In this episode, our host Dr. Sabeen Dhand interviews Dr. Pascal Jabbour, Division Chief of Neurovascular Surgery & Endovascular Neurosurgery at Jefferson University. We discuss the current training landscape for vascular neurosurgery, the open versus endovascular debate, and Dr. Jabbour’s perspective on multispecialty collaboration in vascular neurology.

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SHOW NOTES

Dr. Jabbour starts the episode by recounting his time in residency and how his mentor inspired him to pursue a vascular neurosurgery fellowship. It is becoming increasingly common for neurosurgery residency programs to require their trainees to complete a rotation in vascular neurosurgery. He also speaks more about the residency program at Jefferson and different community hospitals that Jefferson is affiliated with. Having affiliates across a wide geographic area helps his department better serve the community by saving time and reducing the need to transfer patients.

Next, Dr. Jabbour describes his own practice, which incorporates both endovascular and open procedures. He emphasizes that there is little benefit from debating superiority between the two methods, since neurosurgeons should focus on the disease process and select the method that best serves each patient. Training in both methods is a necessity.

Finally, we cover the topic of collaboration between neurosurgeons, interventional neuroradiologists, neuroradiologists, and neurologists. Each specialty brings something different to the table, whether it is procedural skill, knowledge of anatomy, or expertise in disease processes. Dr. Jabbour encourages physicians to look past turf wars and recognize the importance of cross training and building a strong overall vascular team.

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RESOURCES

Twitter:

@PascalJabbourMD

Society of Neurointerventional Surgery (SNIS):

https://www.snisonline.org/

AANS/CNS Cerebrovascular (CV) Section:

https://cvsection.org/

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In this episode, host Dr. Michael Barraza interviews interventional radiologist Dr. Samdeep Mouli about controversies in prostate artery embolization, including technique, durability, and how we can leverage the data to unite IRs and establish PAE as standard of care.

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SHOW NOTES

Dr. Mouli discusses his role as director of translational research in interventional radiology at Northwestern. He reviews the most recent major data on PAE. There have been two major papers, one from a Portuguese group and another from a Brazilian group. The take home points from these papers are regarding the durability of symptoms and the safety profile of PAE. The biggest positive of PAE is that it is the safest among all minimally invasive surgeries. Dr. Mouli argues that PAE should be pursued as first line treatment for benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTs). Another upside of PAE is that it doesn’t prevent patients from undergoing any other medical or surgical intervention in the future.

One of the barriers to PAE becoming first line therapy is that there is currently no standardization among operators. Everyone still does it differently, whether by using different microcatheters, particle sizes, or other technical factors. This gives urologists ground to stand on when they argue against PAE. Dr. Mouli feels IRs should approach BPH with the same rigor that urologists do. He believes we need to use the long-term data to prove that PAE is safe, durable and yields better sexual outcomes than TURP or other minimally invasive surgical procedures. This can be accomplished via publishing guidelines for IRs. He believes a good starting place is to only use 300-500 micron particles for de-novo PAE cases. It has been proven this size is safe and results in very low non-target embolization compared to the 100-300 micron size, which more commonly causes this complication and results in more sexual dysfunction.

Dr. Mouli says urologists are pushing for surgical intervention before exhausting medical management and argues that IRs should do the same. He believes offering PAE early is in the best interest of patients, because waiting to fail medical management can cause further complications. Dr. Mouli does not get pre-procedure vascular imaging or MRI. This is because he uses intra-procedure cone beam CT. He does this as part of his procedure to map out collaterals and other blood supply to the prostate. He then targets these arteries with coils before using particle embolization on the prostate gland itself. He does this because his goal is to match the 5 year success rate demonstrated in recent studies of over 80 percent, with a less than 20% recurrence rate. He ends by stating that the long-term data show a 10-30% re-treatment rate across all treatment modalities. Knowing this, he feels even stronger that PAE should be the first line therapy, considering it is the least invasive option, it is safe and has the lowest rates of sexual dysfunction. If patients prefer more invasive procedures in the future, they can still go that route, or they can elect for repeat PAE as needed.

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RESOURCES

Triago Bilhim Paper:

https://link.springer.com/article/10.1007/s00270-022-03199-8

Francisco Carnevale Paper:

https://pubmed.ncbi.nlm.nih.gov/33308534/

UK-ROPE Study:

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

In this episode, host Ally Baheti interviews interventional cardiologist Dr. Hady Lichaa of Ascension St. Thomas Heart about wire senses, including ways to build tactile and visual skills, selection of workhorse and specialty wires, and the do’s and don’ts of crossing lesions.

