazon.com/DIALYSIS-NOT-YOUR-LIFE-Redefine/dp/B09L4XGGNX

Novel Device Prior to Balloon Angioplasty for Dysfunctional Arteriovenous Access: Analysis of a Real-World Registry by Race and Sex Cohorts:

https://www.openaccessjournals.com/articles/novel-device-prior-to-balloon-angioplasty-for-dysfunctional-arteriovenousaccess-analysis-of-a-realworld-registry-by-race-and-sex-16852.html

FLEX Vessel Prep 12 Month AV Registry Data and 12 Month Belong PAD Data Shows Benefit to Micro-incisions Before Balloon or DCB Treatment:

https://www.venturemedgroup.com/wp-content/uploads/2022/12/VEITH-Data-FINAL.pdf

Angioplasty with novel, easy-to-use, bladed Flex Vessel Prep system “could replace standard of care”:

https://www.youtube.com/watch?v=iRpkrURx1mc

Surgical AVF Articles Atlas Condensed - sAVF Overview - Creation Maturation and Difficulties:

https://docs.google.com/document/d/1f26FT65s03oZjjeZhBVy8auz0h8PTNvX3CWU5Xi_H5c/edit?usp=share_link

Surgical AVF Articles Asif A, Early Arteriovenous fistula failure:

https://drive.google.com/file/d/1zZEWgxsdBM4MKCQFjw0U04ra_hB9Ey_N/view?usp=share_link

Surgical AVF Articles Asif A - Best Vascular Access in the Elderly - Time for Innovation:

https://drive.google.com/file/d/1IpH-KnZyfN5Rqm_kxLnERnEJD6vcjAO8/view?usp=sharing

Surgical AVF Articles EV Today - Managing Cephalic Arch Stenosis:

https://drive.google.com/file/d/17yVd2M706YCtX-xTK6teesgZqzVIgUoN/view?usp=share_link

VentureMed 2024 FLEX Vessel Prep System Reimbursement Guide:

https://www.venturemedgroup.com/wp-content/uploads/2024/04/MMA-CTO-15690_FlexVesselPrepSystem-BillingGuide_Lv6-003.pdf

BackTable VI Podcast Episode #139 - AV Fistula & Graft Maintenance with Dr. Ari Kramer:

https://www.backtable.com/shows/vi/podcasts/139/av-fistula-graft-maintenance

BackTable VI Podcast Episode #292 - Dialysis Interventions with Drug-Coated Balloons, Covered Stents and More with Dr. Ari Kramer:

https://www.backtable.com/shows/vi/podcasts/292/dialysis-interventions-with-drug-coated-balloons-covered-stents-more

For hepatocellular carcinoma (HCC) patients who are not candidates for liver transplant or resection, lesion ablation can be a curative treatment. With multiple ablation options available and still under investigation, it can be challenging to navigate the differences between them. In this episode, Dr. Tyler Sandow hosts a discussion with interventional radiologists Dr. Kirema Garcia-Reyes, Dr. Sabeen Dhand, and Dr. Kevin Burns on the various ablation options for HCC and when to use each one.

Physicians, nurses, nurse practitioners, and physician assistants can follow this link to earn CME / CE credits for completing an accredited learning activity related to this discussion:

https://www.cmeuniversity.com/course/take/125738

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This podcast is supported by an educational grant from AstraZeneca Pharmaceuticals and Boston Scientific.

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SYNPOSIS

The doctors first discuss Barcelona-Clinic Liver Cancer (BCLC) Stage A patients, where lesion size and location are key factors in deciding between ablation and transarterial therapies. They then compare cryoablation and microwave ablation, highlighting that cryoablation offers better visualization and control of the ablation zone, while microwave ablation is more effective for treating larger lesions.

Dr. Burns introduces histotripsy, a noninvasive treatment that uses ultrasound energy to mechanically ablate tumors. He shares his experiences as an early adopter of this technology and discusses how intraoperative cone beam CT can help treat lesions located near critical structures or those poorly visualized on ultrasound. Finally, Dr. Garcia-Reyes and Dr. Berman provide insights into patient selection, pre-procedural imaging, and technical tips for Y90.

