BackTable Vascular & Interventional

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

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

---

SHOW NOTES

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

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

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

---

RESOURCES

American Radiology Associates:

https://www.americanrad.com/

Dr. Ben White’s Blog:

https://www.benwhite.com/

Strategic Radiology:

https://www.strategicradiology.org/

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

---

CHECK OUT OUR SPONSORS

Surmodics Sublime Radial Access Platform

https://sublimeradial.com/

Reflow Medical

https://www.reflowmedical.com/

---

SHOW NOTES

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

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

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

---

RESOURCES

Twitter:

@drcumming

LinkedIn:

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

Chiba needle:

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

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

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

---

CHECK OUT OUR SPONSOR

Reflow Medical

https://www.reflowmedical.com/

---

SHOW NOTES

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

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

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

---

RESOURCES

Episode 116- E&M Coding 101:

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

AMA 2022 E&M Guidelines:

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

Email:

[email protected]

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

The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/Sc3ac2

---

SHOW NOTES

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

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

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

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

The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/teT47L

---

CHECK OUT OUR SPONSOR

RADPAD® Radiation Protection

https://www.radpad.com/

---

SHOW NOTES

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

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

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

---

RESOURCES

VAST Clinical Trial:

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

VIA Disc NP:

https://gotviadisc.com/

Owestry Disability Index (ODI):

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

SMART Trial:

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

INTRACEPT Trial:

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

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

---

EARN CME

Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/rVQG40

---

SHOW NOTES

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

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

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

In this episode, host Dr. Sabeen Dhand interviews vascular surgeon Dr. Benjamin Starnes about artificial intelligence in aortic intervention, from aneurysm detection to procedural planning and coordination of aortic aneurysm surveillance.

---

CHECK OUT OUR SPONSOR

Viz.ai

https://www.viz.ai/

---

SHOW NOTES

Dr. Starnes is a vascular surgeon at the University of Washington. He is one of the first adopters of artificial intelligence (AI) in aortic intervention. He uses Viz.ai to help coordinate care for aortic dissections and ruptured aortic aneurysms. He began to implement this due to frustration with an outdated workflow. He serves a large patient population in Washington, Alaska, Idaho, Montana, and Wyoming. With different hospital systems and antiquated methods of communication, he realized it was very inefficient to evaluate a patient from some of these locations, and then have them transferred to Seattle for surgical repair.

Dr. Starnes overviews the outdated workflow that’s prevalent in aortic emergency care. If there is a ruptured aortic aneurysm or aortic dissection, he would first get a call from an ER physician who ordered the imaging. The transfer center wouild be contacted, and then he had to find a desktop to view images from the outside facility. If there was no way to view the images due to incompatible PACS, he had to use a screenshot of an image sent by a provider at that hospital. After reviewing the imaging, he would decide whether to accept the transfer. If a patient is transferred, he would do the procedure and then hand off the patient to the ICU team, who was rarely (never) aware of this transfer until the patient arrived in their unit.

After starting to use Viz.ai, this process has been streamlined. Dr. Starnes modeled the AI platform he uses for aortic emergencies in a similar way that AI stroke alert platforms already function. He now gets an alert on his phone, he is able to view good-quality images on his phone wherever he is, decide on the next steps, and communicate with members of the team in a HIPAA-compliant fashion all via the user-friendly interface. He uses AI software to detect ruptures and dissections and reports that it is very accurate. Dr. Starnes and colleagues at the University of Washington do over 350 aortic cases per year. The implementation of AI has helped them work more efficiently and has improved patient outcomes by cutting down the time from diagnosis to intervention. He hopes that machines can be trained to measure the aneurysm size for stent graft selection and manage elective aortas by integrating surveillance, follow-up, and elective repair. He also is very hopeful that AI will be able to identify many genetic aortopathies due to the integration of genetics and AI.

---

RESOURCES

Viz AI:

https://www.viz.ai

In this episode, Dr. Aaron Fritts interviews Dr. Chris Grilli of Christiana Health about his treatment algorithms and procedural tips for splenic embolization as a treatment for splenic trauma, hypersplenism, and splenic artery aneurysm.

