BackTable Vascular & Interventional

In this episode of BackTable, host Dr. Michael Barraza is joined by Dr. Nainesh Parikh from Moffitt Cancer Center. Dr. Parikh has worked extensively on prostate artery embolizations (PAE), having performed around 250 PAEs since joining Moffitt in 2017. The conversation delves into the multifaceted applications of PAE, with a specific focus on its role in prostate cancer.

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SHOW NOTES

Dr. Parikh outlines the various clinical scenarios where PAE proves beneficial in prostate cancer cases. This includes the potential to shrink the prostate to an optimal size for brachytherapy, decrease volume for operational convenience, and address lower urinary tract symptoms associated with enlarged prostates. Clinical improvement emerges as a major motivator, with Dr. Parikh underscored the importance of ensuring a certain volume reduction before focal therapy, thereby simplifying subsequent treatments.

The conversation extends to the role of PAE in managing radiation prostatitis, categorized clinically as chronic prostatitis. While conventional treatments often fall short for this condition, PAE emerges as an effective solution, especially for the 50% of men typically refractory to standard approaches. Dr. Parikh informs patients of the 70-75 percent chance of improvement while acknowledging the challenges in chronic prostatitis patients.

The episode explores Dr. Parikh's approach to working up patients for PAE, with most referrals originating from the GU tumor board. Dr. Parikh discusses the gland size threshold for PAE assessment, emphasizing that while larger glands generally ease embolization, he occasionally considers PAE for smaller glands based on clinical context. Challenges associated with chronic prostatitis patients are acknowledged, with a focus on managing expectations due to a lower response rate compared to other PAE patients.

Detailed insights into imaging protocols for follow-up are provided. For prostate cancer cases, Dr. Parikh recommends MRI at 6 and 12 weeks post procedure. He notes that there is notable reduction in PSA levels following PAE. Conversely, radiation prostatitis patients do not undergo post-procedural imaging unless PSA levels are detectable.

As the episode concludes, Dr. Parikh highlights the future utility of PAE in prostate cancer, particularly in neoadjuvant settings before local or radiation therapy and even post radiation therapy.

In this episode, host Dr. Chris Beck interviews Dr. Robert Lookstein about the pulmonary embolism response team (PERT) approach for treating acute pulmonary embolisms (PE). Dr. Lookstein is a practicing interventional radiologist in New York City at Mount Sinai Icahn School of Medicine.

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SHOW NOTES

We begin the episode by learning how Dr. Lookstein became involved in the PE space and how acute PE management has evolved. Dr. Lookstein breaks down the PERT at Mount Sinai, PERTs at other academic institutions, and the core qualities of a strong PERT. He walks us through a typical PE presentation, the process of PERT activation, and the workup with risk stratification. Dr. Lookstein also shares a few physical examination pearls for evaluating patients with PE and teasing out acuity vs. chronicity of presentation .

Dr. Lookstein and Dr. Beck discuss endovascular PE interventions - ultrasound accelerated thrombolysis (trade name: EKOS catheter, Boston Scientific), first generation and second generation thrombectomy systems. The doctors also cover how advancements in technology have made these large-bore thrombectomy devices easier to learn about and use. Looking towards the horizon, Dr. Lookstein shares what we can expect from third generation technologies.

We highlight how the primary endpoint of the PERT is to relieve the strain and stabilize/preserve the function of the right ventricle, regardless of how much clot is removed/remains. The doctors discuss the possibility of combined treatment algorithms for PE and the clinical data that has guided PERTs (all linked in resources below). To conclude the episode, Dr. Lookstein shares follow-up, longitudinal care, and how to tackle clot-in-transit.

