BackTable Vascular & Interventional

In this episode, guest host Dr. Peder Horner interviews Dr. Harold Coons about the history of IR, his contributions to the field, where the field is headed, and his advice for trainees and early career IRs.

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SHOW NOTES

Dr. Coons attended Pomona College, where he studied math. He then realized he didn’t want to be a nuclear scientist in the Sputnik era, which was where most opportunities were at the time. He decided to attend medical school at UCLA instead. As a medical student, he saw how happy the radiologists were, so he decided to choose it as a specialty. He had the opportunity to do a carotid arteriogram one day when everyone else was busy. He considered himself a maverick and someone who was always ready to take on a challenge.

He then experienced a moment that changed his life, when Czech radiologist Josef Rösch came to UCLA to visit from the University of Oregon where he was working with Charles Dotter. Dr. Coons saw Dr. Rösch direct puncture the spleen for a spleen portogram, and it took him only 15 seconds. This was incredible to him, and after that, Dr. Coons followed him around whenever he did procedures. They teamed up, Dr. Coons volunteering to be the nurse, because no nurses liked working with Rösch. Coons shaped catheters for him at a steam kettle, watched him do the first TIPS on a dog, and did the first arterial embolization with clotted venous blood under the direction of Dr. Rösch.

After his stint in the Airforce at a hospital in San Antonio, where he honed his embolization skills, he returned to San Diego. He was then working in private practice as the only IR in San Diego. One year, he heard about a meeting at Massachusetts General, so he submitted 6 papers on things he had been doing recently. All his papers were accepted, so he went to the meeting. At his first presentation, the leader of the meeting announced to the audience that he had accepted these papers to expose Coons as a fraud, because these techniques were nothing any academic had ever heard of. He did his presentation, and everyone in the audience, including the meeting leader, believed what he was doing was indeed real. He apologized to Coons and invited him to the speakers dinner, where he sat next to Kurt Amplatz and Plinio Rossi. Rossi convinced him to start publishing his ideas to get the credit he deserved, and to have something to show his children. Dr. Coons was forced to retire early in 1996 due to radiation exposure, but has been an avid innovator, educator, and international speaker since then. His passion for IR and excitement for the future of the field is contagious to all who have the pleasure of hearing him speak.

In this episode, Dr. Jacob Fleming interviews Dr. Olivier Clerk-Lamalice about basivertebral nerve ablation for vertebrogenic back pain, including indications, procedure technique and exciting tech on the horizon in minimally invasive spine interventions.

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SHOW NOTES

Dr. Clerk-Lamalice trained in Canada, first in engineering, and then medicine and diagnostic radiology at the Université de Sherbrooke in Calgary. He then completed a neuroradiology fellowship at Harvard, and a fellowship in interventional pain at The Spine Fracture Institute in Oklahoma City with Dr. Douglas Beall. Furthermore, he obtained his credentials as a fellow of interventional pain practice (FIPP), which is a widely recognized international designation. He now works at a comprehensive outpatient radiology center, where he practices both diagnostic and interventional radiology daily. They offer intrathecal drug administration, spinal cord stimulators, vertebral augmentation, Spine Jack, disc augmentation, nucleolysis, and various nerve blocks and ablations in and out of the spine. Their goal was to create a one stop shop for patients to come for consultation, imaging, expert advice and treatment.

Next, we discuss vertebrogenic back pain and the basivertebral nerve (BVN). The BVN is a nonmyelinated, intraosseous nerve, while most other peripheral nerves are myelinated, meaning they can regenerate. The BVN cannot, so ablation of this nerve is a permanent treatment. It is located within the central portion of the vertebral body midway between the superior and inferior end plates, one third ventral to the posterior wall of the vertebral body. On a sagittal T2 sequence on MRI, there is a triangle at the posterior aspect at the midpoint of the vertebral body called the basivertebral canal, which contains the nerve, artery and vein. The BVN is responsible for vertebrogenic back pain, which is a form of anterior column pain characterized by low back pain worsened by flexion and sitting. It is diagnosed via MRI using the Modic classifications. Modic type 1 (edematous), and type 2 (fibrofatty end plate) changes can be seen in this disease. It can be difficult to distinguish vertebrogenic from discogenic pain due to the fact that the sinuvertebral nerve (SVN), responsible for discogenic pain, crosses paths with the BVN. However, with MRI and an anesthetic discogram, it is possible to determine the etiology and choose the right treatment.

