BackTable Vascular & Interventional

In this episode of the BackTable Podcast, host Dr. Aaron Fritts interviews guest Dr. Thomas Sullivan about the findings from a recent survey exploring the reasons behind professional job changes among interventional radiologists. Dr. Sullivan is the Assistant Program Director of Diagnostic and Integrated Interventional Radiology Residency programs at Wake Forest University.

Dr. Sullivan highlights the importance of mentorship during residency and notes the huge impact of geography and financial compensation in determining job satisfaction and longevity in a role. He also discusses some surprising insights about trainee expectations of future practice settings, the need for a variety in practice caseload, and the desire for about 80% of clinical time to be spent on dedicated IR activities. The conversation also delves into the challenges of equipping residents for rural practice and the potential value of developing a procedural radiology curriculum. Dr. Sullivan anticipates that the survey results will help improve and adapt training paradigms to better align with the evolving landscape of interventional radiology practice.

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RADPAD® Radiation Protection

https://www.radpad.com/

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SHOW NOTES

00:00 - Introduction

02:50 - Discussion on IR Training and Practice

04:51 - Survey Discussion and Key Findings

16:47 - Importance of Diagnostic Skills in IR

19:01 - Deciding Factors for First Job After Training

21:04 - Need for Medical Services in Rural Settings

25:23 - Role of Mentorship in Job Seeking

28:21 - Importance of Networking in Career Development

32:37 - Future of IR Training and Practice

38:23 - Role of BackTable in IR Training

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RESOURCES

SIR 2024 Monday Session (3:27 PM - 3:36 PM MT): Trainee perceptions of current IR workforce: Are we setting our residents up for failure? With Dr. Thomas Sullivan:

https://www.sirmeeting.org/fsPopup.asp?PresentationID=1348792&mode=presInfo

In this episode of the BackTable Podcast, host Dr. Michael Barraza interviews guest Dr. Charles Nutting about prostatic artery embolization (PAE) in the outpatient-based lab (OBL) setting. Dr. Nutting is an interventional radiologist at Endovascular Consultants in Lone Tree, Colorado. The doctors discuss procedure techniques, patient selection, follow-up care, and benefits of the OBL environment over the hospital.

Dr. Nutting emphasizes that it is important to learn PAE in a hospital setting before transitioning to the OBL. He recommends using consistent equipment to help with the learning process. Dr. Nutting also shares his experience with radiopaque beads in PAE and describes the advantages of seeing the deposition of the beads into the gland. The doctors discuss the potential impact of the 2023 American Urological Association (AUA) Guidelines, which for the first time recognizes PAE for the treatment of symptomatic benign prostatic hyperplasia (BPH), and what this might mean for patient volume and interventional radiology training.

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Varian, a Siemens Healthineers company

https://www.varian.com/products/interventional-solutions/embolization-solutions

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SHOW NOTES

00:00 - Introduction

03:03 - Impact of New AUA Guidelines on PAE

04:48 - Benefits of PAE for Patients

06:37 - Role of Primary Care Physicians in PAE

08:18 - Practice of PAE in the OBL

19:08 - Role of Urodynamic Studies

22:23 - Challenges of Treating Small Glands

26:11 - Procedure Steps and Techniques

34:19 - Post-Procedure Care and Follow-up

38:33 - The Future of Prostate Embolization

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RESOURCES

Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia (BPH): AUA Guideline Amendment 2023:

https://www.auanet.org/guidelines-and-quality/guidelines/benign-prostatic-hyperplasia-(bph)-guideline

Efficacy and safety of prostate artery embolization for benign prostatic hyperplasia: an observational study and propensity-matched comparison with transurethral resection of the prostate (the UK-ROPE study):

https://pubmed.ncbi.nlm.nih.gov/29645352/

NICE - Prostate artery embolisation for lower urinary tract symptoms caused by benign prostatic hyperplasia:

https://www.nice.org.uk/guidance/ipg611

Yttrium-90 Radioembolization in the Office-Based Lab:

https://pubmed.ncbi.nlm.nih.gov/32800662/

Role of Urodynamic Studies in Management of Benign Prostatic Obstruction: A Guide for Interventional Radiologists:

https://www.jvir.org/article/S1051-0443(16)30520-6/fulltext

International Prostate Symptom Score (IPSS):

https://www.urologygroup.com/wp-content/uploads/2019/07/IPSS-Form-Before-Tx-_-BPH.pdf

