In this episode, guest host and neurointerventional surgeon Dr. Krishna Amuluru interviews triple-boarded neurointerventional surgeon, neurointensivist, and neurologist Dr. Fawaz Al-Mufti about stroke thrombectomy in special populations.

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MicroVention FRED X

https://www.fred-x.com/

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SHOW NOTES

Fawaz serves as an Associate Professor, Director of Neuroendovascular Surgery Fellowship & Neurocritical-Care Unit, Assistant Dean of GME research, and Vice-Chair of Neurology research at New York Medical College, Westchester Medical Center.

First, we define the special populations that have been excluded from stroke thrombectomy randomized controlled trials (RCTs). These populations include octogenarian, nonagenarian, pediatric, and pregnant patients.

Fawaz then recaps the landmark trials that have shaped the field of neuroendovascular surgery, beginning with the handful that were published in 2015/2016. Approaching mechanical stroke thrombectomy in patients in their 80s and 90s and the lack of existing RCT literature is also discussed.

Switching gears, Fawaz then speaks on caring for pediatric patients with large-vessel occlusion (LVO). Krishna and Fawaz cover the relative rarity of pediatric LVOs, significant differences in adult vs. pediatric stroke, and what literature exists to help guide decision-making in this patient population.

Krishna then asks Fawaz about mechanical stroke thrombectomy in pregnant patients. They also cover existing literature, etiologies, and their approaches to intervention. To conclude the episode, Fawaz and Krishna speak on the purposes, applications, extrapolations, and limitations of randomized-controlled trials.

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RESOURCES

SVIN 2023 Annual Meeting:

https://www.svin.org/i4a/pages/index.cfm?pageid=3625

IMS-III Trial 2013:

https://www.nejm.org/doi/full/10.1056/nejmoa1214300

Mr. Clean Study:

https://www.nejm.org/doi/full/10.1056/nejmoa1411587

REVASCAT Study:

https://www.nejm.org/doi/full/10.1056/nejmoa1503780

EXTEND-IA Study:

https://www.nejm.org/doi/full/10.1056/nejmoa1414792

ESCAPE Trial:

https://www.nejm.org/doi/full/10.1056/nejmoa1414905

SWIFT PRIME Trial:

https://www.nejm.org/doi/full/10.1056/nejmoa1415061

HERMES Registry:

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00351-2/fulltext?rss%3Dyes

Thrombolysis in Pediatric Stroke Study (TIPS):

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4342311/

Delay to Diagnosis in Acute Pediatric Arterial Ischemic Stroke Study:

https://www.ahajournals.org/doi/10.1161/strokeaha.108.519066#:~:text=Analysis%20of%20Delay%20in%20Arterial,and%2020%25%20within%206%20hours.

Endovascular Thrombectomy for Pediatric Acute Ischemic Stroke Study:

https://www.ahajournals.org/doi/10.1161/STROKEAHA.121.036361

Recanalization Treatments for Pediatric Acute Ischemic Stroke in France (Kids-Clot):

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2796278

Feasibility, Safety, and Outcome of Endovascular Recanalization in Childhood Stroke: The Save ChildS Study:

https://pubmed.ncbi.nlm.nih.gov/31609380/

Thrombectomy in special populations: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee:

https://jnis.bmj.com/content/14/10/1033

O-039 diameters of large vessels in children and compatibility with adult interventional stroke devices: children are not little adults:

https://jnis.bmj.com/content/7/Suppl_1/A21.1

Endovascular Thrombectomy for Pediatric Acute Ischemic Stroke: A Multi-Institutional Experience of Technical and Clinical Outcomes:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8660626/#bib28

WEB Device from Microvention TERUMO:

https://www.microvention.com/products/web-family

En este episodio de BackTable, la Dra. Sara Lojo Lendoiro entrevista al Dr. Alberto Alonso, radiólogo intervencionista en la Clínica Universidad de Navarra, sobre la importancia del trabajo multidisciplinar e interdisciplinar en la Radiología intervencionista.