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SHOW NOTES

Dr. Lichaa starts by outlining four different components of wire senses: visual sense, tactile sense, IVUS, and the digital subtraction angiography (DSA) roadmap. First, visual aspects are a combination of 2D wire sliding and looping, 3D rotation, and the course of the wire relative to the vessel architecture. By combining these visual cues, the operator can determine if the wire is inside the true lumen, within the vessel wall, or entirely outside of the vessel.

The next factor is tactile sense. Each type of wire strikes a balance between resistance to rotation / advancement and torque transmission. This balance is determined by wire characteristics such as core material, tapers, tip design, and coating. Dr. Lichaa encourages operators to test out different wires and focus on mastering their favorite workhorse wires. Additionally, there are specialty wires that can be employed in certain cases, such as CTO wires with heavy tip, tapered tip wires to enter microchannels, and supportive wires for the use of other equipment.

Additionally, we discuss how intravascular ultrasound (IVUS) leads to safer outcomes because it allows the operator to confirm that they are in the true lumen and measure vessel size before deploying stents or balloons. DSA can also help determine location and help map out different strategies if a first option fails.

Finally, Dr. Lichaa lists some helpful tips for new operators. We highlight the importance of mastering your favorite wires, having backup plans, communicating with staff, and keeping calm in the angio suite.

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RESOURCES

Abbott Command Wire:

https://www.cardiovascular.abbott/us/en/hcp/products/peripheral-intervention/guide-wires/workhorse/hi-torque-command.html

ASAHI Gladius Wire:

https://asahi-inteccusa-medical.com/product/asahi-gladius-014/

ASAHI CONFIANZA Pro:

https://asahi-inteccusa-medical.com/product/confianza-pro-series/

Terumo NAVICROSS Support Catheter:

https://www.terumois.com/products/catheters/navicross.html

Teleplex Turnpike Catheter:

https://www.teleflex.com/usa/en/product-areas/interventional/coronary-interventions/turnpike-catheters/index.html

ACT ONE Technology:

https://medical.asahi-intecc.com/en/technologies

Philips Pioneer Reentry Catheter:

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

Cordis OUTBACK Reentry Catheter:

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

In this episode, host Dr. Chris Beck interviews chest and interventional radiologist Dr. Robert Suh about his lung biopsy technique, including how he approaches pain management, and his take on the best way to seal the biopsy tract to prevent air leaks.

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SHOW NOTES

Dr. Suh begins by telling us about his background and current practice at UCLA. He was trained in interventional radiology but did a second fellowship in chest radiology due to the job market at the time. At UCLA they have a very organ-specific practice, and Dr. Suh has spent his whole career on chest and lung imaging and procedures. He splits his time between procedures, triage and planning, clinic and administrative days.

Before a lung biopsy, Dr. Suh sees the patient when they arrive and reviews their procedure. He ends the patient meeting by putting the ball back into their court by coaching them on their breathing. He tells them to take a small breath in and hold it. He has them concentrate on this while on the table which gives them more control in an unfamiliar environment. He uses mild or moderate sedation, and feels that the most important part of pain management is properly numbing the parietal pleura as it is somatically innervated. To do this, he brings a 19 gauge coaxial needle up to the extrapleural space, which looks like a black band of fat, and administers at least 10cc of lidocaine or bupivacaine. Once the parietal pleura is numb, the procedure goes much better because the needle is not tugging on the pleura with each breath. For subpleural lesions, he prefers a tangential approach, which crosses more lung parenchyma but yields a better sample than the shorter perpendicular approach. If a target is inaccessible, he first tries to reposition the patient and does not hesitate to consult interventional pulmonology to discuss alternative approaches.

Dr. Suh discusses how he previously used blood patches at the end of the biopsy to seal the tract, and why he changed his technique. He now exclusively uses BioSentry, a hydrogel polymer that functions similarly to a blood patch. After deploying the BioSentry through the introducer needle he waits 3-5 minutes, checks for pneumothorax development, and if there is no pneumothorax he sends patients home within 30 minutes without doing a post-biopsy chest x-ray.

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RESOURCES

MD Anderson Study:

https://pubmed.ncbi.nlm.nih.gov/15673500/

Memorial Sloan Study:

https://pubmed.ncbi.nlm.nih.gov/30480487/

AngioDynamics BioSentry:

https://www.angiodynamics.com/product/biosentry-tract-sealant-system/

In this episode, co-hosts Drs. Ally Baheti and Mike Barraza interview diagnostic radiologist and blogger Dr. Ben White, who speaks about private equity (PE) ownership of radiology practices, the nationwide radiologist shortage, and advice for navigating job offers.

