BackTable Vascular & Interventional

What’s needed to build a successful lymphangiography practice? Dr. Bill Majdalany joins host Dr. Chris Beck to answer this question and to discuss advancements in lymphangiography over the past decade. Dr. Majdalany is the Chief and Vice Chair of Research of Interventional Radiology at University of Vermont.

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Guerbet

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SYNPOSIS

The doctors provide insights on various lymphatic procedures such as thoracic duct embolization, stenting, and recanalization. They also discuss the evolving significance of lymphatic medicine in interventional radiology and its potential applications in treating conditions like ascites and variceal bleeding. The conversation underscores the interconnected nature of the lymphatic system throughout the body, emphasizing the revolutionary potential of lymphangiography in modern medicine.

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TIMESTAMPS

00:00 - Introduction

04:23 - Building a Lymphangiography Practice

08:36 - The Lymphatic Revolution

17:42 - Practical Tips and Equipment for Lymphangiography

30:09 - Advanced Interventions and Tools

48:45 - Future of Lymphatic Interventions

51:23 - Conclusion and Resources

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RESOURCES

BackTable VI Podcast Episode #135 - IR Residency Pathways & Getting In! (Part 1)

with Dr. Jeff Bodner and Dr. Bill Majdalany:

https://www.backtable.com/shows/vi/contributors/dr-bill-majdalany

Seminars in Interventional Radiology - Lymphatics:

https://www.thieme-connect.com/products/ejournals/issue/10.1055/s-010-49075

Lymphatic Anatomy:

https://www.techvir.com/article/S1089-2516(16)30042-7/abstract

What is the final frontier of interventional radiology? Dominic Tanzillo and Dr. Richard Moon believe it could be space. Dominic is a 3rd year medical student at Duke University interested in interventional radiology (IR) and space medicine, and Dr. Moon is a Professor at Duke University and an expert in hyperbaric and aerospace medicine.

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Medtronic DCB

https://www.medtronic.com/us-en/healthcare-professionals/products/cardiovascular/drug-coated-balloons.html

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SYNPOSIS

Dominic and Dr. Moon cover the potential for IR in deep space missions, focusing on the unique challenges astronauts face, such as altered blood flow, increased clotting risks, and the impacts of microgravity on the human body. The episode dives into NASA’s investments in portable medical technologies, the practicalities of emergency medical procedures in space, and the need for minimally invasive interventions. The significance of IR in diagnosing and managing vascular issues in space is discussed, as well as the broader implications for future Mars missions and long-term space travel.

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TIMESTAMPS

00:00 - Introduction

02:36 - IR in Space

20:04 - Medical Issues Astronauts Face

26:27 - Remote Surgery and Telesurgery

30:45 - Emergency Evacuations in Space

32:32 - More on Space Medicine

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RESOURCES

Aerospace Medicine Association:

https://www.asma.org/about-asma/careers/aerospace-medicine

Translational Research Institute for Space Health:

https://www.bcm.edu/academic-centers/space-medicine/translational-research-institute

Space Medicine Coursera:

https://www.coursera.org/learn/space-medicine-duke

What Space Medicine Taught Me About Science Communication | Dominic Tanzillo | TEDxDuke:

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

Dominic Tanzillo:

https://dominictanzillo.github.io/

While GLP-1 agonists continue to gain popularity in the medical management of diabetes and obesity, Dr. Cliff Weiss is exploring bariatric arterial embolization (BAE) as an adjunctive therapy to help patients sustain weight loss. Dr. Weiss, the Director of IR Research at Johns Hopkins, joins the show to discuss the techniques and impacts of BAE for obesity treatment.

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Reflow Medical

https://www.reflowmedical.com/

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SYNPOSIS

Dr. Weiss outlines his initial research interest in gastric embolization of the fundus to reduce ghrelin production. He began by studying the use of sclerosants for embolization but later shifted to using embolic spheres. BAE involves the targeted embolization of the left gastric artery, with or without the left gastroepiploic artery, using 300-500 micron embolic spheres. Dr. Weiss also employs a dilute mixture of spheres and a vasodilator to achieve distal arterial penetration.

He describes the role of BAE in conjunction with existing surgical and pharmaceutical treatments. According to his experience, patients undergoing BAE achieve maximum weight loss 6-9 months after the procedure and can maintain this weight when they follow up in a weight management clinic. Additionally, Dr. Weiss reviews data from BAE studies, including the BEAT Obesity Trial and the recent BEATLES Trial.