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SHOW NOTES

El Dr. Alonso introduce el término de interdisciplinariedad, que ocurre cuando distintas especialidades trabajan de manera combinada para interconectarse y potenciar las ventajas de cada una, con un objetivo común. El Dr Alonso defiende que todas las disciplinas son finitas, y debido a ello, existen puntos ciegos y una ausencia de alternativas si se depende solamente de una especialidad. Fomentar el trabajo en equipo con otras especialidades es importante para los radiólogos intervencionistas porque puede ayudarles, no solo con los procedimientos técnicos, sino también con la parte clínica.

En este episodio, se enfatiza la importancia del análisis de los resultados de los procedimientos a corto y largo plazo. Para Alonso, ser autocrítico es importante y recomienda que se elimine la subjetividad en la medida de lo posible. Menciona que los errores y los malosentendidos entre las diferentes especialidades ocurren si no existe comunicación y confianza entre los distintos especialistas: es necesario que nos centremos en el factor humano, más que la reputación o el ego, para construir las relaciones personales, dejando atrás el narcisismo existente en la medicina.

Finalmente, se resumen algunos escenarios en los que la interdisciplinariedad puede mejorar el manejo de los pacientes, siendo especialmente importante en pacientes complejos como pacientes pediátricos y oncológicos. El Dr. Alonso termina el episodio animando a los oyentes a fomentar la comunicación con el resto de las especialidades, promover la autocrítica y evaluar los resultados obtenidos, así como impulsar el trabajo interdisciplinar en las diferentes unidades de radiología intervencionista.

In this episode, guest host and interventional radiologist Dr. Dana Dunleavy interviews neurointerventional radiologist Dr. Wayne Olan about growing neuroIR and IR through a neurosurgery department. Wayne serves as the Director of Interventional and Endovascular Neurosurgery at George Washington University Medical Center.

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MicroVention FRED X

https://www.fred-x.com/

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SHOW NOTES

First, Wayne tells us more about his training, journey in academia, and role in building robust neuroIR and IR service lines through his leadership of the neurosurgery department at his institution. Wayne also shares how powerful being involved in interdisciplinary clinics can be in growing the scale, reach, and impact of minimally-invasive image guided interventions. These collaborations include neuroIR/neurosurgery for neuro clinic and IR/ gynecology for fibroid clinic.

Dana and Wayne then discuss how neuroIR and IR has evolved over the years, highlighting watershed moments and key innovations. They discuss sacroiliac joint interventions in detail and how MSK has become one of IR’s newest subspecialties.

Wayne shares his history of playing and coaching lacrosse, and he also tells us about the Q-Collar and his role in serving on the company’s board of medical advisors. The device has been shown to protect the athletes’ brains from concussive and subconcussive impacts by increasing internal jugular vein pressure.

We conclude the episode with some parting wisdom from Wayne regarding career paths, navigating reimbursements and insurance as a neuroIR or IR, and finding joy and purpose at and outside of work.

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RESOURCES

SI-Bone, iFuse TORQ Device:

https://si-bone.com/providers/solutions/trauma/ifuse-torq

SI-Bone, iFuse Triangle Device:

https://si-bone.com/providers/solutions/ifuse

Stryker, Spine Jack Device:

https://www.stryker.com/us/en/interventional-spine/products/spinejack-system.html

Q-Collar Company web-page:

https://q30.com/

Q-Collar Studies / Research Briefing:

https://q30.com/pages/fda-reviewed

Boston University CTE Clinic:

https://www.bu.edu/cte/

In this episode, host Aaron Fritts is joined by Lake Odom and Chas Sanders. Lake is an IR technologist with over a decade of experience, and Chas is the founder and CEO of MARGIN, a company that handles supply chain and outpatient OBLs and ASCs. They focus on the vital role that techs play in maintaining the culture, workflow, and efficiency in an office-based lab (OBL).

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Siemens Healthineers

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

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SHOW NOTES

The episode starts with a discussion on what a team lead should be looking for when hiring a IR or cath lab tech. Lake notes that experience and teamwork skills are essential. However, the willingness to learn can also make up for the lack of experience, especially because experience in one office does not always translate to another practice, since every practice has different needs and procedures.

Positive work culture and fair compensation are crucial to employee retention. While the physician plays a large role in defining the culture in a practice, it is also important that IR techs are trusted with the responsibility of maintaining the culture, as their roles are very patient-facing and key in practice efficiency. In the discussion of paying techs on a salary versus an hourly system, Lake notes how a salaried tech is more likely to feel like a part of the team and is more invested in the success of the practice.

