In this episode, Dr. Aaron Fritts interviews interventional radiologist Dr. Abdulaziz Alharbi of the Ministry of National Guard Health Affairs in Saudi Arabia. They discuss Dr. Alharbi’s approach to planning and performing sharp recanalization of the superior vena cava (SVC) for dialysis, transplant, and cancer patients.

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Dr. Alharbi starts by describing how patients get referred to him, mainly due to end stage renal disease, chronic obstruction, and the need for dialysis access. Additionally, some patients seek access for central lines, and others have acute obstructions due to malignancies. Depending on the patient’s clinical condition, comorbidities, upcoming medical procedures, and anatomy, he will then decide if the patient is an appropriate candidate for SVC recanalization and obtain a CT scan. This imaging guides further decision-making on whether to access the obstruction from the internal jugular or brachiocephalic vein. The CT also helps him think about potential complications, such as cardiac tamponade in an obstruction close to the heart and pulmonary edema in all recanalizations. These risks are communicated to each patient accordingly.

Prior to starting the procedure, Dr. Alharbi ensures that there are multiple access sites prepared, including neck, bilateral arms, and femoral access. He also ensures that there are tools that he is comfortable using and a support team in place. A colleague will usually help him by obtaining femoral access and placing a target snare distal to the obstruction.

Dr. Alharbi walks us through a typical case. First he slowly advances a Chiba needle towards the target. His choice in sheath length depends on the length of the occlusion and the access point. A longer occlusion accessed through the brachiocephalic vein requires a longer sheath than a short occlusion accessed through the internal jugular vein. Next, we discuss stent sizing. Dr. Alharbi notes that it is preferable to oversize, to prevent stagnation of flow. In short occlusions, he uses bare self-expandable stents. In longer occlusions or cancer patients, he uses covered stents since there is more precise deployment.

The post-procedure anticoagulation regimen usually includes heparin and an antiplatelet agent for 2-3 weeks. Then, patients are switched to apixaban for 6 months. Beyond this, patients are either taken off of anticoagulation if they are asymptomatic and there is good SVC inflow, or reverted back to their preexisting anticoagulation regimen that they had due to other comorbidities.

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RESOURCES

PAIRS 2023:

https://pairscongress.com/

Dr. Abdulaziz Alharbi Twitter:

https://twitter.com/DrAlHarbiA_Aziz

In this episode, host Dr. Michael Barraza interviews Dr. Rehan Quadri, interventional radiologist, about the definition, indications and techniques for treating clot in transit. 

We begin by defining and describing when to treat clot in transit. Traditionally, the definition is the washing machine mobile clot in the right atrium (RA) or right ventricle (RV). In these situations, the next place for the clot to travel is the pulmonary artery (PA). Mortality in these cases can reach as high as 30%, which is why these cases are considered emergencies. There is another category of clot in transit where a clot is partially adhered to a vessel wall, catheter, or heart valve. They are most commonly diagnosed via an echocardiogram, or found incidentally on a CT angiogram. They commonly present as catheter malfunction with symptoms resembling SVC syndrome.

Dr. Quadri explains his usual method for retrieving clot in transit, though he notes each case is complex and different depending on the etiology and the overall status of the patient. In general, unless there is a massive PE, he treats the clot in transit before the PE. He always ensures with the preoperative echocardiogram that there is no interatrial shunt or patent foramen ovale (PFO). At the beginning of the case he checks PA and RA pressures. 

He uses a 24 French Inari Flowtriever with FLEX technology, which helps with tough angles. He uses ICE guidance in all clot in transit cases. To help with orientation when using the ICE catheter, he recommends pointing it anteriorly while entering the RA, then using the Eustachian ridge, an echogenic line in the RA, to confirm you are in the RA and indicating that you should see the tricuspid valve as you advance. He uses the FlowSaver device, and always has 2 units of blood in the room just in case. At the end of the case, he remeasures the PA pressures, then injects through the Inari sheath to verify that there is no residual before finally doing a pulmonary arteriogram. He sends all the clots to pathology, and has seen that the morphology is usually mixed, with some organized fibrin in addition to acute thrombus.