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RESOURCES

PERT Consortium:

https://pertconsortium.org/

Ultima Trial:

https://www.bostonscientific.com/en-EU/medical-specialties/vascular-surgery/venous-thromboembolism-portal/pulmonary-embolism/clinical-data/ultima.html

HI-PEITHO Trial:

https://www.bostonscientific.com/en-EU/medical-specialties/vascular-surgery/venous-thromboembolism-portal/pulmonary-embolism/clinical-data/hi-peitho.html

CANARY Trial:

https://www.acc.org/Latest-in-Cardiology/Clinical-Trials/2022/10/25/19/42/CANARY

PE-TRACT Trial:

https://evtoday.com/articles/2023-feb/pe-tract-a-closer-look

STORM-PE Trial:

https://pertconsortium.org/storm-pe-trial/

PEERLESS II Trial:

https://ir.inarimedical.com/news-releases/news-release-details/inari-medical-announces-peerless-ii-randomized-controlled-trial

In this episode, host Dr. Aaron Fritts interviews vascular surgeon Dr. Syed Hussain and interventional radiologist Dr. Omar Saleh about new innovations in closure devices.

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https://www.vasorum.ie/

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SHOW NOTES

We begin the episode by discussing how closure devices have evolved over recent years and gained popularity in both hospital and OBL settings. Dr. Hussain and Dr. Saleh highlight the logistical advantages associated with a consistent, reliable closure device. Both doctors speak about their patients’ reported experiences and preferences for different types of closure devices and the importance of having a variety of options at hand.

Dr. Saleh and Dr. Hussain also introduce the new CELT ACD closure device from Vasorum. We learn how to place a CELT, and Dr. Saleh highlights the ease of deployment and the reliability of results. Dr. Hussain also shares his experience in using the CELT, comparing its deployment to a “mic drop”. Additionally, we discuss if there are any potential drawbacks or special considerations that may exist in using CELT compared to other devices.

The doctors cover the time from CELT closure to ambulation/discharge, citing an abstract published in Journal of Vascular Surgery (see resources below). Dr. Hussain and Dr. Saleh also report very few closure-site complications when using CELT, good outcomes with calcified arteries, and ease of bailout options. To conclude the episode, we discuss how physicians can get CELT and other products into their hospital or OBL through the Agency for Healthcare Research and Quality (AHRQ), Consumer Assessment of Healthcare Providers and Systems (CAHPS) scores, and other methods.

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RESOURCES

Safety and Efficacy of the CELT ACD Femoral Arteriotomy Closure Device in the Office-based Laboratory:

https://www.jvascsurg.org/article/S0741-5214(22)00945-4/fulltext

Silent cerebral infarct after cardiac catheterization as detected by diffusion weighted Magnetic Resonance Imaging: a randomized comparison of radial and femoral arterial approaches:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1896179/

Vasorum CELT ACD Closure Device:

https://www.vasorum.ie/

In this episode of the "History of IR" series on BackTable, Dr. Alan Matsumoto, Chair of the Department of Radiology at the University of Virginia and a fellow of the Society of Interventional Radiology, joins our host Aparna Baheti. Dr. Matsumoto also serves as the Vice Chair of the American College of Radiology's Board of Chancellors. This installment provides a unique perspective on the life and career of Dr. Matsumoto and sheds light on the evolution of interventional radiology.

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SHOW NOTES

Dr. Matsumoto's journey into IR commenced during his residency in the Department of Radiology at the University of North Carolina. The culture of independence within the department allowed him to gain extensive hands-on experience. Subsequently, after completing a four-year radiology residency followed by a one-year fellowship, Dr. Matsumoto ventured into private practice on the picturesque West Coast of Florida. However, his return to academic medicine was inspired by a profound appreciation for collaborative patient care discussions with referring physicians, marking a departure from the previous norm of merely appeasing them to maintain referral patterns. This transition led him to the University of Virginia, where he partnered with Dr. Tegtmeyer. Dr. Tegtmeyer's meticulous approach in running the IR suite, akin to a surgical suite, cultivated an appreciation for organizational precision and independence.

During this conversation, Dr. Matsumoto fondly reminisces about Dr. Tegtmeyer, who emphasized the art of presenting oneself as an IR doctor to patients. He recognizes Dr. Tegtmeyer's passion for renal angioplasty, acknowledging him and Dr. Thoman Sos as pioneers in the field.