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TIMESTAMPS

00:00 - Introduction

02:04 - Ablation vs Y90 in BCLC A Patients

05:58 - Same-Day Y90

15:55 - Y90 for Large Tumors

17:51 - Ideal Cases for Cryoablation

19:38 - Explanation of Histotripsy

32:09 - Procedural Specifics for Histotripsy

38:21 - Technical Tips for Y90

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RESOURCES

Including the Hollow Viscera (Stomach or Bowel) within the Ice Ball during Cryoablation: A Review of Adverse Events (Abramyan et al, 2024):

https://www.jvir.org/article/S1051-0443(24)00681-X/abstract

CME Accreditation Information:

https://f7cae4ec-b69e-490d-9e0f-19b16a6f146d.usrfiles.com/ugd/f7cae4_a7c37ea3cd1b4d3fa53d5edf8dfe255b.pdf

When deep sedation is required, it can be challenging to implement due to the difficulty of scheduling dedicated anesthesia coverage in the IR suite. Dr. Amy Deipolyi (interventional radiologist and Division Chief at Charleston Area Medical Center, WY) joins host Dr. Ally Baheti to explain an alternative approach to deep sedation through the use of ketamine.

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This podcast is supported by:

Medtronic Abre Stent

https://www.medtronic.com/en-us/healthcare-professionals/products/cardiovascular/deep-venous-stents/abre-venous-self-expanding-stent-system.html

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SYNPOSIS

Dr. Deipolyi begins by sharing how she built a dedicated, academic IR program at a level 1 trauma center in West Virginia. The doctors then discuss the advantages of ketamine for deep sedation in the IR suite, and how Dr. Deipolyi gained administrative approval and implemented the change to achieve an alternative approach to deep sedation for interventional procedures. The discussion also includes how ketamine compares to traditional agents such as fentanyl and Versed. The episode concludes with Dr. Deipolyi’s practical advice to fellow IR’s interested in providing their patients deep sedation via ketamine and her ongoing and future research and outreach efforts.

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TIMESTAMPS

00:00 - Introduction

02:04 - Dr. Deipolyi’s Practice

14:32 - Overcoming Hurdles and Gaining Support

20:12 - Application and Patient Experiences

26:01 - Future of Deep Sedation in IR

28:55 - Conclusion

In the past five years, the use of immunotherapeutic agents for advanced cancers has emerged as a promising alternative to tyrosine kinase inhibitors and chemotherapy, making it an exciting time to be practicing oncology. In this episode, Dr. Tyler Sandow interviews oncology experts about the landscape of advanced hepatocellular carcinoma (HCC) and the current state of immunotherapy treatments. He is joined by medical oncologists Dr. Jonathan Mizrah, Dr. Lingling Du, and Dr. Adam Burgoyne, as well as interventional oncologist Dr. Zachary Berman.

Physicians, nurses, nurse practitioners, and physician assistants can follow this link to earn CME / CE credits for completing an accredited learning activity related to this discussion:

https://www.cmeuniversity.com/course/take/125737

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This podcast is supported by an educational grant from AstraZeneca Pharmaceuticals and Boston Scientific.

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SYNPOSIS

Drs. Burgoyne and Mizrahi provide a primer on immunotherapy and explain how they communicate the principles of this treatment to their patients. Dr. Du discusses the Imbrave clinical trial and how recent studies have shown improved overall survival when immunotherapeutic agents are used, especially when multiple agents targeting various pathways are employed. When choosing between different regimens, the doctors consider factors such as the patient's underlying liver function, symptom burden, and prior treatments.

Importantly, the doctors also discuss contraindications to immunotherapy, including a history of organ transplant, autoimmune disease, and poor performance status—all of which put patients at high risk for deterioration with this treatment. The treatment of patients with poor liver function remains controversial, as underlying cirrhosis may prevent the recovery of liver function. Dr. Berman outlines recent clinical trials studying the effects of transarterial chemoembolization (TACE) combined with immunotherapy. Finally, the doctors discuss the future of HCC treatment and the benefits of continued innovation in both interventional and medical oncology.

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TIMESTAMPS

00:00 - Introduction to Immunotherapy

04:32 - Notable Clinical Trials

13:39 - HCC Etiology and Immunotherapy Outcomes

18:43 - Contraindications for Immunotherapy

23:05 - Adverse Effects from Treatment

25:14 - Combination Therapy

36:22 - Considerations for Immunotherapy Dosing

40:26 - The Future of HCC Treatment

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RESOURCES

Atezolizumab plus Bevacizumab in Unresectable Hepatocellular Carcinoma, IMbrave150 Trial (Finn et al, 2020):

https://pubmed.ncbi.nlm.nih.gov/32402160/

Tremelimumab plus Durvalumab in Unresectable Hepatocellular Carcinoma, HIMALAYA Trial (Abou-Alfa et al, 2022):

https://evidence.nejm.org/doi/full/10.1056/EVIDoa2100070

Nivolumab versus sorafenib in advanced hepatocellular carcinoma (CheckMate 459): a randomised, multicentre, open-label, phase 3 trial (Yau, 2022):