As the discussion shifts to increasing the efficiency and profitability of a practice, Chas discusses how cost awareness is key. It is vital that the physician engages the techs in this conversation, since they are the ones who order tools. The guests wrap up the episode by emphasizing how putting trust in the techs is crucial to the efficiency and profitability of each practice, as they will be the biggest advocates of the practice to the patients.

In this episode, host Dr. Aaron Fritts interviews interventional radiologist Dr. Eric DePopas about digital marketing strategies for physicians. Eric is the Co-Founder and Chief Medical Officer of Helped, a company designed to connect patients to IR physicians.

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Siemens Healthineers

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

Medtronic Ellipsys Vascular Access System

https://www.medtronic.com/ellipsys

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SHOW NOTES

To begin the episode, Eric shares his motivations behind starting Helped and the unique story of sharing this undertaking with his brother and co-founder Kevin DePopas. He discusses his uphill battle of marketing IR services and building a strong patient base.

Eric also covers differences between digital versus in-person marketing. He emphasizes that the digital world is not a substitute for boots on the ground, and he underscores the importance of building word of mouth through strong clinical work and regularly interacting with referring physicians. Eric also shares valuable digital marketing takeaways and questions to ask marketing agencies.

Then, Eric breaks down paid-search (Google), paid-social (Facebook, Instagram, TikTok), and radio marketing strategies. Aaron and Eric discuss how to approach the bottom of the marketing funnel (where potential patients become treated patients), and how to engage and guide patients with interactive online quizzes.

Finally, the doctors examine the value of customer relation management systems (CRMS). Eric explains how CRMS is a high fidelity approach to assessing patient knowledge and how it is a key component in building a truly robust funnel. The episode concludes with Eric giving parting advice and encouragement for physicians in the marketing world.

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RESOURCES

Helped Website:

https://www.tryhelped.com/patient-home

In this episode, interventional nephrologist Dr. Neghae Mawla discusses endovascular AV fistula creation with our host Dr. Christopher Beck.

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BD Advance Clinical Training & Education Program

https://page.bd.com/Advance-Training-Program_Homepage.html

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SHOW NOTES

We start off the episode by discussing Neghae’s current practice at Dallas Nephrology Associates, where most of his patient referrals come from his partners. Patients who come to see Neghae receive a standard vein mapping via ultrasound to determine whether they should receive an endovascular or a surgical procedure. If patients’ veins fit certain specifications, such as superficial location (cephalic, median cubital), large enough size (2-2.5 mm) and presence of large perforating veins (2 mm), then they are better candidates for an endovascular approach.

However, these rules do not perfectly predict fistula success. Neghae noticed that even if patients fit the above criteria, their fistulas don’t always mature correctly. With experience, he began to take into consideration the brachial vein size as well. While this is not part of the official vein mapping criteria, he has seen that if the brachial vein is significantly larger than the superficial veins, it could have a competitive outflow and hinder the maturation of the fistula.

The conversation then shifts to the types of devices used to create the anastomosis for the fistulas, WavelinQ and Ellipsys. Neghae notes that while most patients do well with either device, some patients do better with one over the other. Thus, he suggests that physicians are trained on both devices if possible, to guarantee the best outcomes. To end the episode, Neghae reflects on his previous decade of experience with endovascular AV fistulas and shares wisdom about failures and successes that he has learned from.

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RESOURCES

ASDIN White Paper: Management of cephalic arch stenosis endorsed by the American Society of Diagnostic and Interventional Nephrology:

https://cdn.ymaws.com/www.asdin.org/resource/resmgr/positionpaper/Cephalic_Arch.pdf

ASDIN White Paper: Patient selection, education, and cannulation of percutaneous arteriovenous fistulae:

https://cdn.ymaws.com/www.asdin.org/resource/resmgr/positionpaper/ASDIN_EndoAVF.pdf

ASDIN Certification ink:

https://www.asdin.org/page/pAVFCert

In this episode, co-hosts Dr. Aaron Fritts, Dr. Michael Barraza, and Dr. Eric J. Keller discuss social media ethics in medicine.