The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/D3g0nd

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SHOW NOTES

Dr. White starts the episode by sharing his passion for writing, especially regarding topics that have affected his journey in medicine. His blog features topics that are useful for both trainees and physicians. His current practice structure is an independent diagnostic radiology practice, which is fully owned by physician partners. He thinks that this “priva-demics” job is well-suited to his interest in teaching residents and medical students. He also enjoys the autonomy that the practice has in staffing– it can remain non-bureaucratic and flexible to address patient care.

Next, Dr. White explains the factors driving the rise of PE buyouts of radiology practices, including the pros and cons of becoming a PE-owned practice. During a buyout, radiologists are offered more cash and stocks upfront in exchange for a loss of practice autonomy and a cap on future salaries. While PE firms usually advertise buyout as an opportunity to strengthen the practice with more resources, obtain help with debt payment, and eliminate inefficiencies, these benefits may not come to fruition in the long term. Additionally, radiologists may leave practices if they are not satisfied with PE management and priorities, which result in staffing shortages. Buyouts also affect independent radiology practices, since PE-owned practices are able to offer higher salaries for less work, which artificially inflate salaries across the radiology market. Dr. White fears that smaller practices and hospitals will lose their radiology workforces and will be forced to shed low-paying contracts and cease to provide imaging services for patient populations who need medical care the most. Additionally, there is unavoidable friction that arises when third party employers come between the patient-physician relationship.

Finally, Dr. White gives advice to radiologists about approaching each job prospect with a holistic perspective, including job factors that cannot be measured. He encourages early career radiologists to identify their values and ask themselves if they view their next job as simply a short term stop, or if they want to set up roots for the long term. This distinction can help guide them in making career decisions.

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RESOURCES

American Radiology Associates:

https://www.americanrad.com/

Dr. Ben White’s Blog:

https://www.benwhite.com/

Strategic Radiology:

https://www.strategicradiology.org/

In this episode, host Dr. Aparna Baheti interviews interventional radiologist Dr. Michael Cumming about his Chiba needle technique for difficult CTOs, including how to perform the technique safely and how to approach complications.

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SHOW NOTES

Dr. Cumming is one of three interventional radiologists at a private practice OBL in Minneapolis, MN. He treats patients with significant vascular disease, and has developed an approach to tackle heavily calcified chronic total occlusions (CTOs). He first used this technique on a patient with superficial femoral artery (SFA) CTOs, rest pain at night and short distance claudication. The patient was a poor candidate for surgical bypass. He began the case using the conventional technique (glide wire) but after failing twice because the wire wasn’t stiff enough, he asked for a Chiba needle. He used extravascular ultrasound (EVUS) and got part of the way through the SFA occlusion, but couldn’t completely cross the lesion because the needle was too short. He then went looking for a longer needle, and found a 65cm Chiba on the Cook website.

Dr. Cumming explains his escalation algorithm, which he uses in every revascularization case. He starts with glide wire (straight or angled), and if he gets to the point where the wire loops on itself, rather than advancing the wire and risking subintimal reentry, he stops. It is important to him to remain true lumen if possible. Next, he tries the back end of the glide wire. Third, he puts an anchoring balloon in and tries again with the back end of the glide wire. If none of these options work, he will either try his Chiba technique or try a retrograde approach from a tibial artery. If he spends more than 5 minutes on any of these steps, he moves on to the next step. He emphasizes the importance of having a plan ahead of time, rather than trying to figure out your next steps mid procedure.

For the Chiba technique, Dr. Cumming uses the 65cm Chiba (with or without stylet) through a 40cm Kumpe catheter. He advances it over an 018 nitinol or stainless steel wire. He shapes the Chiba needle based on whether he is trying to cross a lesion or enter the ostium of an artery. Using fluoroscopy, often in the orthogonal plane, he advances the needle by spinning it. Using this technique is relatively safe if you know where you are in the vessel and go slowly. Nevertheless, he says complications will still occur due to the severity of vascular disease. If the needle or wire goes extraluminal or perforates the artery causing heavier bleeding, he always has a plan. He uses balloons to try to tamponade the bleed, and occasionally injects thrombin to the area using a spinal needle. The most dangerous complication is heavy extravasation below the knee in the calf compartments that can lead to compartment syndrome.