https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(21)00604-5/abstract

Nivolumab (NIVO) plus ipilimumab (IPI) vs lenvatinib (LEN) or sorafenib (SOR) as first-line treatment for unresectable hepatocellular carcinoma (uHCC): First results from CheckMate 9DW (Galle, 2024):

https://ascopubs.org/doi/10.1200/JCO.2024.42.17_suppl.LBA4008

Randomized Phase 3 LEAP-012 Study: Transarterial Chemoembolization With or Without Lenvatinib Plus Pembrolizumab for Intermediate-Stage Hepatocellular Carcinoma Not Amenable to Curative Treatment (Llovet, 2022):

https://pubmed.ncbi.nlm.nih.gov/35119481/

EMERALD-1: A phase 3, randomized, placebo-controlled study of transarterial chemoembolization combined with durvalumab with or without bevacizumab in participants with unresectable hepatocellular carcinoma eligible for embolization (Lencioni, 2024):

https://ascopubs.org/doi/10.1200/JCO.2024.42.3_suppl.LBA432

CME Accreditation Information:

https://f7cae4ec-b69e-490d-9e0f-19b16a6f146d.usrfiles.com/ugd/f7cae4_a7c37ea3cd1b4d3fa53d5edf8dfe255b.pdf

Proximity to innovation often gives rise to further innovation. This trend is especially true in interventional radiology. Dr. Gregg Alzate (interventional radiologist in San Diego, California) joins host Dr. Ally Baheti to share his career pearls for early and mid-career IRs, and how he came to pioneer the Alzate Retrograde Antegrade Maneuver (A-RAM).

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This podcast is supported by:

Reflow Medical

https://www.reflowmedical.com/

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SYNPOSIS

Dr. Alzate starts by sharing his early influences, including his time with interventional radiology giant Dr. Harold Coons. The doctors also cover the importance of proper vessel access techniques, innovative approaches to limb salvage, and how to address complex chronic total occlusions (CTOs). Dr. Alzate then goes on to give us a thorough walkthrough of the A-RAM. The episode concludes with Dr. Alzate’s closing thoughts on being open to adopt new techniques, the impact of strong mentorship, and importance for consuming and sharing knowledge.

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TIMESTAMPS

00:00 - Introduction

03:05 - Dr. Alzate’s Journey

25:52 - A-RAM Technique

34:26 - CTO’s and Heavy Calcium

40:16 - Moral Injury in Medical Practice

43:35 - Honoring Dr. Harold Coons

46:23 - Closing Thoughts and Reflections

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RESOURCES

Ohki, Takao et al. “Long-term results of the Japanese multicenter Viabahn trial of heparin bonded endovascular stent grafts for long and complex lesions in the superficial femoral artery.” Journal of vascular surgery vol. 74,6 (2021): 1958-1967.e2.

https://www.jvascsurg.org/article/S0741-5214(21)01011-9/fulltext

Kedora, John et al. “Randomized comparison of percutaneous Viabahn stent grafts vs prosthetic femoral-popliteal bypass in the treatment of superficial femoral arterial occlusive disease.” Journal of vascular surgeryvol. 45,1 (2007): 10-6; discussion 16.

https://www.jvascsurg.org/article/S0741-5214(06)01612-0/fulltext

Of all the topics covered during interventional radiology training, dosimetry education is often delayed until after IRs enter clinical practice. In this episode, Drs. Tyler Sandow and Sabeen Dhand host a roundtable discussion with experts on the dosimetry fundamentals that all Y90 operators should understand. They are joined by interventional radiologists Drs. Zachary Berman, Kirema Garcia-Reyes, and Siddharth Padia, who provide their expert insights.

Physicians, nurses, nurse practitioners, and physician assistants can follow this link to earn CME / CE credits for completing an accredited learning activity related to this discussion:

https://www.cmeuniversity.com/course/take/125736

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This podcast is supported by an educational grant from AstraZeneca Pharmaceuticals and Boston Scientific.

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SYNPOSIS

The group agrees that dosimetry is not a one-size-fits-all approach. Dosing strategies depend on factors such as tumor size, perfusion territory, underlying liver function, the choice between glass versus resin spheres, and treatment intent. These considerations are illustrated with real-life case examples. The doctors also explore voxel-based dosimetry, a method for calculating the amount of radiation absorbed by different parts of the tumor. They stress the importance of learning how to perform accurate dosage calculations.

Finally, the conversation touches on data from major Y90 trials, current guidelines, and the evolving perspective on Y90 as a potential curative treatment, rather than merely a bridging therapy.