In this episode of the BackTable Podcast, host Dr. Chris Beck interviews guest Dr. Gary Tse about the innovative technique of thyroid ablation and its role in treating benign thyroid nodules. Dr. Tse is a practicing interventional radiologist at UCLA Health.

Dr. Tse highlights the procedural details, patient experiences, potential complications, and follow-up protocols of thyroid ablation. He emphasizes the importance of consistent communication with patients during these procedures, given that the patients are under minimal anesthesia. He explains how interventional radiologists can benefit from embracing this procedure due to their expertise in ultrasound usage, as it leads to reduction in recovery times and complications for patients. Dr. Tse also briefly discusses the future potential of thyroid embolization for larger goiters. He encourages other IR specialists to consider adopting this procedure, which he believes should become a standard of care.

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CHECK OUT OUR SPONSORS

Siemens Healthineers

https://www.siemens-healthineers.com/

Varian, a Siemens Healthineers company

https://www.varian.com/products/interventional-solutions/embolization-solutions

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SHOW NOTES

00:00 - Introduction

04:03 - Dr. Tse’s Career Journey and Transition to Academics

06:32 - Discussion on Thyroid Interventions

09:15 - Building Referral Patterns for Thyroid Interventions

11:50 - Thyroid Ablation Procedure Overview

21:23 - Post-Ablation Outcomes and Goals

25:52 - Avoiding Complications

32:55 - Post-Procedure Follow-Up

36:14 - Exploring Thyroid Embolization

42:23 - Final Thoughts and Future Prospects

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RESOURCES

2017 Thyroid Radiofrequency Ablation Guideline: Korean Society of Thyroid Radiology:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6005940/

Recurrent Laryngeal Nerve Injury in Thermal Ablation of Thyroid Nodules-Risk Factors and Cause Analysis:

https://pubmed.ncbi.nlm.nih.gov/35311971/

Effectiveness of Injecting Cold 5% Dextrose into Patients with Nerve Damage Symptoms during Thyroid Radiofrequency Ablation:

https://doi.org/10.3803/EnM.2020.35.2.407

Revisiting Rupture of Benign Thyroid Nodules after Radiofrequency Ablation: Various Types and Imaging Features:

https://doi.org/10.3803/EnM.2019.34.4.415

Thyroid arterial embolization to treat Graves' disease:

https://pubmed.ncbi.nlm.nih.gov/17354140/

Thyroid Embolization for Nonsurgical Treatment of Nodular Goiter: A Single-Center Experience in 56 Consecutive Patients:

https://www.jvir.org/article/S1051-0443(21)01212-4/fulltext#%20

In this episode, host Dr. Chris Beck interviews Dr. Jason Wagner about his experience with using the Hemodialysis Reliable Outflow (HeRO) graft and the Surfacer system for treating patients with end stage renal disease (ESRD) and limited vascular access options. Dr. Wagner is a practicing vascular surgeon in Sarasota, Florida.

Dr. Wagner explains the steps to implant a HeRO endovascular graft, how it provides a durable and reliable outflow for hemodialysis patients, and how it can be used and revised based on the patient’s needs. He also discusses the Surfacer system in obtaining central venous access, its advantages, and the necessity of preoperative imaging. Dr. Wagner emphasizes the critical role of continued learning in utilizing and optimizing these advanced dialysis solutions.

The suggestions and other information, which may include Merit products, are for the practitioner’s convenience and for general information purposes only. This information does not constitute medical or legal advice. Before using, refer to the Instructions for Use (IFU) for indications, contraindications, warnings, precautions, and directions for use.