Dr. Matsumoto also provides valuable insights into the technological landscape of IR in the past, underscoring the absence of contemporary tools like C-arms and pre-shaped catheters. Consequently, IR practitioners had to adapt and innovate, often crafting and modifying instruments, including innovative solutions like using styrofoam for embolizations or shaping catheters with bunsen burners.

Furthermore, Dr. Matsumoto delves into the challenges faced by early practitioners, highlighting the need for caution to avoid detractors exploiting mistakes to diminish the value of IR procedures and potentially restrict the scope of IR practice. Balancing the role of a friendly collaborator with technicians and nurses while assuming leadership in the IR suite is a pivotal aspect of his journey.

Dr. Matsumoto then elaborates on his pivotal involvement in aortic work in 1998, as he helped establish a core lab and collaborated with device companies along with CT and vascular surgeons. This work allowed him to be a part of the approval process of Medtronic’s AneuRx endograft in 1999, where he testified at the FDA hearing for this groundbreaking product designed to treat AAA’s.

The transition to leadership within the department of IR at the University of Virginia marked another significant chapter in Dr. Matsumoto's career. Despite assuming this role unexpectedly after the passing of Dr. Tegtmire, he embraced the challenge. His vision for the department revolves around a heightened focus on clinical operations and streamlining patient responsibilities to enhance efficiency while upholding a culture of excellence.

Dr. Matsumoto concludes this episode with valuable insights into strengthening an IR department by effectively promoting and communicating the value of services to the broader medical community.

In this episode, host Dr. Chris Beck interviews interventional radiologist Dr. Kush Desai (Northwestern University Feinberg School of Medicine) and vascular surgeon Dr. Steve Abramowitz (MedStar Washington Health Center) about iliofemoral venous stenting.

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https://www.cookmedical.com/divisions/vascular-division/

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SHOW NOTES

We start this episode by reviewing the evolution of knowledge and treatment of venous disease over recent years. Dr. Desai and Dr. Abramowitz identify referral patterns that connect patients with vascular and interventional physicians, and they emphasize how most patients are diagnosed in primary care pathways rather than in the emergency room. The doctors also underscore the importance of educating referring physicians and patients on the impact of early intervention and how vascular and interventional physicians are well-equipped to provide specialized care and management of venous disease.

Dr. Desai and Dr. Abramowitz explain their work-up of patients with deep venous disease. The doctors cover necessary imaging studies and conservative treatments for clinic visits. They also explain their procedural approach, access sites, patient positioning preferences, and more.

The doctors share guiding anatomical landmarks and recommendations on tools for crossing, along with their decision-making process in treating post-thrombotic patients. They also discuss best practices in venous stenting and post-operative follow up algorithms. We conclude this episode with important advice on how to avoid dangerous life-threatening outcomes.

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RESOURCES

Society of Interventional Radiology Position Statement on the Endovascular Management of Acute Iliofemoral Deep Vein Thrombosis (2023):

https://www.sciencedirect.com/science/article/pii/S1051044322013173

A review of the incidence, outcome, and management of venous stent migration:

https://www.sciencedirect.com/science/article/abs/pii/S2213333X2100411X

In this episode, interventional radiologists Dr. Aaron Fritts, Dr. Vishal Kumar, and Dr. Chris Beck discuss types of sedation for IR procedures.

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SHOW NOTES

We start the discussion off by dividing the spectrum of patient sedation into three tiers: local anesthesia, moderate sedation with fentanyl and Versed, and deep sedation which encompasses anything beyond fentanyl and Versed. The conversation revolves around the fluidity of this spectrum, underscoring the ease with which patients can transition between these sedation levels, thereby adding layers of complexity to the decision-making process. Chris emphasizes the significance of embracing trauma-informed care, highlighting the potential for IR procedures to be maximally traumatic despite their minimally invasive nature. The doctors emphasize the importance of establishing comprehensive pre-procedural patient education to align expectations about pain management.

