BackTable Vascular & Interventional

In this episode, Dr. Aaron Fritts interviews Dr. Raghy Kolluri, the system medical director of Vascular Medicine at OhioHealth, about his workup and treatment algorithm for severe venous disease.

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SHOW NOTES

To start, Dr. Kolluri reviews the CEAP (Clinical, Etiological, Anatomical, Physiological) classification of venous disorders and describes how patients commonly get referred to his practice. The majority of his patients fall into the C4 through C6 category (presenting with skin changes, lipodermatosclerosis, and/or recurrent ulcerations) and get referred by podiatrists and wound care clinics. Dr. Kolluri feels that treating severe venous disease is very rewarding because he has the opportunity to manage outcomes from a vascular and overall clinical standpoint.

Next, Dr. Kolluri walks through a typical workup. He emphasizes the importance of taking a thorough history, with special focus on past DVT, trauma, and foreign body placement (stents, filters, DeWeese clips). These characteristics could be evidence for deep venous disease. On the other hand, a venous ulcer with a more benign history signifies superficial venous disease. An ultrasound venous insufficiency study, as well as CT venogram, will determine location and severity of disease. If both superficial and deep venous disease are present, Dr. Kolluri will first address the deep disease.

He outlines Varithena, radiofrequency ablation, endovascular laser ablation, and foam sclerotherapy as treatment options. Varithena and foam sclerotherapy are endovascular options for patients with tortuous veins. However, Varithena should not be used in patients at high risk for venous thromboembolism, as there is less precise control over treatment. Most commonly, Dr. Kolluri relies on radiofrequency ablation. He also describes his method for laser ablation and foam sclerotherapy with sodium tetradecyl sulfate. Additionally, Dr. Kolluri shares his innovative Sclerotherapy-Assisted Phlebectomy (SAP) technique and how it increases accuracy and minimizes blood loss. He emphasizes that phlebectomy of the saphenous vein should not be overused, as it can preclude the possibility of future bypasses. Overall, his background in thrombosis and anticoagulation helps him customize treatment for each individual patient.

The doctors focus on a central theme that venous insufficiency is a chronic and progressive disease, and continued follow up is essential. This involves management of co-existing conditions like lymphedema, peripheral arterial disease (PAD), and infected ulcers. Collaboration with other medical and surgical specialties, occupational therapists, and the patients themselves is essential for ensuring that patients can make appropriate lifestyle changes and follow up throughout their disease course. Finally, Dr. Kolluri shares insight on the push to make vascular medicine an ABIM-certified specialty.

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RESOURCES

Ep. 111- Underutilization of Foam Sclerotherapy:

https://www.backtable.com/shows/vi/podcasts/111/underutilization-of-foam-sclerotherapy

CEAP Classification of Venous Disorders:

https://www.ncbi.nlm.nih.gov/books/NBK557410/

Incidence of and risk factors for iliocaval venous obstruction in patients with active or healed venous leg ulcers:

https://www.jvascsurg.org/article/S0741-5214(10)02617-0/fulltext

American Vein and Lymphatic Society (AVLS):

https://www.myavls.org/annual-congress-2022.html

Foam Sclerotherapy Augmented Phlebectomy (SAP) Procedure for Varicose Veins: Report of a Novel Technique:

https://www.ejvesreports.com/article/S2405-6553(18)30044-6/fulltext

OSU Lymphedema Center:

https://cancer.osu.edu/for-patients-and-caregivers/learn-about-cancers-and-treatments/specialized-treatment-clinics-and-centers/lymphedema-center-of-excellence

The clinical characteristics of lower extremity lymphedema in 440 patients:

https://pubmed.ncbi.nlm.nih.gov/31992537/

In this episode, host Dr. Michael Barraza interviews interventional radiologist Dr. David Johnson about practice building in an IR/DR group, including factors that make a good job, and how he formed one of the largest PAE practices in the Southeast.