In this episode, our host Dr. Ally Baheti interviews interventional radiologist Dr. Nikki Keefe about safety considerations for pregnant and breastfeeding IR patients.

Dr. Keefe’s personal experience with pregnancy during her IR training sparked her interest in this topic. A lot of IR patients are pregnant or breastfeeding, so it is important to be cognizant of radiation and medication exposures and how they should be altered. She emphasizes the importance of establishing a protocol when these patients present.

We review radiation doses of various IR procedures and risk stratification based on gestational age. At each stage of pregnancy, there are different risks of disruptions in organogenesis, effects on neural tube development, and predisposition to cancer. Elective procedures should usually be deferred until after delivery. The most common and necessary procedures performed in pregnant patients are PICC line placement, nephrostomy tube, and treatment of postpartum hemorrhage. Dr. Keefe also shares her tips for minimizing fluoroscopy time and deciding between different diagnostic imaging modalities that present both maternal and fetal radiation risks.

Next, we discuss medication safety. Iodinated contrast is safe to give during pregnancy, while gadolinium is not. Sedation with opioids is generally safe, but their sustained use or administration around the perinatal period can cause neonatal withdrawal symptoms. Benzodiazepines can also be used for amnesia and anxiety reduction, and midazolam has a good safety profile and long half life. However, abnormally extended use of benzodiazepines can cause floppy infant syndrome (sedation, muscle laxity, failure to suckle). Dr. Keefe notes that pregnant patients have to start on higher doses than the standard, since they have higher blood volume and increased renal clearance of these medications. Lovenox is the safest known anticoagulant for pregnant women. Additionally, fetal heart monitoring should be performed before and after the procedure.

Finally, we talk about specific cases of patient positioning when placing nephrostomy tubes, transhepatic access for gallbladder tubes, treatment of visceral artery aneurysms before pregnancy, and selection of  imaging modalities to detect pulmonary embolism.

In this episode, host Dr. Aaron Fritts interviews Dr. Jim Melton, vascular surgeon, and Dr. Blake Parsons, interventional radiologist, about progress in the OBL and ASC space, including reimbursement updates, partnering with a private equity firm, and value based care.

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SHOW NOTES

We begin by discussing new developments in Dr. Melton’s and Dr. Parson’s practice. Over the past year, they have partnered with a private equity firm, Assured Healthcare Partners to create Heart and Vascular Partners (HVP). They now cover Oklahoma City, Colorado Springs, Denver, Pueblo, and parts of Illinois and Indiana. They employ mostly hospital based physicians’ ready to start their own office based lab (OBL) or ambulatory surgery center (ASC). The physicians under HVP are cardiologists, vascular surgeons, and interventional radiologists.

The two discuss the advantages of aligning with a private equity firm. For them, it provided the scale and capability to provide value-based care when it becomes widely adopted. Additionally, the payer has a much lower cost for the service in the outpatient space versus the hospital. All the physicians in HVP maintain local control over their practices, which was one of their main goals when they decided to partner with a firm.

Next, we cover reimbursement cuts and the trends in OBLs and ASCs. On the arterial side of business, they are seeing that OBLs are down 10-15% in reimbursement rates, whereas ASCs are up 3-30%. For iliac interventions in the ASC, they have seen a 30-50% increase in balloon angioplasty and stenting, and up to a 60% increase for Shockwave. On the embolization side, arterial and venous reimbursement has dropped in the OBL by 7-8% and increased in the ASC by 3-30%. Alternatively, the CPT code for embolization for end organ ischemia (UFE, PAE) is still well reimbursed in the OBL. They caution listeners on genicular artery embolization and cryoneurolysis due to the risk of not getting it reimbursed and having to pay money back.