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TIMESTAMPS

00:00 - Introduction

03:21 - Early Research and Development of BAE

07:39 - Potential Role of BAE in Obesity Treatment

16:03 - Procedure Details

25:28 - Post-Procedure Care and Patient Management

28:06 - Insights from the BEAT Obesity Trial

33:38 - BEATLES Trial

37:38 - Combination Therapy for Obesity

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RESOURCES

BEAT Obesity Trial:

https://pubs.rsna.org/doi/full/10.1148/radiol.2019182354

LC Bead/Bead Block:

https://www.bostonscientific.com/en-US/products/embolization/lc-bead.html

EmboSpheres:

https://www.merit.com/product/embosphere-microspheres/

EMBIO Trial:

https://bmjopen.bmj.com/content/13/9/e072327

BEATLES Trial:

https://www.jvir.org/article/S1051-0443(23)01155-7/fulltext

How can physicians and industry partners collaborate effectively to enhance patient care? Dr. Adam Tanious, Assistant Professor of Vascular Surgery at the Medical University of South Carolina, joins host Dr. Aaron Fritts to explore strategies for navigating physician-industry relationships.

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SYNPOSIS

The doctors share their experiences in partnering with the medical device industry. The conversation covers the benefits of industry partnerships, the challenges of avoiding conflicts of interest, and the critical role of education in preparing new physicians for these interactions. Dr. Tanious also delves into his thought-provoking TED Talk on big business in surgery, and discusses the value of business education for physicians.

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TIMESTAMPS

00:00 - Introduction

02:12 - Medicine and Business

05:01 - Business Knowledge for Physicians

15:05 - Physician-Industry Relationships

27:26 - Industry Relationships in Medical Training

33:08 - Ethical Considerations and Influence in the OR

35:00 - Leveraging Industry Resources for Better Training

43:24 - Future of Medical Technology and Collaboration

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RESOURCES

Big Business and Surgery: Who Belongs in Your Operating Room?:

https://youtu.be/kksVjF0fI_w?si=LADwqrbXPz3VsFm4

Quantic MBA Program:

https://quantic.edu/blog/category/fields-of-study/accounting/

The price of a cup of coffee:

https://vascularspecialistonline.com/the-price-of-a-cup-of-coffee/

The management of portal hypertension has drastically evolved over the years. What are the current best practices? And what’s coming next? Dr. Tom Leventhal and Dr. Siobahn Flanagan from University of Minnesota Medical School join us for an interdisciplinary discussion. Dr. Leventhal is an Associate Professor of Transplant Hepatology and Dr. Siobhan is an Associate Professor of Interventional Radiology.

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Cook Medical Embolization

https://www.cookmedical.com/interventional-radiology/coils-home/cook-products/?utm_source=backtable&utm_medium=digital&utm_campaign=vasc_ir_p_awa_embolization_2024_amer

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SYNPOSIS

The doctors discuss current collaborative approaches that are improving portal hypertension patient care, the impact of contemporary clinical practices in transplant hepatology and IR, and the imminent future of portal hypertension treatments. Dr. Leventhal also gives his insight on what could be on the horizon, touching on in-vitro organ creation, xenotransplants, and stem cells phasing out immunosuppression.

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TIMESTAMPS

00:00 - Introduction

06:10 - Managing Portal Hypertension

07:51 - Current Collaborative Practices

10:38 - Patient Referral and Management

15:25 - Initial Workup for Portal Hypertension

19:27 - Role of Biopsy in Diagnosis

24:02 - Patient Scenarios for TIPS Referral

32:04 - Ultrasound and Intracardiac Echocardiography (ICE) in TIPS

38:09 - Clinical Management

52:48 - Future of Transplant and Organ Growth

We are back with Part 2 of All Things Enteral Access with Dr. Peter Bream! We discuss various aspects of enteric access and management of complications with G and GJ-tubes.

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SYNPOSIS

Dr. Bream provides detailed advice on troubleshooting common issues such as leaking tubes, infections, and clogs. He emphasizes the importance of a multidisciplinary approach in managing special populations, such as patients with ALS and head and neck cancer, and offers guidance for safe and effective procedures. The conversation is rich with practical tips, tricks, and valuable insights that cater to both new and experienced practitioners.

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TIMESTAMPS

00:00 - Introduction

01:47 - Special Populations

07:21 - ALS Patients

09:57 - Head and Neck Cancer Patients

14:05 - Techniques for Gastric Bypass and Altered Anatomy

18:11 - Addressing G-Tube Issues

27:16 - Converting G to GJ-Tubes

31:11 - Advanced Tips and Tricks

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RESOURCES

Weighted Tip Extensions Result in Fewer Gastrojejunostomy Tube Migrations and Increase Tube Lifespan:

https://www.jvir.org/article/S1051-0443(22)01243-X/abstract

Do you have questions about enteral access? Dr. Peter Bream’s got you covered! In this episode Dr. Bream, former Professor at UNC Chapel Hill School of Medicine and current private practice interventional radiologist, shares his extensive knowledge on enteral access.