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SHOW NOTES

Dr. Johnson found his current job, his first out of fellowship, via a job board. His wife, an ER physician, was looking for a job at the same time, which complicated their search slightly. They ultimately found their current positions by being flexible and understanding that no job is perfect. Dr. Johnson believes that when searching for a job, “you can't let the best be the enemy of the good.” What he was looking for in a job was a practice where he could do a lot of IR in a situation where he could build the IR practice that he wanted. He notes that this is something you should try to find out beforehand during the job search because, at some practices, it’s very difficult to change the way things work and the types of procedures they do. One of the most important things to consider and something he recommends to anyone looking for an IR job is the potential for growth. He cautions that this is a long game you must be ready to play. You can't expect to come in and change or build a practice in 2-3 years.

After he found his footing and established himself in his new job, he began to grow his practice by finding out what the need was in his community. He started by marketing multiple service lines and seeing which would stick. He did this so that he could feel things out and see which physicians ended up referring to him, and which didn’t. It can be hard to balance practice building while in a combined DR/IR practice due to your DR responsibilities, due to quotas and RVUs. He says that you need to keep your mind on the long game in this situation. He did this by talking to at least one clinician every day about a patient he could help in some way. He figured that if he did this for two years, he would slowly get his name out and build a referral base. Most of these calls were low yield, but it paid dividends for him in the long run. About 1-2 years in, he began getting calls from physicians that he had talked to asking if he could do something for a patient.

Finally, Dr. Johnson speaks on how he approached prostate artery embolization (PAE), a procedure that previously didn’t exist in Fort Myers, FL, and used it to turn his practice into one of the biggest PAE centers in the Southeast. He thought of the procedure as a challenge, which he was looking for, and he knew there was a need in the community, so it was something he realized could grow. He didn’t know how to do PAE, but he turned to the STREAM Meeting to learn the technique. He stresses that this was not a fast process. It took 18 months from when he attended STREAM to when he got his first patient on the table. His first patients were self-referred. He built referrals by doing the procedure well and garnering good outcomes. Importantly, he provided good consults and follow-ups, always making sure to include a follow-up with their urologist to whom they reported the good results. To help his clinic run successfully, he had to hold himself accountable to ensure things got done. He relies heavily on digital reminders as well as a great medical assistant who does most of his scheduling. For his PAE patients, who often experience post-PAE syndrome, it is important to him to be available for them; he doesn't want them to feel abandoned. He gives them his cell phone and tells them to call him day or night. It is important to him to be more than just the technician. He wants to be there for them, to be the first person they call, to be their physician. He also believes closing the loop with referring providers is crucial to maintain rapport and a strong stream of new referrals.

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RESOURCES

STREAM Meeting:

https://www.thestreammeeting.com

In this crossover episode between BackTable VI and BackTable Innovation, Dr. Chris Beck interviews Dr. Riad Salem (Chief of Interventional Radiology at Northwestern University) and Peter Pattison (President of Interventional Oncology at Boston Scientific) about how TheraSpheres for Y90 radioembolization became a mainstay in the IR toolkit for HCC and where the technology is heading next.

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SHOW NOTES

To begin, Peter outlines how the original concept of TheraSpheres began at the University of Missouri, as a collaboration between Drs. Delbert Day and Gary Ehrhardt, who combined their ceramic and nuclear chemistry expertises to create radioactive glass beads and published a paper in 1987. After animal and human testing, the product was licensed to the company Nordion, where Peter worked. The product was given a humanitarian device exemption (HDE) from the FDA, which allowed TheraSpheres to be used for investigational purposes.

In the late 1990s, Dr. Salem was in his early interventional oncology career and heard about TheraSpheres. He recognized the enormous potential that this technology had to ensure known amounts of radioactive doses were delivered to the tumor and minimize adverse effects. In fact, he noticed that his Y90 patients had less pain, post-embolization syndrome, and hospitalization than his transarterial chemoembolization (TACE) patients. In the mid 2000s, he collected and submitted data to various conferences and journals, but he was met with criticism from the IR world, which was more comfortable with TACE, since it was the current standard of care.

In 2011, Nordion decided to run a clinical trial, EPOCH, which eventually showed that the addition of TARE to systemic therapy for colorectal metastases to the liver led to longer progression free survival.