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RESOURCES

Twitter:

@drcumming

LinkedIn:

https://www.linkedin.com/in/drmichaelcumming

Chiba needle:

https://www.cookmedical.com/products/ir_dchn_webds/

In this episode, host Dr. Ally Baheti interviews interventional radiologist Dr. Ryan Trojan about recent changes to the AMA’s evaluation and management (E&M) coding in the inpatient and outpatient settings.

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SHOW NOTES

Dr. Trojan reflects on changes in his practice since his first BackTable interview in March 2021. Onboarding a nurse practitioner made a large difference in being able to bill for follow up visits. Dr. Trojan also notes that some complex procedures require prior consultation, while other simple procedures do not. This categorization depends on the practice structure.

Next, we discuss the 2021 changes to outpatient E&M coding, which will also be reflected in 2023 changes to inpatient coding. These changes place more emphasis on time-based billing and allows physicians to bill for telehealth time with patients before / after / during their visit, as opposed to only face-to-face visits. Dr. Trojan relies on time-based billing more than component-based billing, since time spent with the patient reflects the complexities and comorbidities of each patient’s case. His initial appointment codes typically fall in the level 4 or 5 categories, which indicate moderate or high complexity. Follow up codes usually qualify as level 3, which indicates low complexity.

Finally, Dr. Trojan responds to questions from the audience about understanding global periods, billing for diagnostic and interventional service within the same practice, and billing for consults. Overall, he emphasizes the importance of documenting patient encounters and coding to capture revenue and recognize IR contributions to patient care.

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RESOURCES

Episode 116- E&M Coding 101:

https://www.backtable.com/shows/vi/podcasts/116/evaluation-management-em-coding-101

AMA 2022 E&M Guidelines:

https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management

Email:

[email protected]

In this episode, host Dr. Aparna Baheti interviews interventional nephrologist Dr. Satyaki Banerjee about peritoneal dialysis, including indications, placement technique, and tips for preventing complications.

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SHOW NOTES

Dr. Banerjee is an interventional nephrologist at a private practice OBL in Albuquerque, NM. He has completed around 750 PD catheter placements to date. Indications for PD include patients with renal failure and a glomerular filtration rate (GFR) less than 15%. Regardless of the etiology of renal failure (i.e. hypertension, diabetes), or symptoms (i.e. uremia, volume overload), PD, like hemodialysis (HD), is an option. PD is becoming increasingly popular due to patients’ ability to do it from home rather than at a dialysis clinic 3 days per week. It also empowers patients to manage their own health. Though obesity used to be a contraindication for PD, it no longer is, and Dr. Banerjee frequently places PDs in patients with a BMI of 40. The only contraindication is an abdominal wall with extensive scarring that prevents the location of a clear window.

Next, Dr. Banerjee overviews his PD workup. He does a consultation that includes an ultrasound of the abdominal wall (to verify the absence of a hernia or diastasis recti), discussion of risks, and review of post-procedure instructions. The night before, he gives his patients 60mL of lactulose after a liquid diet that evening. Before the procedure, he ensures his patients' bowel and bladder are empty, and places a foley catheter if there is concern for bladder obstruction. He holds Coumadin and Eliquis for 2 days prior to the procedure, and Aspirin and Plavix the day of. His goal for INR is less than 1.5. If they are hyperkalemic, he gives Lokelma, a new powder medication, which he prefers over Kayexalate. He measures the patient's beltline, and where they wear their pants, and always asks if they would prefer the catheter on their right or left.

Dr. Banerjee discusses his method for placing PD catheters. He uses a triple prep of chlorhexidine, iodine, and ChloraPrep. He starts by doing a scout x-ray to mark the pelvic rim. He accesses the peritoneum from a paraumbilical approach, just lateral to the spine, and always goes through the rectus muscle. He injects lidocaine until he reaches the posterior rectus sheath, where he switches to contrast. He likes to see a spider web dissipation of contrast to confirm he is intraperitoneal. He prefers a stiff glide for his wire, and an 18 French peel away. After introducing the wire, if it forms the classic loop around the pelvis, then he proceeds to serial dilation. PD catheters are different than PleurX catheters because they have a swan neck and a double cuff. The deep cuff must be in or on the rectus muscle, and the swan neck should be hanging over the rectus. He uses a Vicryl purse-string suture to anchor the deep cuff. He tunnels about 2 inches away from the deep cuff, with the superficial cuff ending in the subcutaneous fascia. He infuses antibiotics through the catheter, usually vancomycin and cefepime. His PD patients can start dialysis the day after the procedure. He then sees his patients one week later for a dressing change and 2 weeks later for a second dressing change and to review home instructions with the PD nurse.