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Merit HeRO Graft

https://www.merit.com/product/merit-hero-graft/

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SHOW NOTES

00:00 - Introduction

02:25 - Dr. Wagner’s Experience in Vascular Surgery

05:49 - Understanding End-Stage Vascular Access

08:52 - Introduction to the HeRO Graft

16:15 - Implantation of the HeRO Graft

28:38 - The Surfacer: A Game Changer in Vascular Access

31:49 - Potential Risks and Precautions with the Surfacer

33:38 - Using Both HeRO Graft and Surfacer

36:31 - Final Thoughts and Resources on Both Devices

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RESOURCES

Think Dialysis Access Course from Merit:

https://www.merit.com/education/courses/thinkaccess/

HeRO Graft: Indications, Technique, Outcomes, and Secondary Intervention:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8856774/

KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update:

https://pubmed.ncbi.nlm.nih.gov/32778223/

The Surfacer:

https://bluegrassvascular.com/surfacer-2/

This week on the BackTable Podcast, Dr. Darren Klass shares his experiences in the treatment of aortic dissections. Dr. Klass is an interventional radiologist at the University of British Columbia.

Dr. Klass underscores the criticality of intraoperative decision-making, the use of intravascular ultrasound (IVUS), and the importance of taking a multidisciplinary approach. The conversation further explores the nuances of treating acute complicated aortic dissections, stabilizing the intermedial flap, follow-up protocols, and the importance of raising awareness about this high risk disease.

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Cook Medical Aortic Interventions

https://www.cookmedical.com/aorticbacktable

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SHOW NOTES

00:00 - Introduction

07:45 - Identifying and Treating Type B Aortic Dissections

09:35 - Role of Imaging

18:24 - Patient Journey Through Aortic Dissection Treatment

29:35 - Importance of Intravascular Ultrasound

39:01 - Petticoat Technique

47:12 - Role of Lumbar Drains

50:10 - Importance of Follow-ups

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RESOURCES

Cook Medical Essential Prescribing Information:

https://www.cookmedical.com/patient-resources/aortic-dissection/aortic-dissection-cook-medical-products/

Dr. Darren Klass’ ResearchGate Profile:

https://www.researchgate.net/profile/Darren-Klass

The Society of Thoracic Surgeons/American Association for Thoracic Surgery Clinical Practice Guidelines on the Management of Type B Aortic Dissection:

https://www.sts.org/sites/default/files/content/TBAD_Guideline_2022.pdf

Krukenberg E. Beiträge zur Frage des Aneurysma dissecans. Beitr Patho Anat Allg Pathol. 1920; 67:329-351. (Paper that first described acute intramural hematoma from 1920):

https://cir.nii.ac.jp/crid/1571698600607606272

Acute Aortic Dissection and Intramural Hematoma: A Systematic Review:

https://pubmed.ncbi.nlm.nih.gov/27533160/

The PETTICOAT Technique for Complicated Acute Stanford Type B Aortic Dissection Using a Tapered Self-Expanding Nitinol Device as Distal Uncovered Stent:

https://pubmed.ncbi.nlm.nih.gov/28279721/

En este nuevo episodio de BackTable, el Dr. Fernando Gómez Muñoz y la Dra. Sara Lojo Lendoiro profundizan en el complejo y específico campo de la radiología intervencionista pediátrica.

Al enfatizar las diferencias existentes entre los pacientes adultos y los niños, el Dr. Gómez Muñoz destaca la necesidad de capacitación y enfoques especializados para el manejo de casos pediátricos, especialmente en términos de variantes propias de la edad del paciente como la volemia o el tamaño de los vasos. Se examinan críticamente los desafíos en los procedimientos intervencionistas, particularmente en relación con las complejidades propias del trabajo con pacientes pediátricos y la dificultad añadida de los materiales necesarios. Además, el Dr Gómez Muñoz comparte su trayectoria profesional, su paso por el Great Ormond Street Hospital de Londres y su continuo aprendizaje de colegas de todo el mundo.