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Medtronic Concerto

https://www.medtronic.com/us-en/healthcare-professionals/products/cardiovascular/peripheral-embolization/concerto.html

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SYNPOSIS

The discussion covers various insertion techniques, the use of different types of tubes including NG, G, and GJ tubes, and specialized methods like the Balloon-Assisted Gastrostomy (BAG) and Percutaneous Transesophageal Gastrostomy (PTEG). Dr. Bream also provides valuable insights on handling complications, patient preparation, and post-procedure care, making this episode a comprehensive guide for all things enteral access. Be sure to check out Part 2 next.

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TIMESTAMPS

00:00 - Introduction

03:00 - Tubes for Enteral Access

15:48 - Techniques and Personal Experiences

29:59 - Limitations and Techniques for Stroke Patients

30:45 - Patient Comfort and Sedation

37:16 - Complications and Safety Measures

39:14 - Palliative Techniques and Special Cases

49:49 - Post-Procedure Care and Maintenance

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RESOURCES

Percutaneous gastrostomy:

https://pubmed.ncbi.nlm.nih.gov/6414043/

Retrospective comparison of outcomes and associated complications between large bore radiologically inserted gastrostomy tube types:

https://pubmed.ncbi.nlm.nih.gov/30073401/

Single-Step Method for Pull-Type Gastrostomy Tube Placement:

https://pubmed.ncbi.nlm.nih.gov/31542269/

Balloon Assisted Gastrostomy (BAG) YouTube Video:

https://youtu.be/GuF7BYW2Hm0?si=6xUIDQaQV-ywX1ua

IR Playbook: A Comprehensive Introduction to Interventional Radiology (1st edition):

https://link.springer.com/book/10.1007/978-3-319-71300-7

IR Playbook: A Comprehensive Introduction to Interventional Radiology Second Edition 2024:

https://link.springer.com/book/10.1007/978-3-031-52546-9

Pediatric gastrostomy tubes and techniques: making safer and cleaner choices:

https://pubmed.ncbi.nlm.nih.gov/29180216/

The use of drug-coated balloons (DCBs) for peripheral arterial disease has been controversial in the past. However, new data and updated FDA guidance have helped these devices regain popularity. In this episode of the BackTable Podcast, Dr. Ally Baheti hosts a discussion with Dr. Sahil Parikh, an interventional cardiologist in New York City, and Dr. John Park, a vascular surgeon in Omaha.

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BD Lutonix

https://www.bd.com/en-us/products-and-solutions/products/product-families/lutonix-drug-coated-balloon-pta-catheters

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SYNPOSIS

They review the historical controversy surrounding the potential late-mortality risks associated with Paclitaxel-coated devices, discuss more recent literature on the safety and efficacy of DCBs, and examine the implications of the FDA’s updated guidance in 2023. This update was made possible through collaborative efforts across specialties and regulatory bodies to establish best practices for vascular interventions. They also delve into patient selection criteria, lesion characteristics, and practical considerations for choosing between DCBs and other revascularization options. Each provider shares their treatment algorithm for DCB use in peripheral arterial disease.

Dr. Park uses DCBs as a first-line treatment for patients with complete occlusions, CLTI symptoms, or lifestyle-limiting claudication, with adjunctive stenting sometimes required afterwards. In his experience, DCBs work best in lesions shorter than 100 mm and are preferable in locations where stenting is not feasible, such as across the knee joint.

Dr. Parikh similarly prefers DCBs over plain balloon angioplasty and places stents in longer lesions. He notes that Hunter’s canal is a challenging area to treat with DCBs alone and may require atherectomy or intravascular lithotripsy. He recommends considering drug-eluting stents as a proactive measure to prevent more costly interventions for future restenosis.

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TIMESTAMPS

00:00 - Introduction

02:14 - History of DCB and Controversy

07:46 - Updated Research and 2023 FDA Guidelines

16:44 - Importance of Collaboration and Patient Preference

26:34 - DCB Treatment Algorithms

33:31 - Drug-Eluting Stents

35:46 - Approach for Patients with Claudication

37:22 - DCB Sizing and Dose

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RESOURCES

Risk of Death Following Application of Paclitaxel‐Coated Balloons and Stents in the Femoropopliteal Artery of the Leg: A Systematic Review and Meta‐Analysis of Randomized Controlled Trials (2018):

https://www.ahajournals.org/doi/10.1161/JAHA.118.011245

FDA- Treatment of Peripheral Arterial Disease with Paclitaxel-Coated Balloons and Paclitaxel-Eluting Stents Potentially Associated with Increased Mortality–Letter to Health Care Providers (2018):

www.fda.gov/medical-devices/letters-health-care-providers/update-treatment-peripheral-arterial-disease-paclitaxel-coated-balloons-and-paclitaxel-eluting