Finally, we discuss the steps of the procedure. Dr. Clerk-Lamalice uses an 8 gauge needle via a transpedicular approach, as is common for other spine procedures. He ensures the probe is positioned in the center of the vertebral body, parallel to the endplates. The nerve is ablated for 15 minutes at 85 C. The procedure takes 45 minutes, which includes an epidural steroid injection to bridge pain control during the periprocedural period. Patients usually go home within one hour after the procedure, and begin to experience the results within a couple days. There have been two trials for BVN ablation, which have made this intervention the most minimally invasive and evidence-based treatment for vertebrogenic pain. These studies indicated 25% of patients had a 50% reduction in pain, while 75% of patients had a 75% reduction of pain. Within that 75%, 30% reported being almost entirely pain free. To date, the study has followed participants to 8 years, and the results show the treatment is durable.

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RESOURCES

Ep 210: Modern Vertebral Augmentation

https://www.backtable.com/shows/vi/podcasts/210/modern-vertebral-augmentation

Ep 94: Spine Interventions

https://www.backtable.com/shows/vi/podcasts/94/innovation-in-spine-interventions

Relievent device for BVN ablation:

https://www.relievant.com/intracept/procedure-details/

Find this episode on backtable.com to view the full list of resources.

In this episode, host Dr. Chris Beck interviews Dr. Alexander Ushinsky about his standard workup and treatment when performing arterial thrombectomy in acute limb ischemia (ALI).

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SHOW NOTES

In the past three years, Dr. Ushinksy has focused on building up peripheral vasculature service lines at the Mallinckrodt Institute of Radiology at Washington University in St. Louis. He has acquired skills not only in treatment of ALI, but also in building referral bases and collaborating with vascular surgeons and cardiologists. To begin, we review important aspects of a focused history and physical exam. It is crucial to assess whether the patient has underlying peripheral arterial disease (PAD), other thromboembolic diseases, or underlying coagulopathies. Different etiologies of thrombus could require additional consultation with hematologists and cardiologists. Additionally, timing of symptom onset is important to consider when planning interventions in an on-call setting. Dr. Ushinsky relies on extremity pulse exams using bedside doppler and the Rutherford Classification System for ALI to ascertain whether intervention can be helpful. In cases of Rutherford class 1-2a, intervention is usually warranted. Cases that fall into class 2b may or may not require intervention, and cases in class 3 and beyond usually do not gain benefit from intervention since lower extremity paralysis and clot burden is so severe.

With regards to types of interventions, Dr. Ushinsky highlights two common IR procedures– lysis catheter placement and endovascular thrombectomy. In the past, lysis catheters were the only available endovascular treatment. We walk through catheter placement, noting that in order to gain maximum benefit, the catheter should be placed across the entirety of the thrombus, with holes proximal and distal to the lesion, so that tPA can be infused throughout the clot and have appropriate inflow and outflow tracts. Good candidates for lysis catheter placement include patients who have extensive clot burden in small vessels and those who have underlying CLI that can be definitively addressed in a later procedure. A major difference between lytic catheter placement and thrombectomy is that patients receiving lytic therapy require admission to the ICU for close monitoring and frequent neurovascular checks.

Next, we pivot to discussion about newer thrombectomy devices. Dr. Ushinsky describes pros and cons of common devices that are used in his practice and types of cases that would benefit from each one. Thrombectomy is useful if there is a low clot burden that can be addressed in a single session. Additionally, this procedure is more appropriate than lysis catheter placement if the patient is elderly, has had recent surgery, or is otherwise a poor candidate for systemic tPA. Dr. Ushinsky always performs a diagnostic angiogram at the beginning of the case and a completion angiogram to confirm that the lesion has been fully treated. Overall, he believes that the best intervention for a patient is the one that the practitioner feels the most adept at and can safely perform.