En el podcast también se explora la necesidad de una colaboración multidisciplinar y se analiza la relación entre los radiólogos intervencionistas y los cirujanos pediátricos. Se subraya la importancia de una comunicación clara con las familias de los pacientes durante procedimientos o diagnósticos particularmente complejos, afirmando que la atención al paciente comienza con el manejo de las emociones y expectativas de los propios médicos.

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SHOW NOTES

00:00 - Introducción a la radiología intervencionista pediátrica

01:27 - Comprender las diferencias entre pacientes adultos y pediátricos

03:08 - Desafíos en radiología intervencionista pediátrica

08:29 - El papel de la formación y la especialización

13:25 - Cómo afrontar las emergencias médicas pediátricas

19:02 - La importancia del enfoque multidisciplinario en la atención pediátrica

26:23 - El futuro de la radiología intervencionista pediátrica

42:44 - Conclusión: La importancia de la radiología intervencionista pediátrica

In this episode, guest host Dr. Dana Dunleavy and guest Dr. Douglas Beall delve into the transformative potential of neuromodulation in the treatment of chronic pain, particularly for painful diabetic neuropathy (PDN). Dr. Beall is an interventional musculoskeletal radiologist practicing at Oklahoma Spine in Edmond, Oklahoma.

Dr. Beall recounts his journey, from his beginnings in the military to his experiences with navigating institutional resistance to his clinical practice, and finally the process of moving to private practice. He discusses the positive impact of spinal cord stimulation on patients with PDN and reflects on its effectiveness in reducing pain and improving neurologic function. He underscores the crucial role of interventional radiologists in managing PDN, while also advocating for the integration of these specialists in pain management clinics. Dr. Beall argues that interventional radiologists possess unique skill sets adept for neuromodulation, which opens up new treatment possibilities in the process. He shares insights on the evolution of spinal cord stimulation technology, reimbursement considerations, and the importance of clinical trials in refining treatment approaches. The episode ends with an invitation for interested physicians to participate in professional forums and learn more about this burgeoning field.

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Nevro HFX Spinal Cord Stimulator

https://www.hfxforpdn.com

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SHOW NOTES

00:00 - Introduction

02:30 - Challenges and Triumphs of a Solo Practice

14:44 - Evolution of Neuromodulation in Practice

17:05 - Impact of Neuromodulation on Painful Diabetic Neuropathy

31:53 - Unique Mechanism of High Frequency Neuromodulation

46:02 - Role of Interventional Radiologists in Neuromodulation

54:11 - Future of Neuromodulation in Interventional Radiology

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RESOURCES

Douglas Beall, MD Research Gate Profile:

https://www.researchgate.net/scientific-contributions/Douglas-P-Beall-39583252

Long-term efficacy of high-frequency (10 kHz) spinal cord stimulation for the treatment of painful diabetic neuropathy: 24-Month results of a randomized controlled trial:

https://pubmed.ncbi.nlm.nih.gov/37536514/

High-Frequency 10-kHz Spinal Cord Stimulation Improves Health-Related Quality of Life in Patients With Refractory Painful Diabetic Neuropathy: 12-Month Results From a Randomized Controlled Trial:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9256824/

Neuromodulation Interventions for the Treatment of Painful Diabetic Neuropathy: a Systematic Review:

https://link.springer.com/article/10.1007/s11916-022-01035-9

High-frequency spinal cord stimulation at 10 kHz for the treatment of painful diabetic neuropathy: design of a multicenter, randomized controlled trial (SENZA-PDN):

https://link.springer.com/article/10.1186/s13063-019-4007-y

In this episode of BackTable Podcast, host Dr. Ally Behati invites interventional cardiologist Dr. Thomas Davis, Director of the Cardiac Catheterization Lab at St. John Hospital and Medical Center, to discuss re-entry devices, with a focus on the Pioneer Plus Catheter.