Procedures that automatically trigger the requirement for an anesthesia team include procedures such as TIPS, tumor ablations, as well as declot procedures more recently. Decisions regarding anesthesia for these procedures are additionally influenced by factors such as the patient's condition, history of methadone exposure, the preference of the IR providers, and the comfort level of nursing staff.

Vishal highlights the game-changing concept of having an anesthesia team present for real-time monitoring and the administration of nerve blocks during IR procedures. This collaboration is especially helpful for complex interventions. Vishal advocates for prioritizing patient safety over logistical considerations. He firmly contends IRs should be empowered to decide the level of anesthesia care since they have the most experience with the specific procedures and are best suited to recognize anesthesia needs.

The conversation delves into the American Society of Anesthesiologists (ASA) scoring system, which categorizes patients based on their health status from ASA 1 (healthy) to ASA 6 (brain death). While IR procedures usually involve ASA 3 or ASA 4 patients, today’s discussion uncovers the tendency among clinicians to underestimate a patient's ASA classification while overestimating their pain tolerance. The discussion raises critical questions about whether the IR community has grown complacent with moderate sedation in procedures and whether alternative approaches are warranted.

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RESOURCES

American Society of Anesthesiologists Classification (ASA) Classification:

https://www.ncbi.nlm.nih.gov/books/NBK441940/

In this episode, host Dr. Ally Baheti interviews vascular surgeon Dr. Steven Abramowitz and interventional radiologist Dr. Angelo Marino on managing venous stent rethrombosis with the RevCore device. Steven is the Chair of Vascular Surgery at MedStar Washington Hospital and Angelo is an Assistant Professor of Interventional Radiology at Yale School of Medicine.

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SHOW NOTES

We start this episode with Steven and Angelo’s experience in venous interventions and how venous stent rethrombosis presents. The doctors then tell us more about how stent failure can precipitate, inflow and landing zone considerations, and stenting location. Angelo then goes onto introduce the RevCore device.

Both Steven and Angelo share their experience in using the RevCore device in venous stent rethrombosis, and their preferred access site(s) when using this tool. They also discuss specific maneuvers, troubleshooting, and other tools they use alongside the RevCore system. We conclude this episode with the doctor’s overall treatment algorithm for venous stent rethrombosis and follow-up plans.

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RESOURCES

Inari Medical RevCore Device:

https://www.inarimedical.com/revcore/

In this episode, host Dr. Chris Beck continues the discussion on managing hepatocellular carcinoma (HCC) with Dr. Tyler Sandow and Dr. Juan Gimenez, interventional radiologists at Ochsner Health in New Orleans, Louisiana.

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Boston Scientific TheraSphere

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SHOW NOTES

We continue the conversation where we left off in Part 1. Tyler and Juan share their thoughts on lobar treatment vs. radiation segmentectomy, selection strategies, and their preferred combination of ablation and Y-90. Tyler also reviews the core tenets of Y-90 treatment and references a handful of major landmark trials and studies.

Juan highlights more studies that guide their approach to preoperative mapping and intraoperative delivery of Y-90. Juan emphasizes cone-beam CT and how this technique has significantly evolved over the years. We cover dosimetry software, navigation software, and the calculation of treated tumor volumes. Additionally, Tyler and Juan discuss their change in treatment approach for especially complex cases, which can involve factors such as extrahepatic feeders and difficult treatment locations. We also discuss the redistribution of flow and how underlying liver disease may affect treatment plans.

We wrap up Part 2 of our discussion by highlighting the doctors’ current research pursuits. Tyler tells us about exciting new developments in the tumor marker arena, the emerging role of albumin in HCC, and the rising popularity of radiation segmentectomy in metastatic disease. Juan shares a few closing thoughts on the extrahepatic applications of Y-90 and the advantages of using AI in interventional radiology.