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RESOURCES

Rutherford Acute Limb Ischemia Classification System:

https://www.jvascsurg.org/article/S0741-5214(97)70045-4/fulltext#secd69653256e1488

Boston Scientific AngioJet Thrombectomy System:

https://www.bostonscientific.com/en-US/products/thrombectomy-systems/angiojet-thrombectomy-system.html

Penumbra Indigo Thrombectomy System:

https://www.penumbrainc.com/peripheral-device/indigo-system/

AngioDynamics Auryon Thrombectomy System:

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

Rotarex Excisional Atherectomy System:

https://www.bd.com/en-us/products-and-solutions/products/product-families/rotarex-rotational-excisional-atherectomy-system

Pounce Thrombectomy System:

https://pouncesystem.com/

Find this episode on BackTable.com to see the full list of resources.

In this week’s episode. Dr. Aaron Fritts interviews co-hosts and IRs Dr. Ally Baheti and Dr. Chris Beck about indications, procedural steps, and patient education for tunneled pleural and peritoneal catheters.

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SHOW NOTES

First, we review indications for tunneled catheters, the most common ones being malignancies. Since tunneled catheters are known to carry a risk of infection, their placement is often used as a palliative care measure. In addition to malignancies, they can also be used to improve symptoms in patients with congestive heart failure, cirrhosis, pancreatitis, autoimmune diseases, and chylothorax. Dr. Baheti emphasizes the importance of establishing chronicity and recurrence of the effusions before placing the tunneled catheter. For example, some patients with ascites could better benefit from a TIPS procedure rather than a peritoneal catheter.

Dr. Beck gives us advice for placing pleural tunneled catheters. He positions the patient to ensure the best access point, using a cloth roll underneath the ipsilateral hip and having the patient raise the ipsilateral arm. He also uses lidocaine injections for pain control and he makes a gentle curve to get a smooth angle of the catheter.

Dr. Baheti shares her own experiences with pleural tunneled catheter placement. She tunnels along the intercostal space and angles the needle into the posterior space to achieve a smooth angle. She also chooses the biggest fluid pocket to drain, where the fluid is at least 5 cm. She emphasizes that pre-procedural planning and the final location of the catheter tip has a large influence on whether or not the catheter can successfully drain fluid.

Throughout a patient’s care, clear communication with insurance, the patient, and the home caretakers are very important. Finally, Dr. Fritts says that the most important part about the procedure is counseling the pt. Realistically, it is hard for physicians to find time to explain the specific instructions of home care, so it is important to delegate at least one person on the medical team to do this.

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RESOURCES

PleurX Drainage System:

https://www.bd.com/en-us/products-and-solutions/products/product-families/pleurx-pleural-catheter-system

In this panel episode recorded at SIR 2023, Drs. Stephen Hunt, Chuck Martin, and Gaurav Gadodia update us on current applications and future directions of augmented reality in interventional radiology.

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Medtronic Ellipsys Vascular Access System

https://www.medtronic.com/ellipsys

Reflow Medical

https://www.reflowmedical.com/

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SHOW NOTES

Dr. Hunt explains the differences between virtual reality (VR), augmented reality (AR), and mixed reality (MR) since there is increasing levels of overlap between virtual and real worlds with each category . He notes that all three are being explored in surgical fields, especially orthopedics and neurosurgery. Within IR, augmented reality can be used to adjust images and subtract out respiratory motion, making biopsies and ablations safer and more effective. Dr. Hunt became interested in AR when his PIGI Lab at the University of Pennsylvania needed 3D models to access liver tumors in experimental mice. Additionally, AR is a useful tool for planning difficult procedures and teaching interventional procedures to trainees across the globe.

Dr. Martin speaks about the intersection of medicine and industry. He directs research studies for Mediview, a company focused on bringing AR into medical imaging. Dr. Martin speaks about the important role that industry plays in commercializing an invention and getting it into operators’ hands. As larger companies enter the AR space, accessibility and user interfaces will improve. Additionally, the shift towards AR product development can guide future FDA regulations.

Dr. Gadodia’s engineering background made him excited to enter the AR space as resident at the Cleveland Clinic. He highlights applications of AR in the non-academic setting. Using a headset could increase procedural efficiency and access to care.