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TIMESTAMPS

00:00 - Introduction

01:59 - Dosimetry Education During Training

05:46 - Benefit of Individualized Dosing

11:01 - Complications from High Doses

15:19 - Dosage Calculation Cases

22:51 - Duration of Response to Y90

25:00 - Dosing Based on Treatment Intent

29:11 - Challenging Case Example

42:31 - Voxel-Based Dosimetry

45:15 - Using Dosimetry Software

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RESOURCES

LEGACY Trial (Salem et al, 2021):

https://pmc.ncbi.nlm.nih.gov/articles/PMC8596669/

Voxel-based tumor dose correlates to complete pathologic necrosis after transarterial radioembolization for hepatocellular carcinoma (Pianka et al, 2024):

https://pubmed.ncbi.nlm.nih.gov/38913189/

RAPY90D Trial (Kappadath et al, 2023):

https://jnm.snmjournals.org/content/64/supplement_1/P268

Clinical, dosimetric, and reporting considerations for Y-90 glass microspheres in hepatocellular carcinoma: updated 2022 recommendations from an international multidisciplinary working group (Salem et al, 2023):

https://pubmed.ncbi.nlm.nih.gov/36114872/

International recommendations for personalised selective internal radiation therapy of primary and metastatic liver diseases with yttrium-90 resin microspheres (Levillain, 2021):

https://link.springer.com/article/10.1007/s00259-020-05163-5)

CME Accreditation Information:

https://f7cae4ec-b69e-490d-9e0f-19b16a6f146d.usrfiles.com/ugd/f7cae4_a7c37ea3cd1b4d3fa53d5edf8dfe255b.pdf

Robot-assisted technology has revolutionized surgical fields such as general surgery and urology—could interventional radiology be the next frontier? In this episode of the BackTable podcast, host Dr. Jacob Fleming explores the transformative potential of robotic-assisted percutaneous biopsies and ablations with experts Dr. Govindarajan “Raj” Narayanan from the Miami Cancer Institute and Dr. Sean Tutton from UC San Diego.

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This podcast is supported by:

Quantum Surgical

https://www.quantumsurgical.com/

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SYNPOSIS

Dr. Narayanan begins by sharing his initial interest in robotic applications for tumor ablations, aiming to maximize efficiency in his practice. Dr. Tutton then highlights the advantages of robotics for probe placement, especially in challenging cases. The two doctors discuss the logistics of the robotic system, including setup, imaging, and access choices. They also reflect on the learning curve associated with robotics and how it gradually enhances procedural efficiency while reducing mental fatigue. This improvement allows them to take on more complex cases with confidence. Overall, both experts agree that robotics has the potential to democratize minimally invasive procedures, offering new opportunities for skill development and advancement within the field of interventional radiology.

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TIMESTAMPS

00:00 - Introduction to the Podcast

03:30 - Developing an Interest in Robotics

10:44 - Integration of Robotics in the Procedural Suite

13:27 - Logistics of Robot System

18:38 - Planning for Percutaneous Access

22:39 - Future Implications of Robotics on Training Programs

35:51 - Efficiency and Volume Management with Robotics

40:39 - Learning Curves for Robotic Procedures

48:09 - Conclusion and Final Thoughts

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RESOURCES

Quantum Surgical Epione Robot:

https://www.quantumsurgical.com/epione/

ACCLAIM Trial:

https://www.sio-central.org/ACCLAIM-Trial

Welcome to the first episode of BackTable Tumor Board, and our first recording session at our new in-person studio! Guest host Dr. Tyler Sandow (interventional radiologist) leads a multidisciplinary discussion about patient care coordination in hepatocellular carcinoma (HCC) diagnosis and treatment, with insights from his colleagues at Ochsner Health– Dr. Steven Young (hepatologist), Dr. Jonathan Mizrahi (medical oncologist), and Deondra Bonds-Adams (patient navigator).

Physicians, nurses, nurse practitioners, and physician assistants can follow this link to earn CME / CE credits for completing an accredited learning activity related to this discussion:

https://www.cmeuniversity.com/course/take/125735

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This podcast is supported by an educational grant from AstraZeneca Pharmaceuticals and Boston Scientific.

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SYNPOSIS

The team speaks on the value of having multiple specialties weigh in on treatment conversations that are tailored to each patient’s medical history and risk factors, such as underlying cirrhosis and portal hypertension. Deondra highlights the importance of assessing the patient’s understanding of their disease and the role of physician extenders and schedulers in patient education. Dr. Young discusses the value of outreach clinics and streamlining the transplant evaluation process. Finally, Dr. Mizrahi gives advice on building referral networks and establishing early contact with transplant centers.