Dr. Riad has focused his efforts on training more IRs on the methodology of Y90, since this was an important step to increasing adoption and minimizing missteps with the new technology. He believes that the advent of Y90 has resulted in better angiography, since IRs are more cognizant of off-target embolization. Dr. Salem also petitioned at the US Nuclear Regulatory Committee to allow IRs to become the authorized users for Y90 injection and advocated to add TARE to the National Comprehensive Cancer Network guidelines for liver cancer. Both of these developments allowed TARE to become more widely adopted.

Finally, Peter discusses the competition that TheraSpheres has faced from TACE and SIRSpheres (resin-based radioembolization). He shares exciting new developments that have occurred since acquisition by Boston Scientific. These include exploration for the extra-hepatic use of TheraSpheres in glioblastoma and prostate cancer.

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RESOURCES

BackTable Ep. 223- Portal Vein Recan #ReCanDoIt with Dr. Riad Salem:

https://www.backtable.com/shows/vi/podcasts/223/portal-vein-recan-recandoit

Therapeutic Use of 90Y Microspheres:

https://pubmed.ncbi.nlm.nih.gov/3667306/

A phase I dose escalation trial of yttrium-90 microspheres in the treatment of primary hepatocellular carcinoma:

https://pubmed.ncbi.nlm.nih.gov/1327493/

Hepatic radioembolization with yttrium-90 containing glass microspheres: preliminary results and clinical follow-up:

https://pubmed.ncbi.nlm.nih.gov/7931662/

Humanitarian Device Exemption:

https://www.fda.gov/medical-devices/premarket-submissions-selecting-and-preparing-correct-submission/humanitarian-device-exemption

EPOCH Trial:

https://ascopubs.org/doi/full/10.1200/JCO.21.01839

Radioembolization with 90Yttrium Microspheres: A State-of-the-Art Brachytherapy Treatment for Primary and Secondary Liver Malignancies:

https://www.jvir.org/article/S1051-0443(07)60901-4/fulltext

In this episode, cohosts Dr. Aparna Baheti and Dr. Aaron Fritts interview interventional radiologist Dr. Sandeep Bagla about “The Halo Effect”, including how to recognize when you are being subjected to bias, and how to critically evaluate bad outcomes to improve your practice and enhance patient safety.

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

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SHOW NOTES

Dr. Bagla begins by describing the halo effect. The halo effect describes the tendency for people to overestimate the value of individual positive attributes when evaluating the whole. Thiis can happen when we form our opinions of people, techniques, and even medical devices. The opposite is also true, named the horn effect, where we tend to overestimate negative attributes. They are both forms of bias. In interventional radiology, the halo effect can impact case outcomes by contributing to operator tunnel vision and the reluctance to waver from the desired way of executing a procedure.

For Dr. Bagla, the idea of the halo effect came about while working with new colleagues, many of whom do things differently than he did. He realized that in IR, physicians do things a certain way because that’s how they learned in training, whether it really is the safest and best way, or just the most familiar. He also sees the horn effect occur often when people start using a new device. If the device doesn’t work well for them the first time, many often refuse to use it in the future based on that first experience. He summarizes by noting that in IR, there are so many opportunities to become biased, whether through the halo effect or the horn effect.

Lastly, Dr. Bagla reviews how he works to avoid these inherent biases. The first step in overcoming this bias is to understand its presence. Next, you must stop and realize that what you are doing is not working, whether due to the procedural approach, the device, or the way you are using the device. Dr. Bagla believes we must be critical of ourselves and try to think outside of our preferred wire, catheter, or device. In order to do this, you must go through the steps and review your checklist in order to determine which step the problem occurred at. Only by doing this can you avoid falling victim to these biases that are so prevalent in medicine.

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RESOURCES

BackTable Episode 195: Disclosures of Conflicts of Interest

https://www.backtable.com/shows/vi/podcasts/195/disclosures-of-conflicts-of-interest

In this next installment of our Back to the Basics series, Drs. Aaron Fritts and Chris Beck discuss their techniques, considerations, and tips for ensuring safe and high quality renal biopsies.