Finally, we discuss major shifts in industry and medicine that favor the increasing use of AR, such as industry’s need for clinician input in product development, the multitude of startups working on the same issues, and the overarching goal of patient safety.

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RESOURCES

Ep. 7- Lung Tumor Ablation with Dr. Stephen Hunt:

https://www.backtable.com/shows/vi/podcasts/7/lung-tumor-ablation

Ep. 53- International IR Volunteer Work with Dr. Stephen Hunt:

https://www.backtable.com/shows/vi/podcasts/53/international-ir-volunteer-work

Mediview:

https://mediview.com/

Microsoft HoloLens:

https://www.microsoft.com/en-us/hololens

Penn Image-Guided Interventions (PIGI) Lab:

https://www.med.upenn.edu/pigilab/

In this multidisciplinary episode, guest host and vascular surgeon Dr. Krishna Mannava interviews interventional cardiologist Dr. John Phillips about when and how he treats dissections after balloon angioplasty in peripheral vasculature.

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SHOW NOTES

Since arterial dissection is a known and common complication of balloon inflation, Dr. Phillips emphasizes the importance of distinguishing between dissections that are flow-limiting and need to be treated, and those that are not flow-limiting. The dissection can be evaluated by measuring pressure gradients and intravascular ultrasound (IVUS). If the dissection flap arc is greater than 180 degrees, Dr. Phillips generally considers it to be flow-limiting. Next, he will determine plaque composition in the area of the dissection. If it is calcified or long, he will deploy a woven nitinol stent. If he needs to target a more specific area that is not calcified, he will use the Tack Endovascular System.

The doctors discuss more details about the Tack system. It is a scaffold system that was created specifically for use in dissections after balloon angioplasty in narrowed vessels. The deployment of multiple small devices contributes to an overall lower metal burden than a stent would introduce. The system also has an adaptive and overlapping sizing platform to address dissection in different vessels in the same procedure. Since the Tacks are only meant to scaffold the dissection flap, they do not exert as much radial force as a stent does. This is the reason why Dr. Phillips generally avoids using it in heavily calcified areas. Dr. Phillips also answers submitted audience questions regarding the indications, technique, billing, and education opportunities for the Tack system. Overall, he encourages practitioners to get in touch with their local sales representatives for more information, and brings up the possibility of remote proctoring in the future.

In terms of follow up care after balloon angioplasty and Tack placement, Dr. Phillips prescribes dual antiplatelet therapy for three months and possible switches to monotherapy afterwards. This is the same regimen as he prescribes for patients with stents. Additionally, surveillance duplex appears similar in patients with Tacks and stents.

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RESOURCES

Tack Dissection Repair Device:

https://www.usa.philips.com/healthcare/product/HCIGTDTCKESYSTM/tack-endovascular-system-dissection-repair-device

Dr. John Phillips Twitter:

https://twitter.com/midohiovascular

In this episode, Dr. Aaron Fritts interviews Dr. Gregory Makris about making the transition to industry, including how to market yourself, and how to maintain your clinical and technical skills while working in industry.

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SHOW NOTES

Dr. Makris is from Greece, and he did his initial training there. He then continued his training in vascular medicine in London, and has been working there ever since. Over the past year, he has been working for Bayer Pharmaceuticals in vascular therapeutics as director, and global clinical lead. He has a hybrid work environment where he works virtually for Bayer, and travels frequently, but still maintains a clinical position at his practice one day a week. He wanted to do this because he enjoys practicing IR and wanted to maintain his clinical and technical skills.

Next, we discuss how he decided to get into industry, particularly pharmaceuticals. He never envisioned he would join industry while training. A decade ago, there was a bad reputation about physicians who left medicine to join industry. People often remarked these physicians were soulless or had joined the dark side. Now, there is much less criticism, and there are growing numbers of physicians choosing to partner with industry. Dr. Makris was working as an attending when he started getting more exposed to industry at conferences. He started to imagine a role in medical device innovation, and with a background in research, he knew he had expertise that would be useful to industry as a physician scientist. Somewhat surprisingly, an opportunity came up with Bayer in pharmaceuticals. It was a global role, and involved clinical and research development of vascular medications, which was appealing to him as an IR with a PhD in vascular medicine and someone passionate about global outreach. He also sensed he was ready for a new challenge in his career, so he accepted the role.