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RADPAD® Radiation Protection

https://www.radpad.com/

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SHOW NOTES

To kick-off the episode, the three IR physicians discuss “clot porn” and all the debate associated with posting case-related findings (clots, imaging, etc) on social media with device/company name visible. Dr. Keller, who has a strong background in medical ethics, shares his thoughts on the matter and underscores the 6 pitfalls of medical social media: patient privacy, patient dignity, information accuracy, conflict of interest, justice inequity, and interprofessional respect.

From Dr. Keller, we learn that the crux of the matter tends to circle back to two central issues– how the case is shared and intentions behind sharing. Additionally, Dr. Keller shares unique data on the relation between how often a medical device company is mentioned in social media posts, how often physicians are compensated for their public endorsements, and whether or not conflict of interests are disclosed.

Dr. Barraza and Dr. Keller then compare TikTok, Instagram, and Twitter’s roles and potentials in medicine. The trio discuss Twitter’s past, present, and future influences on medical research, networking, innovation, and education. They also consider the need for more clear, comprehensive social media posting guidelines issued by specialty societies and ideas for patient consent forms over social media posting.

To wrap up the episode, the doctors discuss interprofessionalism, dealing with social media trolls/negativity, and personal vs. professional accounts. Dr. Keller notes that 85% of the general public turns to social media networks to seek healthcare information, which highlights the online presence of physicians and how they are often held to a higher ethical standard on social media platforms.

For listeners wanting to learn more about social media ethics in medicine, the annual Western Angiographic Interventional Society (WAIS) in Palm Springs, California (October 7-11, 2023) will have dedicated medical social media ethics panels and discussions built into programming. Be sure to register and attend! Link to the WAIS webpage below.

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RESOURCES

Western Angio Interventional Symposium 2023 Schedule:

https://www.westernangio.org/

Western Angio Interventional Symposium 2023 Registration:

https://www.westernangio.org/event-5048807

Link to Thomas Webb study:

https://www.jvir.org/article/S1051-0443(22)01727-4/fulltext

CMS Sunshine Database:

https://openpaymentsdata.cms.gov/

In this episode, host Dr. Sabeen Dhand interviews Dr. John Rundback about analysis of arterial calcifications using microCT.

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AngioDynamics Auryon System

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

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SHOW NOTES

Dr. Rundback starts by describing the basic differences between microCT and current imaging techniques. MicroCT is a non-destructive imaging method where the x-ray source is stationary but the subject is on a rotating stage. This method can create 3D imaging with a 3 to 5 micron resolution. On the other hand, in traditional CT imaging, the subject is stationary and the x-ray source rotates, which gives a 3 to 5 millimeter resolution.

Then, the episode shifts to a discussion on Dr. Rundback’s recent study, in which he used microCT to evaluate the treatment effect of medial arterial calcification in below knee interventions after Auryon laser atherectomy. For this study, arteries were dissected out of cadavers with cardiac risk factors. These artery segments were then subject to different energies from the Auryon laser. MicroCT was performed before and after the procedure to analyze the degree of calcification. These trials have shown that atherectomy using the Auryon laser could increase compliance of the treated arteries. MicroCT has also helped expand knowledge about different types of calcification and how atherectomy differentially impacts them.

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RESOURCES

Treatment effect of medial arterial calcification in below-knee after Auryon laser atherectomy using micro-CT and histologic evaluation:

https://pubmed.ncbi.nlm.nih.gov/37400346/

Auryon Atherectomy Device:

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

In this episode, host Dr. Aaron Fritts interviews Dr. Junjian Huang & Dr. Sean Maratto on navigating early-career changes. Both Dr. Huang and Dr. Maratto touch on a range of their early-career experiences and offer their advice, insights, and realizations.

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RADPAD® Radiation Protection

https://www.radpad.com/

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EARN CME

Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/9clNvR

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SHOW NOTES

The trio begin by discussing the responsibilities of stepping up as new attendings and dive into all that goes into maintaining and building new service-lines. Both Dr. Huang and Dr. Maratto underscore the importance of being as available as possible, taking every brick and mortar case with enthusiasm and drive, and truly getting to know your referring physicians. These actions go a long way in successfully establishing and expanding IR service-lines.