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SHOW NOTES

First, the doctors discuss indications and contraindications for biopsy. In the outpatient setting, the doctors have noticed that proteinuria is the most common reason for referral, followed by lupus nephritis. For inpatients, acute unexplained kidney failure is an additional indication. It is important to talk with nephrologists to weigh the risks and benefits of renal biopsy, especially if the patient has a coagulopathy, is experiencing uncontrolled hypertension, or is too unstable to lay prone on the table. The SIR Guidelines app is a useful tool to risk stratify patients.

In terms of imaging, CT or ultrasound can be used, although they each have unique advantages. Ultrasound allows for real-time guidance and the ability to use the probe to hold pressure on the kidney to prevent bleeding. On the other hand, CT allows for better imaging in patients with larger body habitus and allows the patients to lay prone. Dr. Fritts emphasizes that the best imaging modality is the one that the operator is most comfortable with, since this will ensure maximal safety for the patient. One helpful tip when planning a biopsy is to avoid needle entry into the paraspinal muscles, since this could change the trajectory of the needle and cause pain.

Both doctors prefer to use moderate sedation if the patient can tolerate it. This sedation usually has the added benefit of facilitating an intra-procedural blood pressure dip, which protects against bleeding when biopsying hypertensive patients. Since sedation can alter breathing patterns, starting sedation early (before scanning the patient) can be helpful in establishing a steady breathing pattern before the procedure starts. Dr. Beck also recommends checking blood pressure while the patient is in pre-operative care, in order to predict whether or not they might require additional intra-procedural antihypertensive medications such as hydralazine, labetalol, or clonidine. Since blood pressure control is a cornerstone of a safe procedure, each doctor has their own safety threshold for blood pressure.

Then, the doctors discuss different types and sizes of biopsy needles. While a 16G needle can obtain better diagnostic samples, the 18G needle might have a lower risk of bleeding complications. The doctors also share their preferred brands of needles.

The episode concludes with tips for surveilling patients in the post-procedural period and dealing with bleeding complications. Dr. Beck describes his protocol for re-scanning patients to check for large hematomas and keeping them under observation for at least three hours. If there is a large hematoma, emergency embolization must be performed.

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RESOURCES

SIR Guidelines App:

https://apps.apple.com/us/app/sir-guidelines/id1552455529

SIR Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions:

https://www.jvir.org/article/S1051-0443(19)30407-5/fulltext

18G BioPince Biopsy Needle: https://www.argonmedical.com/products/biopince-full-core-biopsy-instrument

Bard Mission Biopsy Needle:

https://www.bd.com/en-us/products-and-solutions/products/product-families/mission-disposable-core-biopsy-instrument

Temno Biopsy Needle:

https://www.merit.com/peripheral-intervention/biopsy/soft-tissue-biopsy/temno-evolution-biopsy-device/

On this episode, BackTable VI host Dr. Christopher Beck shares the mic with two Maternal Fetal Medicine (MFM) specialists, Drs. Roxane Rampersad at Washington University and Tony Shanks at Indiana University, to discuss cross-specialty management of postpartum hemorrhage (PPH) between OBGYN and interventional radiology (IR).

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In this episode, host Dr. Aaron Fritts interviews interventional cardiologist Dr. Rohit Amin about his private practice PE response team, including his treatment algorithm, follow-up protocol, and how he believes AI can contribute to PE care.

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SHOW NOTES

Dr. Amin trained at Ochsner Clinic in New Orleans, and now works in private practice in Pensacola, Florida. He and a partner decided to start a PE response team (PERT) to better serve patients in the area and expand their practice. It took a lot of groundwork. They had to pitch it to administration and raise awareness, which they did by hosting CME such as grand rounds. They struggled to get a pulmonologist on board in 2013 when there was less clinical data and guidelines.