He recommends being very honest with yourself about your abilities and your limitations when starting out in a new role in industry. Additionally, you should be open to learning new roles, and be flexible with time and travel. Dr. Makris says that the best way to maintain a clinical role is to have a frank conversation with your practice and explain what you can offer them and how to work out a deal that benefits both parties. Most practices will be willing to keep you on part time. If they are not, there are numerous opportunities to stay in medicine, whether through locums or reaching out to other practices that need help. Dr. Makris ends by saying that as a physician, there are many ways to have career satisfaction and work-life balance, while still contributing to healthcare and helping patients. He sees his new role as an opportunity to contribute to the bigger picture, which is advancing healthcare and medical standards.

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RESOURCES

Ep 128: Device Innovation with Dr. Atul Gupta

https://www.backtable.com/shows/vi/podcasts

Ep 57: Practicing IR in the UK with Dr. Gregory Makris

https://www.backtable.com/shows/vi/podcasts/57/practicing-ir-in-the-uk

Linked In:

https://www.linkedin.com/in/gregory-makris-m-d-ph-d-dic-frcr-22118660/?originalSubdomain=uk

Twitter:

@GregMakris23

In this episode, host Dr. Aaron Fritts interviews Dr. Jim Melton and Amanda Stanley about intravascular lithotripsy in the ASC, including reimbursement trends, patient selection and the future of the device.

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Shockwave Medical

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SHOW NOTES

We begin by discussing Amanda’s role in the practice. She is an ex OR nurse and has been clinical director for their original hybrid ASC/OBL in Oklahoma City for 8 years. She has taken on many roles over the years, the most recent being COO. Some of her functions under this title include clinical revenue cycle management (RCM), payer negotiation, credentialing and accreditation. Since partnering with a private equity firm, she has also been collaborating with others in ASCs they have acquired around the country.

Dr. Melton states that intravascular lithotripsy (IVL) reimburses very well in the outpatient space, but that this is only true in the ambulatory surgery center (ASC) and does not translate to outpatient based labs (OBLs). Medicare pays for all associated Shockwave intravascular lithotripsy CPT codes, commercial insurance does not. They found in their practice that by using the Medicare fee schedule, they could prove to their local commercial insurance providers that it was worth paying for, and they are now getting it approved via both parties. Specifically, C9765, which is for IVL, percutaneous transluminal angioplasty (PTA) and stenting, pays $5000 more than the code that is just for PTA and stenting.

Lastly, we go over sizing and patient selection. In the ASC, he most commonly uses the 5.5, 6 and 7, which all go through a 5-6 Fr slender sheath in the foot. If you use an 8 then you’ll need a 7 Fr sheath, and if you use a size 9, 10, or 12, you’ll need an 8 Fr sheath. Dr. Melton emphasizes the importance of selecting the right patients for the ASC and hospital. In those with significant comorbidities or a femoral artery that will need a size 9, 10 or 12 balloon, he tends to do these in the hospital. He finds that he places a stent more often than not after IVL and PTA because of what he sees using intravascular ultrasound (IVUS). He shares a tip for using the current IVL balloon. Because it emits the strongest sonic pressure impulse at the center of the balloon, he uses IVUS to mark the most calcified segment, then targets this area with the center of the balloon. He remarks that the newer version, coming out soon, has a shorter balloon and emits the same strength across its entire length, allowing you to skip this step.

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RESOURCES

Ep. 287 OBL/ASC Reimbursement Update January 2023

https://www.backtable.com/shows/vi/podcasts/287/obl-asc-reimbursement-update-jan-2023

In this episode, host Dr. Aparna Baheti interviews Dr. Tarang Patel, diagnostic radiologist and creator of the Doctor Money Matters Podcast, about private equity in radiology, from why to get in to how to get out.

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SHOW NOTES

After getting out of the air force, Dr. Patel didn’t know what to do with the significant salary increase he was given. He had a lot of questions and wanted to learn how to manage his finances as a physician. In 2015, he created a website, which soon developed into a podcast. In doing this, his goal was to speak with guests who were experts in aspects of physician finance so that he could learn. He was also interested in disseminating the information with others, because he knew many physicians had similar questions about finance.