---

CHECK OUT OUR SPONSOR

Boston Scientific Embold Fibered Coils

https://www.bostonscientific.com/en-US/products/embolization/embold-detachable-coil-system.html

---

SHOW NOTES

Dr. Grilli explains that the most common indication for splenic embolization is trauma. He walks us through different trauma guidelines for grading splenic trauma. At his institution, if only a small portion of parenchyma is involved, the patient is monitored. If significant trauma and vascular injury is present and the patient is mostly stable, the patient gets referred to IR. Dr. Grilli notes that the decision to refer to IR or trauma surgery is also institutionally dependent. Across most institutions, it is more common to monitor pediatric splenic trauma rather than intervene.

Next. Dr. Grilli walks us through an embolization for splenic trauma. He will most often opt for femoral access, unless there is underlying pathology or very large body habitus. He uses a 5Fr sheath and then navigates to the splenic artery with a C2 angiographic catheter. Then, he performs angiography to visualize the bleed, decide if he wants to embolize proximally or distally, and chooses his embolic agent.

The doctors discuss pros and cons of using plugs, coils, and liquid embolics. Coils can induce stasis more quickly than a plug can. There are also coils with different materials and mechanisms of deployment. Dr. Grilli notes that an angiographic run at the end of an ideal case would show that the embolic device has obstructed flow in the main artery and the spleen is now being perfused by collaterals.

Finally, we address non-traumatic indications for splenic embolization. In hypersplenism, oncologists will refer patients to IR to address platelet sequestration. Dr. Grilli says that these cases require embolization of segmental branches of the splenic artery, in the effort to kill off 40-70% of the spleen. This procedure could introduce significant adverse effects that must be discussed with the patient beforehand. In embolization of splenic artery aneurysms, Dr. Grilli prefers to use long packing coils or covered stents.

---

RESOURCES

ChristianaCare IR Residency:

https://residency.christianacare.org/vascular-interventional-radiology

AAST Spleen Injury Scale:

https://www.aast.org/resources-detail/injury-scoring-scale#spleen

WSES Classification and Guidelines for Splenic Trauma:

https://pubmed.ncbi.nlm.nih.gov/28828034/

Cobra 2 (C2) Catheter:

https://meritoem.com/product-category/catheters-extrusions/diagnostic-peripheral/performa-impress/cobra-2/

Sarah Catheter:

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

Penumbra Pod Device:

https://www.penumbrainc.com/peripheral-device/pod/

Embold Fibered Coil:

https://www.bostonscientific.com/en-US/products/embolization/embold-detachable-coil-system.html

Interlock Coil:

https://www.bostonscientific.com/en-US/products/embolization/interlock-and-idc-detachable-embolization-coils.html

Management of Hypersplenism by Partial Splenic Embolization With Ethylene Vinyl Alcohol Copolymer (Onyx):

https://www.ajronline.org/doi/full/10.2214/AJR.10.4401?mobileUi=0

MYNXGRIP Closure Device:

https://cordis.com/na/products/close/endovascular/mynxgrip-vascular-closure-device

AngioSeal Closure Device:

https://www.terumois.com/products/closure/angio-seal-vascular-closure-devices/angio-seal.html

CELT Closure Device:

https://www.veryanmed.com/usa/products/celt-acd-vascular-closure-device/

In this episode, guest host Dr. Lorenzo Patrone interviews vascular surgeon Dr. Isabelle Van Herzeele about the current state of vascular skills education and the future of vascular conferences.

---

CHECK OUT OUR SPONSORS

Reflow Medical

https://www.reflowmedical.com/

Medtronic IN.PACT 018 DCB

https://www.medtronic.com/018

---

SHOW NOTES

The doctors are on site at Paris Vascular Insights, a conference where interactivity is built into every session. Dr. Van Herzeele speaks about the importance of offering hands-on skills workshops in addition to traditional lectures. She believes that interactive learning is essential for all trainees. Additionally, skill development involves collaboration between industry and clinicians. She also emphasizes the importance of brief case-based lectures that spark discussion and encourage audience members to ask questions. The doctors mention the difficulties involved with encouraging audience participation, such as language barriers and fear of judgment. To address these challenges, it is important to create a safe environment that is conducive to learning, since clarification in a training session would yield better patient outcomes.