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RESOURCES

Heart and Vascular Partners:

https://heartandvascularpartners.com

In this episode, our host Dr.Michael Barraza interviews Drs. Jawad Hussain and Alan Sag about how they implemented thyroid artery embolization into their respective private and academic practices.

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Dr. Hussain discusses how he started doing thyroid embolizations. It was born out of a need to replace thyroid RFA, since the thyroid RFA generator was not yet approved in his health system. At Duke, Dr. Sag collaborated with endocrinologists and endocrine surgeons to address a need to treat non-surgical candidates with bulk symptoms. These symptoms can include supine dyspnea, dysphagia, and aspiration risk. Together, they developed an institutional protocol for post-procedural management. Dr. Sag emphasizes that everything an IR needs to perform a goiter embolization is probably already available to them.

Next, the doctors describe how they implemented thyroid embolization in their respective practices. Dr. Sag approached his institution’s weekly tumor board of endocrine specialists to introduce the concept. When talking to non-surgical patients, he offers thyroid embolization as a palliation alternative to tracheostomy and percutaneous gastrostomy as airway protection for patients with aspiration risks. Dr. Hussain describes patients with TR-3 and TR-4 nodules who require repeat FNA. Embolization can be a valuable option for them, since it is a quick outpatient procedure with minimal side effects. Additionally, he communicates to patients that IRs have experience with applying transcatheter embolizations in different spaces in the body and sets the expectation that shrinkage will be a gradual process. Both doctors emphasize the importance of informed consent in a relatively new palliative procedure. In terms of the research landscape for thyroid embolization, Dr. Hussain says that publishing a large retrospective multicenter study would revolutionize the procedure, since it could show efficacy and safety. Dr. Sag believes that RFA and embolization are complementary technologies that can be used in different scenarios.

Dr. Hussain shares his treatment algorithm, which includes getting a CTA after each consultation, to map out variable anatomy and select hypertrophied vessels. Deep cannulation is key to preventing reflux and non-target embolization. Additionally, he does a two week follow up for post-procedural symptoms and a 2 month imaging appointment. Dr. Sag describes a joint clinic with endocrine surgeons. Every patient gets a visit from each service on the same day, and the doctors are able to convene and make joint decisions based on patient and goiter factors. He recommends getting a cone beam CTA to rule out anastamoses to aerodigestive structures and the cervical spinal cord. In his embolization, he uses 300-500 micron Embospheres and leaves at least one quadrant untreated to spare some thyroid and parathyroid glands. He also administers decadron and a medrol dose pack. Lab follow-up happens at day 7, when most thyroid hormone peaks occur. If patients are still experiencing symptoms after two months, Dr. Sag will consider repeating the embolization.

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RESOURCES

Thyroid Embolization for Nonsurgical Treatment of Nodular Goiter: A Single-Center Experience in 56 Consecutive Patients (Yilmaz et al):

https://pubmed.ncbi.nlm.nih.gov/34256121/

ACR TI-RADS:

https://www.acr.org/Clinical-Resources/Reporting-and-Data-Systems/TI-RADS

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

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

In this episode, host Dr. Aparna Baheti interviews Dr. Merve Ozen, interventional radiologist, about how to integrate ICE for TIPS, including why she uses a vampire stick, her needle preference, and tips for single operators.

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Dr. Ozen begins by discussing the challenges she faced when introducing this new technique into her practice at the University of Kentucky. She faced pushback from administration about procedure time and anesthesia time. She now does all her TIPS with intracardiac echocardiography (ICE) guidance, but she keeps CO2 available in case of device malfunction, which would cause her to revert to the traditional method of CO2 angiography.

It takes time to learn how to navigate the ICE probe, also called intravascular ultrasound (IVUS), but it helps with complicated cases like thrombosed portal veins and Budd-Chiari syndrome. She uses the “vampire stick” technique, which is a side by side internal jugular access technique for the TIPS needle and the US probe. She puts her TIPS access more medial, which makes it more stable, and places her ICE access more lateral.