Dr. Davis shares his experience in using the Pioneer Plus, an intravascular ultrasound (IVUS) guided re-entry catheter in treating critical limb ischemia (CLI), especially in cases where it is difficult to stay intraluminal. He explains a novel ‘reorientation technique’, which allows proceduralists to remain in the true lumen while treating a chronic total occlusion. Dr. Davis also describes his workflow and decision points about when to reach for the catheter. To finish the episode, he covers post-procedure patient management, imaging follow up, and opportunities to learn more about treatment of peripheral vascular disease.

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Philips Pioneer Plus

https://www.usa.philips.com/healthcare/product/HCIGTDPPLUS/pioneer-plus-ivus-guided-re-entry-catheter

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SHOW NOTES

00:00 Introduction to the Back Table Podcast

02:09 Dr. Davis’ Practice in CLI Treatment

04:18 The Decision to Use the Pioneer Plus Catheter

07:31 The Reorientation Technique for Staying in the True Lumen

11:49 Using Intravascular Ultrasound to Guide Your Wire

17:33 Learning and Troubleshooting with IVUS

21:48 Preparing for Subintimal Work

28:26 Post-Procedural Management and Imaging

30:12 Advice for Proceduralists in the CLI Space

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RESOURCES

Pioneer Plus Re-Entry Catheter:

https://www.usa.philips.com/healthcare/product/HCIGTDPPLUS/pioneer-plus-ivus-guided-re-entry-catheter

Outback Re-Entry Catheter:

https://cordis.com/na/products/cross/endovascular/outback-elite-re-entry-catheter

Enteer Re-Entry Catheter

https://www.medtronic.com/us-en/healthcare-professionals/products/cardiovascular/chronic-total-occlusion-devices/enteer.html

The Amputation Prevention Symposium (AMP) Meeting:

https://www.hmpglobalevents.com/amptheclimeeting

In this episode of the BackTable Podcast, guest host Dr. Krishna Amuluru interviews Dr. Fawaz Al-Mufti about recent trials on large core strokes and how they may impact practice. Dr. Al-Mufti is a practicing neurointerventionalist and serves as the Associate Chair of Neurology for Research at New York Medical College.

Dr. Al-Mufti examines the cost-effectiveness and socioeconomic implications of successful treatment of patients with large core strokes. The doctors highlight various stroke thrombectomy trials including the RESCUE-Japan, SELECT2 Trial, and TENSION trials. The discussion also covers how these findings affect thrombectomy expansion in lower resource settings and the future outlook of endovascular thrombectomy procedures.

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RADPAD® Radiation Protection

https://www.radpad.com/

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SHOW NOTES

00:00 - Introduction

02:53 - Large Ischemic Core Infarcts

06:06 - The Importance of ASPECTS

11:59 - Large Ischemic Core Trials

23:37 - Socioeconomic Implications of Thrombectomy

38:08 - The Future of Thrombectomy

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RESOURCES

Mission Thrombectomy:

https://missionthrombectomy.org/

The Alberta Stroke Program Early CT score (ASPECTS): A predictor of mortality in acute ischemic stroke:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8515558/

Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomized trials (HERMES Study):

https://doi.org/10.1016/S0140-6736(16)00163-X

Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging (DEFUSE III Trial):

https://www.nejm.org/doi/full/10.1056/nejmoa1713973

Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct (DAWN Trial):

https://www.nejm.org/doi/full/10.1056/nejmoa1706442

Endovascular Therapy for Acute Stroke with a Large Ischemic Region (RESCUE-Japan Trial):

https://www.nejm.org/doi/full/10.1056/nejmoa2118191

Trial of Endovascular Thrombectomy for Large Ischemic Strokes (SELECT2 Trial):

https://www.nejm.org/doi/full/10.1056/NEJMoa2214403

TESLA Trial: Rationale, Protocol, and Design:

https://www.ahajournals.org/doi/10.1161/SVIN.122.000787

Endovascular thrombectomy for acute ischaemic stroke with established large infarct: multicentre, open-label, randomized trial (TENSION Trial):