Next, we discuss the private equity (PE) landscape, specifically in Phoenix, where Dr. Patel practices. He is a hospital employee and has never been part of a PE owned practice, but knows many in Phoenix who went through the Rad Partners buyout there. He explains the evolution of the Rad Partners deal. There were three dominant radiology groups that employed over 100 radiologists. They were approached by Rad Partners and decided to sell and become one large group. This resulted in one dominant radiology group in all of Phoenix. These physicians were all locked into a 5 year contract, which ended in late 2022. At this time, there was a mass exodus of radiologists from this group due to their dissatisfaction with the way the practice was run or how their contracts ended up playing out. Dr. Patel explains how they were able to attract so many people by incentivizing the deal with a heavy cash to share ratio. This gave providers a sense of a guarantee, which a higher share buyout would not have provided. This is because the PE company ascribes value to the shares, and it is unknown at onset whether they will financially profit in the long run.

Dr. Patel further explains that joining a PE owned practice is generally a bad deal for young radiologists, because they are offered lower salaries and don’t get any buyout. This has resulted in PE companies failing to hire young doctors. Additionally, many older doctors near retirement use a PE deal as a way to get a large cash payout, work for a few more years, and retire. Dr. Patel believes that due to hiring difficulties and the high debt burden of many PE companies, they will start to close practices, which will open up the market for new practice models. He believes the radiology landscape will be vastly different in 5 years than it is now. Dr. Patel ends by saying you should never trust an offer that advertises low risk and high return. Additionally, for young radiologists looking for jobs out of training, he urges you not to follow the highest offer, but rather find the practice you enjoy going to work at everyday, even if the pay is lower. In the end, you will make the money, and it is worth enjoying your job and your colleagues.

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RESOURCES

Ep. 287 OBL/ASC Reimbursement Update January 2023

https://www.backtable.com/shows/vi/podcasts/287/obl-asc-reimbursement-update-jan-2023

In this episode of BackTable, Dr. Bagrodia interviews Dr. William Flanary, a physician-comedian popularly known as Dr. Glaucomflecken, about lessons he has learned as a two-time testicular cancer survivor and the importance of humor in medicine.

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

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SHOW NOTES

First, Dr. Glaucomflecken shares about his first diagnosis of testicular cancer. During his third year of medical school he felt a lump in his testicle, which led to a quick workup, diagnosis, and a full orchiectomy. The diagnosis was emotionally difficult, as he was in his mid-twenties and healthy. He returned to comedy, a skill he had developed in high school and college, to cope with his diagnosis. This time, however, he started to practice medical-based comedy with his new experiences as a medical student. He recounts other discussions he had about his cancer, such as fertility, the possibility of chemotherapy, and active surveillance.

Four years after his first orchiectomy, he received his second diagnosis of testicular cancer during his last year of residency. He recounts feeling distraught and overwhelmed, as questions about fertility, hormone replacement, medical expenses, and postponing residency became more serious. He decided to have a full orchiectomy and testosterone replacement therapy, which solved his issues with fatigue and irritability. Additionally, his wife got him involved in testicular cancer support groups and foundations, including one called First Descents, an organization that encourages young adults with cancer to explore the outdoors. He notes that young patients are often overlooked in cancer support groups and encourages cancer patients to find their support networks outside of friends and family as well.

Then, Dr. Flanary discusses his experience with suffering from cardiac arrest in 2020, which led to his wife doing ten minutes of chest compressions to keep him alive. He reflects on this event and concludes that it taught him how to be a better physician to his patients by making sure he involves patients’ families and encouraging him to address medical insurance issues directly.

Finally, Dr. Flanary discusses how he uses humor to advocate and educate patients on social media. He notes that comedy can stimulate conversation and debate and encourages physicians to have social media presence.

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RESOURCES

Knock Knock Hi Podcast

https://podcasts.apple.com/us/podcast/knock-knock-hi-with-the-glaucomfleckens/id1659572053

First Descents

https://firstdescents.org/