After getting access, she spends time understanding the anatomy in the liver. Prior CT is useful for getting information about patient specific anatomy. She then uses ICE to view the portal vein and hepatic vein on the same plane, then she advances the needle with one stick. Dr. Ozen prefers a Rösch-Uchida needle versus a Colapinto because she feels she can better visualize it with ICE. One thing she recommends spending time on is understanding where to start introducing your needle. If there is clot or liver stuck in the needle and preventing blood return, she recommends flushing the needle, or advancing it and then pulling back gently. She ends by stating that learning how to operate the ICE probe is a steep learning curve, but one that every IR should invest time in. It cuts down on anesthesia and fluoroscopy time, and provides a level of safety that is simply not achievable with traditional methods.

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RESOURCES

ARRS 2022 Abstract on ICE TIPS:

https://apps.arrs.org/AbstractsAM22Open/Main/Abstract/E2038

In this episode, host Jacob Fleming interviews interventional radiologist Tony Brown and orthopedic oncologist Daniel Lerman about their multidisciplinary IR/orthopedics practice and innovative techniques for pelvic fixation in metastatic cancer patients.

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The guests recount their first case together, a “no option” patient in which they collaborated on a tripod fixation of an acetabulum, using a combination of screw placement and cementoplasty. They realized that they were both invested in improving minimally invasive fixation and helping patients with pain management and daily functioning. Their collaboration blossomed into a joint practice of MSK interventional oncology that offers biomechanics knowledge of orthopedic surgery and the precise image guidance of interventional radiology. With the rise of systemic cancer therapies, more patients are living with metastatic bone disease, and this new treatment paradigm could offer them a true joint reconstruction and stable fixation. Overtime, they have streamlined the technique to make their cases more efficient and precise.

Despite their advances, Dr. Brown notes that MSK interventional oncology still has a long way to go. In the community, pelvic fractures usually go untreated. He speaks about the importance of outreach to radiation oncologists and orthopedic surgeons and letting them know about new methods of pelvic fixation. Dr. Brown encourages IRs who are curious about MSK interventions to get in contact with colleagues who are already doing innovative techniques and device companies that offer classes. Additionally, there is a need for innovation in instrumentation. Most pelvic intervention tools have been adopted from spine tools; however pelvic anatomy and pelvic lesions are vastly different. Dr. Lerman highlights the uniqueness of each patient’s disease, tumor, and bone lysis. He believes that there is a need to elucidate why different patients respond to different types of constructs.

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RESOURCES

Institute for Limb Preservation:

https://www.limbpreservationcolorado.com/

Musculoskeletal Tumor Society (MSTS):

http://msts.org/

In this episode, host Dr. Jacob Fleming interviews Dr. Luigi Manfrè, spine interventional neuroradiologist and chair of the European Society of Neuroradiology about treatment of spinal stenosis and spondylolisthesis using interspinous fusion spacers.

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Dr. Manfrè reviews his technique for interspinous spacer placement. He uses local anesthesia which he administers with a spinal needle. He adjusts the angulation and entry point using CT, then inserts the guide wire. When he has it positioned between two spinous processes, and when the wire abuts the facet, this is the end point of the guide wire. He then uses soft tissue dilators through a 5mm incision before placing a spacer over the spacer delivery system. He usually places 8-12mm spacers, occasionally using 14mm spacers.

One of the main pitfalls that happens when placing spacers is oversizing. Dr. Manfrè believes that this is a more common phenomenon in open surgical decompression due to patient placement in the operating room. Patients are often placed prone with a pillow beneath their abdomen to flex the lumbar spine and aid in exposure and insertion of spacers. However, this causes measurements to be greater than they are in natural spine mechanics.