Next, we discuss how the PERT algorithm functions in his private practice. An ER doctor or hospitalist evaluates the patient first. If the CT shows proximal thrombus, the PERT is notified. If it is a massive PE or submassive with clinical severity, he does thrombectomy promptly. If there is no elevated troponin and normal hemodynamics, the patient gets admitted and evaluated with a stat echo and venous doppler. Dr. Amin’s practice prefers an echo with PE protocol to risk stratify RV dysfunction - i.e. RV size, tricuspid annular plane systolic excursion (TAPSE). He also evaluates pulmonary artery (PA) pressure, PA saturation, and cardiac index which are important clinical factors that determine the optimal route of intervention. For patients with submassive PE who get admitted overnight, he gives all patients a heparinoid, preferably lovenox over heparin. He sees the patient in the morning and if the clot is submassive or proximal, he does a thrombectomy that day.

Lastly, we cover the importance of treating PE and how Dr. Amin approaches longitudinal follow up. Dr. Amin refers to the ICOPER trial that showed that the 30 day mortality for submassive PE is 15%, higher than that of NSTEMIs. If a PE is left untreated or if treatment is significantly delayed, a patient can develop post-PE syndrome or chronic thromboembolic pulmonary hypertension (CTEPH), which significantly worsen morbidity and mortality. Dr. Amin treats his PE / DVT patients with one week of lovenox before transitioning to a direct oral anticoagulant (DOAC). He sees them in the office in one month and gets an echo at 3 months. He then sees patients semi-annually or annually for 3-5 years.

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RESOURCES

BackTable Episode 196:

https://www.backtable.com/shows/vi/podcasts/196/building-a-pe-response-team

PERT Consortium:

https://pertconsortium.org

ICOPER Trial:

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(98)07534-5/fulltext

In this episode, host Dr. Ally Baheti interviews interventional radiologist Dr. Luke Wilkins about his approach to the subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) technique for crossing challenging chronic total occlusions (CTO) in critical limb ischemia (CLI) patients.

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SHOW NOTES

Dr. WIlkins gives us the basic indication for the procedure, which is when the lesion is unable to be crossed from a purely antegrade approach and other re-entry devices have failed. Dr. Wilkins will always attempt to use an Outback wire and an Enteer balloon before performing the SAFARI technique. There are multiple factors that influence the decision to use SAFARI, such as lesion location, level of calcification, and size of the true lumen at the re-entry point.

Next, Dr. Wilkins walks us through a typical SAFARI. He normally establishes retrograde access in the dorsalis pedis or posterior tibial artery using a 4 cm micropuncture needle and an exchange length Nitrex wire. He uses telescoping catheters from the antegrade direction. When the antegrade and retrograde approaches enter the same subintimal plane, the 2 devices can connect and the lesion can be crossed. If it is challenging to achieve the same intimal plane for both devices, the gunsight approach of overlapping snares can be utilized. After the lesion is crossed, normal angioplasty and stenting can occur.

Dr. Wilkins gives advice on how to make the procedure efficient. In occlusions that are longer than 1 cm, he always makes sure that the foot is prepped before the case starts. He also emphasizes the importance of knowing when to try a different technique and notes that this intuition comes from experience.

Finally, we discuss patency rates for SAFARI patients, which have been relatively high. This technique has made a large impact on limb salvage in a patient population that previously had no other non-surgical options.

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RESOURCES

Rotarex Atherectomy System:

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

Outback Re-Entry Catheter:

https://cordis.com/na/products/cross/endovascular/outback-elite-re-entry-catheter

Enteer Re-Entry Catheter/Balloon:

https://www.medtronic.com/us-en/healthcare-professionals/products/cardiovascular/chronic-total-occlusion-devices/enteer/indications-safety-warnings.html

Nitrex Wire:

https://www.medtronic.com/us-en/healthcare-professionals/products/cardiovascular/guidewires/nitrex.html

CXI Catheter:

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

Outcome and Distal Access Patency in Subintimal Arterial Flossing with Antegrade-Retrograde Intervention for Chronic Total Occlusions in Lower Extremity Critical Limb Ischemia:

https://www.jvir.org/article/S1051-0443(19)31033-4/fulltext

In this episode, host Dr. Michael Barraza interviews interventional radiologist Dr. Doug Hidlay about how he has built a solo IR practice in rural Virginia, including how he got equipment, employees and referrals to build a busy and diverse practice.