FDA- Paclitaxel-Coated Devices to Treat Peripheral Arterial Disease Unlikely to Increase Risk of Mortality - Letter to Health Care Providers (2023): https://www.fda.gov/medical-devices/letters-health-care-providers/update-paclitaxel-coated-devices-treat-peripheral-arterial-disease-unlikely-increase-risk-mortality

Mortality in randomised controlled trials using paclitaxel-coated devices for femoropopliteal interventional procedures: an updated patient-level meta-analysis (2023):

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)02189-X/abstract

Creating an ambulatory surgery center (ASC) with transparent, affordable pricing is possible and can go a long way in protecting our patients’ health, pockets, and futures. Dr. Keith Smith, founder of Oklahoma Surgery Center and the Free Market Medical Association, joins us to explain how to do it.

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Reflow Medical

https://www.reflowmedical.com/

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SYNPOSIS

Dr. Smith shares his journey of creating transparent and affordable healthcare pricing, the challenges faced due to government regulations and insurance companies, and the rapid growth of self-funded companies seeking value in medical services. He highlights the importance of simple, honest pricing and the impact of the Free Market Medical Association in connecting buyers and sellers. Dr. Smith also discusses the expansion of his model beyond Oklahoma and into new surgical centers, emphasizing the need for price transparency in healthcare.

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TIMESTAMPS

00:00 - Introduction

05:06 - Challenges & Growth

14:18 - Self-Funding & Price Transparency

16:47 - Free Market Medical Association

21:44 - Government & Price Transparency

26:19 - Expansion & Future Plans

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RESOURCES

Oklahoma Surgery Center:

https://surgerycenterok.com/

Free Market Medical Association:

https://fmma.org/

How has Laser Atherectomy advanced over the years to treat patients with coronary and peripheral artery disease? Dr. On Topaz, renowned specialist in laser atherectomy, answers exactly that and much more in this week’s episode the BackTable Podcast. Dr. Topaz is an interventional cardiologist and a professor of medicine at Duke University.

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AngioDynamics Auryon System

https://www.auryon-system.com/

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SYNPOSIS

The doctors begin their discussion by comparing traditional Excimer laser and new Auryon laser technologies. The conversation also covers thrombus management, use of lasers in complex plaques, the latest research studies on laser atherectomy, and future developments in laser technology for varied medical applications.

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TIMESTAMPS

00:00 - Introduction

10:01 - Laser Atherectomy & Thrombus Management

21:59 - Laser Applications in Peripheral Arterial Disease

28:12 - Laser in Interventional Cardiology

41:17 - New Laser Technologies

47:50 - Research Findings and Clinical Trials

59:09 - Future Prospects and Applications

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RESOURCES

Book by Dr. On Topaz - Debulking in Cardiovascular Interventions and Revascularization Strategies:

https://www.sciencedirect.com/book/9780128214510/debulking-in-cardiovascular-interventions-and-revascularization-strategies

Book by Dr. On Topaz - Lasers in Cardiovascular Interventions:

https://link.springer.com/content/pdf/10.1007/978-1-4471-5220-0.pdf

Book by Dr. On Topaz - Cardiovascular Thrombus: From Pathology and Clinical Presentations to Imaging, Pharmacotherapy and Interventions:

https://www.sciencedirect.com/book/9780128126158/cardiovascular-thrombus

Paper from Dr. Giancarlo Biamino - The excimer laser: science fiction fantasy or practical tool?:

https://pubmed.ncbi.nlm.nih.gov/15760264/

Clinical Trial from Dr. John Bittl - Predictors of outcome of percutaneous excimer laser coronary angioplasty of saphenous vein bypass graft lesions. The Percutaneous Excimer Laser Coronary Angioplasty Registry:

https://pubmed.ncbi.nlm.nih.gov/8023778/

Paper from Dr. Warren S. Grundfest - https://journals.lww.com/coronary-artery/citation/1990/07000/laser_angioplasty.4.aspx

Paper from Dr. George S. Abela - Abrupt Closure After Pulsed Laser Angioplasty: Spasm or A “Mille-Feuilles” Effect?:

https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1540-8183.1992.tb00830.x

Solid state, pulsed-wave 355 nm UV laser atherectomy debulking in the treatment of infrainguinal peripheral arterial disease: The Pathfinder Registry:

https://pubmed.ncbi.nlm.nih.gov/38566525/