Next, we discuss the historical idea that interspinous spacers induce an unnatural lumbar kyphosis. New research suggests this is not the case. In fact, spacers restore the natural alignment of the spine without inducing kyphosis. Additionally, in patients with stenosis at multiple levels, the addition of a spacer at the worst level improves the morphology of the entire spine. He usually only places one spacer for his patients, and rarely will place two. New unpublished research by Dr. Manfrè on upright MRI shows that spacers placed for patients with spinal stenosis cause expansion of the dural sac by up to 70% by the next day. What’s more, in patients with both stenosis and listhesis, placement of a fusion spacer to correct both the stenosis and the instability result in disappearance of listhesis on MR the day after the procedure.

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RESOURCES

Dr. Manfrè Website:

https://www.manfreluigi.com/index.html

Manfrè Articles:

https://jnis.bmj.com/content/12/7/673.abstract

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8511561/

https://journals.sagepub.com/doi/abs/10.15274/INR-2014-10052

ESNR Hands On Spine Course:

https://www.esnr.org/en/spine-interventional-neuroradiology-full-hands-on-course/about-catania/

New Procedures in Spinal Interventional Neuroradiology:

https://www.springer.com/series/13394

In this episode, host Dr. Jacob Fleming interviews Dr. Luigi Manfrè, interventional radiologist and chair of the European Society of Neuroradiology about how he treats lumbar spinal stenosis using spinoplasty and minimally invasive placement of interspinous spacers.

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Dr. Manfrè discusses his background and how he arrived at his current practice in Catania, Italy. His journey in medicine began with the intention of becoming an ophthalmologist. He then realized he didn’t want to pursue this path, and was told by a teacher he would be studying neuroradiology. He despised neuroradiology prior to this, but soon fell in love “at first sight”. He then went to Toronto to study under pioneers of pediatric neuroradiology. He dabbled in vascular IR before finally finding interventional spine. It began with injections for pain but he soon realized the potential of this field. At the time, surgery was becoming more minimally invasive, and as a radiologist, he knew he could leverage this momentum due to this unique background in radiology that his surgeon colleagues did not have.

Dr. Manfrè believed he could apply the same treatments that conventional spine surgeons were doing in a faster, more precise and less aggressive manner. Spine surgeons were beginning to place interspinous spacers for spinal stenosis, and he was interested in placing these using CT and fluoroscopy guidance. He selects his patients very precisely, because it is important to him to not be using a device on the wrong patient. He endorses collaboration with neurosurgeons and orthopedic surgeons and practices this frequently, often referring patients within his network of collaborators. He selects patients for interspinous spacer placement who have genetic lumbar spinal stenosis causing ligamentous compression of nerves.

His technique involves a combination of CT and fluoroscopy as it has been shown that using CT for procedural planning has been shown to reduce patient radiation exposure by 90%. He then uses fluoroscopy to insert the dilater over the guide wire, put in the spacer and open the spacer, which takes around 20 seconds of fluoro time. The interspinous spacer is a device that is placed in between two spinous processes to slow the progression of spinal stenosis and neurologic injury. The spacer cannot undo any prior neurologic injury, however, due to the progressive nature of this disease process. Surgical placement of a spacer is aggressive, involving general anesthesia in older patients with comorbidities, opening of the spinal canal, and laminectomy, which causes ligamentous instability that requires repair. It can be a three hour procedure, which involves extensive recovery and rehab. Dr. Manfrè places a spacer in 3 minutes, uses local anesthesia and midazolam, a 5mm incision, and no rehab. The primary reason for failure of the procedure is spinous process fracture and bone remodeling. He began performing spinoplasty, a procedure in which he injects 1cc of Polymethyl methacrylate (PMMA) in the adjacent posterior arch to determine if this would impact the success of the spacers. He now routinely performs spinoplasty 2 months prior to spacer placement and has enjoyed very low failure rates since implementation of this technique.

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RESOURCES

Dr. Manfrè Website:

https://www.manfreluigi.com/index.html

Manfrè Articles:

https://jnis.bmj.com/content/12/7/673.abstract

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8511561/

https://journals.sagepub.com/doi/abs/10.15274/INR-2014-10052

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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