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SHOW NOTES

Dr. Hidlay begins by discussing how he was recruited out of fellowship into a medical group in Virginia. They offered him the opportunity to build an entire IR practice and do the kinds of procedures that he wanted to bring with whatever skills he had from his residency at Brown and fellowship at the University of Washington. He is employed by a hospital group where he does about 30% diagnostic radiology, runs his own clinic and sees consults. He was hired to prioritize IR, and feels very supported by his diagnostic colleagues to do so.

We discuss what he learned through this process, and what he wished he would have known. He says the biggest surprises were from his own naivete, having gone straight into this position out of fellowship. The administration was up front with him and told him to expect to have to build this practice from scratch. When he started, he had 6 FTEs including himself, a scheduler, 3 techs and 3 nurses. He started off doing about 10 paracenteses, a couple lung biopsies and some thyroid biopsies per week. He attributes his success to showing up consistently. He asked for time to talk at every local practice and grand rounds. He met with surgeons, hospitalists, and primary care doctors to tell them what he could do, with the idea that even if they didn’t remember, they would have his number and could reach him at any time. What he didn’t realize was how much of a need there was. He soon became overwhelmed by the demand, and realized he was in over his head, doing 12-18 cases daily with the same support staff.

As for acquiring equipment to do procedures, Dr. Hidlay feels he was fortunate to have administration who were willing to believe him when he said he needed certain equipment. When it came to training staff, he often worked with them at the backtable and taught them how to use the image intensifier (II) controls to help them ‘learn by doing’. He started out on call 24/7, while his 3 techs and nurses were on call every 3 days. He slowly adjusted this as it was unsustainable for all, and has more staff now. By volume, he still mostly does light IR and feels that if he didn’t accept these cases he would never have built trust and made connections to referring providers. He also has a kyphoplasty service, a venous thromboembolism (VTE) service, and also does a sizeable volume of renal ablations, chemoembolizations, and emergent bleeds. He is hoping to bring on two more IRs to round out his practice and meet the community demand.

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RESOURCES

BackTable Episode 221: Building a Musculoskeletal Interventional Oncology Service with Dr. Alan Sag

https://www.backtable.com/shows/vi/podcasts/221/building-a-musculoskeletal-interventional-oncology-service

Doug Hidlay Twitter:

@DHidlayVIR

In this episode, host Dr. Aaron Fritts interviews Dr. Marc Sapoval about practicing IR in France, the origins of the Global Embolization Oncology Symposium Technologies (GEST) Conference, and an upcoming conference in MSK embolization.

The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/PX6J62

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Global Embolization Oncology Symposium Technologies (GEST) Conference

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RADPAD® Radiation Protection

https://www.radpad.com/

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SHOW NOTES

First, Dr. Sapoval gives an overview of the French IR landscape. He outlines the training pathway, which is a four year radiology program with an additional two years of IR specialization. He also describes his role at an academic hospital. Dr. Sapoval says that in his country, collaboration with other endovascular specialists depends on both interpersonal relationships and business incentives.

For the remainder of the interview, we talk about how GEST began and where it is today. In 2007, Drs. Marc Sapoval, Jafar Golzarian, and Ziv Haskal started the first GEST conference in Barcelona, after they realized the need for a specific meeting geared towards embolization. This inaugural meeting turned out to be a success, with attendance reaching much higher numbers than they had originally anticipated. Since then, GEST annual meetings have taken place throughout Europe and the United States. In recent years, it has found a permanent home in New York City.

Dr. Sapoval introduces a new smaller conference series called GEST Hot Topics. An upcoming conference in this series focuses on MSK interventions, and it will be held in Paris on January 20-21, 2023. He emphasizes that it is an incredible opportunity to be part of a new field of IR. He highlights speakers who currently lead research efforts in MSK embolization and encourages all listeners to register and attend GEST Hot Topics: MSK Embolization.

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RESOURCES

GEST Hot Topic: MSK Embolization:

https://thegestgroup.com/gest-msk-2023-paris/

GEST Annual Conference 2023:

https://annual.thegestgroup.com/GEST23/Public/mainhall.aspx