Dr. Huang and Dr. Maratto also speak on the nuances of cultural awareness and sensitivity, as every region, hospital, and/or practice does not operate in the same fashion. Both early-career physicians convey the gravity of quickly adapting to the cultural norms of a new workplace and becoming comfortable in new environments. Dr. Maratto adds how conflict resolution is a mainstay throughout all career stages and highlights leadership and clear communication as vital qualities.

We then hear about the ins-and-outs of early-career mentorship from both physicians. Dr. Huang states how some of the most pivotal mentors can be from different fields, to always search for mentors, and to even make mentors through industry. Dr. Maratto shares how it is important to have mentors for both professional and emotional support and to always pay it forward to the next-generation of physicians and trainees.

Dr. Fritts, Dr. Huang, and Dr. Maratto share a real-time mentorship moment and have a conversation on how becoming an attending can be accompanied by extremely important life milestones such as getting married, starting a family, buying a house, and more.

We conclude the episode by discussing some challenges new attendings can face, such as navigating the business-side of medicine and becoming confident in marketing, insurance, and billing. Both early-career physicians agree how these tasks should not be delegated, as they are very worth knowing. Dr. Juang and Dr. Maratto leave us with important parting advice on what they wish they were told when they finished training and became attending physicians.

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RESOURCES

Early Career Section (ECS) of SIR:

https://www.sirweb.org/member-central/volunteer/early-career-section2/

In this episode, host Dr. Ally Baheti interviews interventional radiologist Dr. Saher Sabri and vascular surgeon Dr. Frank Arko about their perspectives on a July 2023 New York Times article about the ethics of peripheral arterial disease (PAD) treatment in outpatient based labs (OBLs) and ambulatory surgery centers (ASCs).

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SHOW NOTES

Dr. Arko emphasizes the importance of approaching articles as an unbiased reader. He acknowledges that sensationalism in the news is common, and while bad actors do exist, he personally knows talented OBL/ASC practitioners. He also notes that the article fails to mention that the majority of these practitioners follow society guidelines to provide appropriate and effective treatment for their patients, rather than prioritizing financial gain. He believes that most non-surgical specialists have the clinical insight to know when patients would be better candidates for open bypasses as opposed to endovascular interventions. Dr. Arko describes the split response to the article within vascular surgeons on social media, based on their personal philosophies of open versus endovascular interventions for PAD.

Dr. Sabri believes that PAD and critical limb-threatening ischemia (CLTI) are not very well known by the general public, this article was a missed opportunity to bring attention to these conditions and disparities in treatments depending on patients’ geographic locations and ethnicities. The article may have the effect of scaring patients away from seeking treatment for PAD and CLTI, as well as receiving care at OBLs, which were originally founded to make interventions more efficient and patient-friendly. Additionally, the article could foster divisiveness between vascular surgeons, interventional radiologists, and interventional cardiologists and as a result, increase barriers to collaboration.

It is important to differentiate between PAD and CLTI and the stage at which patients present to medical care. Limb salvage rates and decisions to intervene and/or amputate are multifactorial and are not as straightforward as the article may imply. Both doctors agree that specialty societies share the responsibility of monitoring their members for overuse of interventions.

In terms of rebates and volume discounts from device companies, the doctors discuss the ethics of cost savings that benefit a hospital system versus savings that benefit a physician-owned OBL. Dr. Arko recognizes that financing an OBL with device company partnerships can be a smart business decision if devices are used appropriately and only when indicated. He speaks about the need for societies to support more randomized control trials that compare the effectiveness of each atherectomy device. We also discuss implications for insurance coverage of PAD/CLTI interventions. Dr. Sabri believes that it is unfortunate when insurance companies become the decision-maker of patient treatments.

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RESOURCES

“They Lost Their Legs. Doctors and Health Giants Profited” (NY Times, July 2023 article):

https://www.nytimes.com/2023/07/15/health/atherectomy-peripheral-artery-disease.html

BEST-CLI:

https://www.bestcli.com/

“Blocked Artery in Your Leg? Here’s What You Should Know” (ProPublica, June 2023 article)

https://www.propublica.org/article/what-to-know-about-peripheral-artery-disease

Outpatient Endovascular Interventional Society (OEIS):

https://oeisweb.com/

Society of Vascular Surgery (SVS) Position Statement:

https://vascular.org/news-advocacy/articles-press-releases/svs-response-new-york-times-article-overuse-interventions