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RESOURCES

LEGACY Trial:

https://www.bostonscientific.com/en-US/medical-specialties/interventional-radiology/interventional-oncology/therasphere/clinical-data/legacy-study.html

RASER Trial:

https://pubmed.ncbi.nlm.nih.gov/35617978/

DOSISPHERE Trial:

https://www.bostonscientific.com/en-US/medical-specialties/interventional-radiology/interventional-oncology/therasphere/clinical-data/dosisphere-01.html

TARGET Study:

https://www.bostonscientific.com/en-US/medical-specialties/interventional-radiology/interventional-oncology/therasphere/clinical-data/target-study.html

Radiation Lobectomy: Preliminary Findings of Hepatic Volumetric Response to Lobar Yttrium-90 Radioembolization:

https://link.springer.com/article/10.1245/s10434-009-0454-0

Radiation lobectomy: Time-dependent analysis of future liver remnant volume in unresectable liver cancer as a bridge to resection:

https://www.sciencedirect.com/science/article/abs/pii/S0168827813004315

ACR–ABS–ACNM–ASTRO–SIR–SNMMI PRACTICE PARAMETER FOR SELECTIVE INTERNAL RADIATION THERAPY (SIRT) OR RADIOEMBOLIZATION FOR TREATMENT OF LIVER MALIGNANCIES:

https://www.acr.org/-/media/ACR/Files/Practice-Parameters/rmbd.pdf

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

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

“Simplicit90y” Boston Scientific Dosimetry Software:

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

In this episode, Dr. Constantinos (Costi) Sofocleous, Dr. Bruno Odisio, and Dr. William Rilling discuss the history of percutaneous liver tumor ablation, takeaways from past and present clinical studies, and the contemporary role of ablation margin confirmation software for optimizing treatment outcomes.

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SHOW NOTES

Costi initiates the discussion by highlighting crucial developments in tumor ablation over the last 15 years. He notes that it took time to realize that tumors larger than 3 cm carried higher rates of local failure, primarily due to insufficient margins. Research eventually found that establishing larger margins, preferably 10 mm margins, resulted in significantly lower recurrence rates. In fact, with these margins, ablation outcomes became even more favorable than surgical outcomes. This shift towards personalizing the approach to each tumor has been instrumental in improving patient outcomes.

The conversation then transitions to innovation within the realm of ablation. There are fewer prospective studies over ablation as a sole treatment, since ablation is often performed in conjunction with surgery. Additionally, the presence of numerous vendors for ablation technology makes it challenging to conduct comprehensive studies.

The doctors also discuss the importance of ablation margins and recurrence. 3D confirmation is correlated with greater control over the procedure. Local recurrence tends to occur in areas where the margin is suboptimal, but the exact standards for what constitutes "suboptimal" margins are yet to be established. Nevertheless, the consensus among experts is that a contrast CT on the day of the ablation and a subsequent 3D evaluation of the images are crucial. This evaluation should be repeated three weeks later to verify the success of the procedure. Costi mentions that at Memorial Sloan Kettering, ablation zone biopsy is an option if necessary, which adds another layer of verification.

The discussion also touches on the importance of using a guidance system for ablation. Bruno underlines the significance of always using CT to verify the procedure. He points out that colleagues in Europe have been using stereotactic guidance for many years, revealing that 40% of the time, the ablation application wasn't placed exactly where they thought it would be based on pre-scans. This is where stereotactic technology becomes invaluable. Costi suggests real-time PET as a beneficial tool, but the challenge lies in justifying these additional steps to payers. Minimum imaging requirements and margin confirmation software are essential components of a guidance system..

The episode culminates in a discussion of a significant trial that involves three different industry sponsors - a landmark effort in the field of oncology. The ACCLAIM trial, which began in 2016, sought to conduct a multicenter study but took four years to secure approval and funding. Costi highlights the reasons for its success, emphasizing the potential for reproducible outcomes that could establish ablation as a strong indication in colorectal cancer. The data suggests that margin confirmation software significantly improves margins, and he hopes that this information will lead to increased reimbursement for the use of these crucial software tools.

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RESOURCES

ACCLAIM Trial:

https://www.sio-central.org/Research-Resources/Research-Grants/ACCLAIM-Trial