In this episode, host Dr. Jacob Fleming interviews Dr. Edward Yoon, interventional MSK radiologist and Chief of IR at the Hospital for Special Surgery. The doctors discuss novel intradiscal therapies to treat anterior column pain, as well as where the field of spine interventions is heading.

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SHOW NOTES

Dr. Yoon outlines his path to his current specialty area. His interest in orthopedics and minimally invasive techniques led him to pursue fellowships in MSK radiology and spine intervention. He highlights how MSK IR is emerging as a cousin to orthopedic surgery, in the same way that VIR is related to vascular surgery. With nine different specialties practicing interventional pain and spine procedures, Dr. Yoon believes that IRs can differentiate themselves by taking ownership of follow up care and complications management. He emphasizes the importance of building a practice instead of waiting for patients to be referred to you. He also highlights the need to collaborate with colleagues in different specialties (orthopedics, PMR, pain management) to educate them about novel IR techniques and patient populations that could benefit from these.

Next, the doctors discuss the leading cause of low axial chronic back pain: stable discogenic pain. Though there has not been a proven treatment to halt degenerative disc disease, there are a few therapies that could help patients with painful symptoms. Dr. Yoon describes his use of anesthetic discogram as a diagnostic and therapeutic tool for discogenic back pain. His injectant is a mix of lidocaine and dexamethasone, and he observes if the patient experiences pain relief. Due to literature that links discograms with accelerated disc degeneration, discograms are less commonly performed today. However, Dr. Yoon believes that many younger patients already have degenerated discs when they present for evaluation and every interventional procedure poses some risk that can reasonably be evaluated in collaboration with the patient. Alongside imaging, he evaluates patient symptoms, the most common being midline back pain that gets worse with flexion or axial loading. Dr. Yoon also offers tips for reading spine MRIs, which include adopting a systematic approach, noting important incidental findings, and correlating findings with patient symptoms.

Finally, Dr. Yoon highlights some exciting therapies that are currently under investigation. The VIA Disc procedure involves an allographic injection of ground up nucleus pulposus into the disc. From the VAST Trial, there is data showing that treatment responders experience pain reduction and improved functioning. Autologous injection options include platelet rich plasma (PRP) and bone marrow aspirate concentrate (BMAC). Spinal modic changes could be treated with basivertebral nerve ablation (BVNA), which is a good option that is low-risk and does not preclude the possibility of future interventions. All of these therapies come with the caveat of unreliable insurance coverage, since many private payers are hesitant about approving them. The disconnect between evidence-based therapies, patient needs, and insurance coverage needs to be addressed if these therapies are to become mainstream.

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RESOURCES

VAST Clinical Trial:

https://pubmed.ncbi.nlm.nih.gov/34554689/

VIA Disc NP:

https://gotviadisc.com/

Owestry Disability Index (ODI):

https://www.aaos.org/quality/research-resources/patient-reported-outcome-measures/spine/

SMART Trial:

https://pubmed.ncbi.nlm.nih.gov/32451777/

INTRACEPT Trial:

https://www.nassopenaccess.org/article/S2666-5484(21)00041-X/fulltext

In this episode, Dr. Bagrodia discusses cultivating a healthy culture inside and outside of the operating room with Dr. Chris Kane, Dean of Clinical Affairs at UCSD and CEO of the UCSD Physician Group.

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SHOW NOTES

First, the doctors discuss the definition of culture, which Dr. Kane defines as the norms of behavior and relationships within an organization. Culture can include dress code, meeting rules, and punctuality. Most of the time, institutional culture is established in an unspoken way. Dr. Kane emphasizes the importance of having a conscious strategy to create a healthy culture and reiterates that trust is a crucial foundation for motivating cultural changes.

Next, the doctors discuss helping team members find meaning in their work. Dr. Kane recommends that surgeons share patient gratitude with their other colleagues who are not frontline medical workers. He acknowledges his staff’s contributions during meetings and expresses his gratitude through written notes. He also recommends communication training for everybody on his team. Then, he shares tips for assessing organizational culture. He believes that it is most important to ask team members what they think the overarching goal of the institution is and to assess the attrition rate through exit surveys. He emphasizes that behavioral norms matter most, as department leaders often lead by example. One detrimental practice is favoritism, which Dr. Kane regards as disrespectful to other team members. Additionally, he shares his personal experiences with changing cultures at different institutions and utilizing change management theories.

Finally, Dr. Kane shares general leadership advice. He highlights the importance of creating a patient-centered environment, leading by influence rather than authority, and the power of positivity.