Dr. Van Herzeele also discusses the experience of women in vascular surgery. She recognizes the importance of a support system, which includes family and flexible training methods. One important training modality is virtual simulation. Online modules and skills kits can provide a way for all trainees, but especially women, to learn new skills or keep up with surgical and endovascular skills when they are not able to be in the hospital. She stresses that simulation is a complement and preparation for real life training, not a substitute.

Finally, the doctors discuss education in the open surgery and endovascular fields. As vascular procedures are becoming more innovative and diverse, proceduralists have started to subspecialize to lean more heavily on endovascular or open procedures, depending on where they train. Dr. Van Heerzeele believes that vascular surgeons can specialize; however, they should maintain both sets of skills and be able to take call and perform the appropriate procedure in the event of an emergency. Additionally, collaborations between physicians in all vascular fields and different vascular care centers are necessary to ensure the best patient care.

---

RESOURCES

Paris Vascular Insights:

https://parisvascularinsights.com/

VEITH Symposium:

https://www.veithsymposium.org/index.php

Society of Vascular Surgery (SVS) Women’s Section:

https://vascular.org/vascular-specialists/networking/svs-womens-section

European Vascular Course:

https://vascular-course.com/

European Society for Vascular Surgery (ESVS):

https://esvs.org/

In this episode, host Dr. Sabeen Dhand interviews Drs. Srini Tummala and Omar Saleh about atherectomy in peripheral arterial disease, including indications, technique, and device selection.

---

CHECK OUT OUR SPONSORS

BD Rotarex Atherectomy System

https://www.bd.com/rotarex

Reflow Medical

https://www.reflowmedical.com/

---

SHOW NOTES

We begin by overviewing the definition of atherectomy and the types of devices. Atherectomy is a procedure that involves the removal of plaque or thrombus and is categorized as a vessel preparation procedure. It is often done before angioplasty and stenting. The goal of the procedure is to obtain luminal gain, meaning that the diameter of the lumen of an artery becomes closer to its original size. There are a variety of devices that allow for different techniques in atherectomy, including rotational, orbital, laser, and directional. They all offer a degree of plaque modification or debulking of the lesion to improve outcomes for angioplasty with or without stenting.

Next, we discuss indications for atherectomy. Both Dr. Saleh and Dr. Tummala begin a peripheral arterial case by doing a full lower extremity angiogram to guide their next steps. They also rely heavily on intravascular ultrasound (IVUS), as this helps determine if the lesion is made of thrombus, calcified, or soft plaque. The type of plaque they find via IVUS as well as the primary location of the plaque will determine which device they will proceed with. There is some controversy regarding atherectomy in regard to its indications and efficacy, mostly due to the lack of randomized control trials and overall data scarcity. Despite this, both Dr. Saleh and Dr. Tummala use atherectomy as vessel prep when they plan on treating a lesion with percutaneous transluminal angioplasty (PTA), either alone or followed by a stent.

Finally, we discuss each operator’s advice for those new to atherectomy or treating peripheral arterial disease (PAD), their most used devices, and their thoughts on performing atherectomy in the subintimal plane (outside of the true vessel lumen). Both operators frequently use rotational excisional atherectomy devices and orbital devices. The specific device varies depending on their setting (OBL vs. hospital), but they recommend choosing a couple of devices and learning how to use them well. When it comes to atherectomy in the subintimal space, both Dr. Tummala and Dr. Saleh recommend against doing this, as it is not an indication for any of the devices, and it risks complications such as the device getting stuck. To avoid doing atherectomy in the subintimal plane, they IVUS as far down the vessel as they can to determine if there are any segments that are subintimal. In legs with only a single runoff vessel or no runoff, they are more conservative with atherectomy due to the risk of embolizing smaller vessels and causing even worse flow to the extremity.

---

RESOURCES

Liberty 360 Trial:

https://csi360.com/clinical-evidence/liberty-360/

BD Rotarex Rotational Atherectomy System:

bd.com/rotarex