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TIMESTAMPS

00:00 - Introduction

00:46 - Multidisciplinary Tumor Board

06:00 - Patient Experience in Treatment Pathways

10:10 - Barriers to Treatment

16:03 - Benefits of IR Clinic

19:33 - HCC Screening and Risk Factors

24:08 - Building Referral Networks

30:34 - Strategies for Effective Scheduling

35:43 - The Future of HCC Treatment

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RESOURCES

CME Accreditation Information:

https://f7cae4ec-b69e-490d-9e0f-19b16a6f146d.usrfiles.com/ugd/f7cae4_a7c37ea3cd1b4d3fa53d5edf8dfe255b.pdf

Welcome to the first episode of BackTable Tumor Board, and our first recording session at our new in-person studio! Guest host Dr. Tyler Sandow (interventional radiologist) leads a multidisciplinary discussion about patient care coordination in hepatocellular carcinoma (HCC) diagnosis and treatment, with insights from his colleagues at Ochsner Health– Dr. Steven Young (hepatologist), Dr. Jonathan Mizrahi (medical oncologist), and Deondra Bonds-Adams (patient navigator).

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This podcast is supported by an educational grant from:

AstraZeneca

https://www.astrazeneca.com/our-therapy-areas/oncology.html

With additional support from:

Boston Scientific

https://www.bostonscientific.com/en-US/medical-specialties/interventional-radiology/interventional-oncology.html

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SYNPOSIS

The team speaks on the value of having multiple specialties weigh in on treatment conversations that are tailored to each patient’s medical history and risk factors, such as underlying cirrhosis and portal hypertension. Deondra highlights the importance of assessing the patient’s understanding of their disease and the role of physician extenders and schedulers in patient education. Dr. Young discusses the value of outreach clinics and streamlining the transplant evaluation process. Finally, Dr. Mizrahi gives advice on building referral networks and establishing early contact with transplant centers.

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TIMESTAMPS

00:00 - Introduction

00:46 - Multidisciplinary Tumor Board

06:00 - Patient Experience in Treatment Pathways

10:10 - Barriers to Treatment

16:03 - Benefits of IR Clinic

19:33 - HCC Screening and Risk Factors

24:08 - Building Referral Networks

30:34 - Strategies for Effective Scheduling

35:43 - The Future of HCC Treatment

Interventional treatment for pulmonary embolism (PE) has significantly evolved in recent years, largely due to advancements in techniques, knowledge, and device technology. Dr. Zarina Sharalaya (interventional and structural cardiologist) and Dr. Ripal Gandhi (interventional radiologist) join host Dr. Chris Beck to discuss the evolving landscape of PE treatment, comparing large-bore mechanical thrombectomy with catheter-directed thrombolysis and exploring outcomes from the PEERLESS randomized control trial.

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This podcast is supported by:

Inari Medical

https://cwa.inarimedical.com/inari-learn

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SYNPOSIS

Dr. Sharalaya and Dr. Gandhi begin by covering risk stratification and treatment algorithms for their patients with PE. The doctors then go onto discuss the procedure in detail, and best practices and techniques for mechanical thrombectomy. The conversation also focuses on the PEERLESS trial, highlighting how the study showed significant benefits of mechanical thrombectomy, including faster symptom improvement, decreased ICU stay, and reduced readmission rates. Dr. Sharalaya and Dr. Gandhi conclude the episode with a series of case presentations.

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TIMESTAMPS

00:00 - Introduction

08:01 - Pulmonary Embolism Risk Stratification and Treatment Algorithms

14:49 - Procedure Overview

24:25 - Best Practices and Techniques in Thrombectomy

34:31 - Peerless Study Overview and Findings

46:50 - Gender Differences in PE Treatment

47:49 - Future of PE Treatment and Advice

51:55 - Case Presentations and Clinical Insights

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RESOURCES

2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS):

https://pubmed.ncbi.nlm.nih.gov/31504429/

PEERLESS II: A Randomized Controlled Trial of Large-Bore Thrombectomy Versus Anticoagulation in Intermediate-Risk Pulmonary Embolism:

https://www.jscai.org/article/S2772-9303(24)01053-6/fulltext

Large-bore Mechanical Thrombectomy Versus Catheter-directed Thrombolysis in the Management of Intermediate-risk Pulmonary Embolism: Primary Results of the PEERLESS Randomized Controlled Trial:

https://pubmed.ncbi.nlm.nih.gov/39470698/