https://www.sciencedirect.com/science/article/pii/S0140673623020329

Evaluation of acute mechanical revascularization in large stroke (ASPECTS ⩽5) and large vessel occlusion within 7 h of last-seen-well: The LASTE multicenter, randomized, clinical trial protocol:

https://pubmed.ncbi.nlm.nih.gov/37462028/

Trial of Endovascular Therapy for Acute Ischemic Stroke with Large Infarct (ANGEL-ASPECT Trial):

https://www.nejm.org/doi/full/10.1056/NEJMoa2213379

Acute endovascular stroke therapy (Dr. Mike Chen Review):

https://pubmed.ncbi.nlm.nih.gov/20535000/

Mechanical thrombectomy is cost-effective versus medical management alone around Europe in patients with low ASPECTS (European Cost Effectiveness Study):

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10313965/

Mechanical Thrombectomy Global Access For Stroke (MT-GLASS): A Mission Thrombectomy (MT-2020 Plus) Study:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10313965/

Noncontrast Computed Tomography vs Computed Tomography Perfusion or Magnetic Resonance Imaging Selection in Late Presentation of Stroke With Large-Vessel Occlusion:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8576630/

In this episode, host Dr. Aaron Fritts is joined by interventional cardiologists Dr. Sameh Sayfo (Baylor Scott & White in Plano, TX) and Dr. Nicolas Shammas (Cardiovascular Medicine in Davenport, IA) for a discussion about critical limb ischemia (CLI) and the use of lasers in below-the-knee (BTK) treatment.

To start, Dr. Shammas explains that infrapopliteal disease is difficult to treat due to the high rate of total occlusions and the high degree of medial calcinosis. Next, he gives an introduction to laser atherectomy for certain plaque locations and morphologies, and he describes previous studies that have shown its efficacy for calcified lesions. Intravascular ultrasound (IVUS) can also help guide vessel sizing, plaque morphology, and appropriate device selection. Dr. Shammas believes that the current atherectomy devices on the market are easy to learn to use and can be incorporated into any CLI program.

The doctors discuss the ongoing multicenter study on outcomes of the Auryon laser atherectomy system in CLI patients. Dr. Shammas reviews the study design, proposed endpoints, and current data on 30 day outcomes. We end the episode with advice on building a strong CLI program, which includes multidisciplinary collaboration, advocating for resources, a variety of different tools, and appropriate management of cardiovascular risk factors.

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AngioDynamics Auryon System

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

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SHOW NOTES

00:00 - Introduction

04:18 - Current Treatment Limitations for Infrapopliteal Disease

07:38 - Laser Atherectomy for Calcified Lesions

12:10 - Learning Curve for Laser Atherectomy Devices

15:38 - 30-Day Results of the Auryon BTK Study

23:35 - Technical Approach and Tools for Infrapopliteal Segments

29:00 - Upcoming Developments in CLI Treatment

31:33 - Advice for Building a CLI Program

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RESOURCES

Calcium 360 Trial:

https://pubmed.ncbi.nlm.nih.gov/22891826/

Auryon Laser Atherectomy System:

https://www.angiodynamics.com/product/auryon/

Nexcimer Laser Atherectomy System:

https://www.usa.philips.com/healthcare/product/HCIGTDPHLLSRSYSTM/laser-system-hcigtdphllsrsystm

30-Day Results of the Auryon BTK Study:

https://www.jacc.org/doi/10.1016/j.jacc.2023.09.194

Midwest Cardiovascular Research Foundation:

http://www.mcrfmd.com/

Life-BTK Study:

https://www.cardiovascular.abbott/us/en/patients/treatments-therapies/peripheral-artery-disease/life-btk.html

Promise II Study:

https://www.nejm.org/doi/full/10.1056/NEJMoa2212754

BackTable Ep. 350- Building a CLI Program with Dr. Zola N’Dandu:

https://www.backtable.com/shows/vi/podcasts/350/building-a-cli-program