BackTable Vascular & Interventional

Vascular surgeon Krishna Mannava and Chas Sanders (founder of MARGIN) discuss their approach to choosing which disposables and devices to stock up on in the outpatient facility, and how to plan for supply chain issues.

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In this episode, host Dr. Aaron Fritts interviews Dr. Krishna Mannava, vascular surgeon and owner of Vive Vascular and Chas Sanders, founder and CEO of MARGIN, LLC about supply chain in an office-based lab (OBL), focusing on disposables and how to pivot amidst impending reimbursement cuts.

The three start by discussing how Dr. Mannava chose to source equipment when building his OBL. He was introduced to Chas Sanders of MARGIN through his advisory firm as they were looking at ways to approach vendors and build inventory. Chas advises against all inclusive packages with one company. Dr. Mannava states that MARGIN has not only helped him get good deals on equipment, but they have mediated relationships with companies and sales reps which has been crucial for him.

Next, they discuss supply chain issues and the impact on healthcare and Vive Vascular. Chas believes the best way to offset this is by not putting all your eggs in one basket. For an OBL, it is better to have a surplus of disposables and throw some out rather than cancel a surgery due to a backorder or recall. Chas shares his thoughts on Management Service Organizations (MSOs) for shared resources, stating that while they can be helpful with sourcing and pricing of supplies, an MSO takes around 10% of revenue which for many OBLs means paying for more than you need. They also discuss the future of multispecialty endovascular centers, and the potential for physician collaboration.

Finally, they discuss reimbursement cuts and how to compensate for this loss. Chas recommends reassessing products, evaluating procedure mix and looking at capacity, as these can all be adjusted to improve profits. Dr. Mannava adds that front desk personnel can help by ensuring insurance, coding and charges are accurate.

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RESOURCES

Vive Vascular:

https://www.vivevascular.com

MARGIN, LLC:

https://www.margin.care

En este episodio de BackTable Español, Dra. Gina Landinez entrevista a Dr. Miguel Montero-Baker sobre la enfermidad arterial periférica y salvamento de extremidades en la comunidad latinoamericana.

In this episode of BackTable Español, Dr. Gina Landinez interviews Dr. Miguel Montero about peripheral arterial disease and limb salvage in the Latin American community.

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Los dos doctores discuten el camino de Dr. Montero-Baker a convirtirse en un Cirujano vascular enfocado en el salvamento de extremidades, su experiencia de construir un centro de preservación, y diferencias culturales entre los pacientes latinoamericanos y estadounidenses. Además Dr. Montero-Baker comparte sus consejos sobre sus técnicas, su equipo preferido, y como superó los retos institucionales para empezar un programa del salvamento extremidad. Finalmente, él enfatiza la importancia de la prevención y la educación del paciente sobre la enfermedad arterial periférica.

The two doctors discuss Dr. Montero's path to becoming an interventional radiologist focused on limb salvage, his experience building a preservation center, and cultural differences between Latin American and US patients. Additionally, Dr. Montero shares his advice on his techniques, his preferred equipment, and how he overcame institutional challenges to start a limb salvage program. Finally, he emphasizes the importance of prevention and patient education about peripheral arterial disease.

In this episode we talk with Dr. John Lipman about his journey to going solo and opening an Outpatient Based Lab (OBL) dedicated to minimally invasive women's interventions, including Uterine Fibroid Embolization (UFE). John also gives us advice on the importance of finding your Ikigai in practice, the secret to a long and happy career!

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Accountable Physician Advisors

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SHOW NOTES

In this episode, interventional radiologist Dr. John Lipman joins host Dr. Aaron Fritts to discuss how he came to be one of the first IRs to own an office-based lab (OBL) and how he decided to specialize in uterine fibroid embolization (UFE).

Dr. Lipman begins by discussing his path to independent practice. After training at Georgetown, Brigham and Women’s and Yale, he worked in a private practice in Atlanta. In 2004, after 14 years and a growing desire to be an independent IR, he found a hospital to partner with where he could work independently. He started with professional fees only before landing a 50/50 joint venture deal with the hospital. He installed an MRI and angio suite and used a retired ER for his recovery rooms.

In 2015 he opened his OBL, the Atlanta Fibroid Center. He was able to lease equipment and buy the real estate with loans and capital he had from his prior practice. He decided to specialize in uterine fibroid embolization for his practice rather than performing a variety of procedures. He says that ultimately, he decided to specialize in what he was most passionate about.

The two discuss how Dr. Lipman received enormous pushback and criticism from many who thought opening a center that only offered one procedure was impossible. He used the antagonism as fuel, and after consulting women's groups in Atlanta he opened an OBL that focused on quality and privacy. Dr. Lipman ends by discussing how OBLs are the future of medicine and that they are a method for physicians to take back ownership of medicine from hospital administrators and recover the patient physician relationship.

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RESOURCES

Outpatient Endovascular and Interventional Society:

https://oeisociety.com

Atlanta Fibroid Center:

https://atlii.com/

In this episode, Interventional Radiologist Sabeen Dhand talks with Interventional Cardiologist S. Jay Mathews about novel techniques for arterial thrombectomy, including a discussion on using large bore devices, a variety of technique tips and tricks, and what's on the horizon for new devices/techniques.

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Boston Scientific Eluvia Drug-Eluting Stent

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SHOW NOTES

In this episode, interventional cardiologist Dr. S. Jay Mathews and our host Dr. Sabeen Dhand discuss various devices used in arterial thrombectomy, including large bore aspiration catheters, the preclose system, separators, and stentrievers.

Dr. Mathews clarifies the definition of “large bore” as a catheter that is 8 Fr or larger. He notes these devices face some resistance in the interventional community, due the belief that arteries may be size prohibitive. However, he notes that the pre-close systems make arterial closure very feasible. Large bore catheters are able to achieve higher aspiration force compared to smaller catheters. Dr. Mathews prefers to use the Lightning 7 or 12 systems from Penumbra because of their angled/atraumatic catheter tips and their flexibility in navigation.

In cases of highly organized thrombus, Dr. Mathews may use separators to break up the clot into smaller and more manageable parts. He also speaks about using filters to capture the clot, but always in conjunction with aspiration, to prevent distal embolization.

The doctors also discuss the role of thrombolysis. Although thrombolysis procedure time is shorter than that of thrombectomy, patients remain ischemic for longer, leading to more reperfusion symptoms. Before placing a lysis catheter, Dr. Mathews recommends re-establishing some flow and creating a channel for more effective delivery of tPA.

Finally, we talk about new research in thrombus morphology and how this will affect future innovation in ultrasonic energy and nano-magnetic particles.

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RESOURCES

Penumbra Lightning Catheter:

https://www.penumbrainc.com/indigo-lightning/

Noninvasive thrombectomy of graft by nano-magnetic ablating particles:

https://www.nature.com/articles/s41598-021-86291-2

The episode begins by discussing the training of a sales rep, which includes learning customer relations, procedure and product details as well as the disease states and anatomy of procedures. Aaron Weeks discusses how a key aspect of sales is understanding product compatibility and knowing what alternatives are available.

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In this episode, Aaron Weeks, program manager at Cook Medical joins host Dr. Aaron Fritts to discuss what it takes to become a sales rep, qualities of a good sales rep, and how to establish customer rapport.

The episode begins by discussing the training of a sales rep, which includes learning customer relations, procedure and product details as well as the disease states and anatomy of procedures. Aaron Weeks discusses how a key aspect of sales is understanding product compatibility and knowing what alternatives are available.

The speakers discuss degrees and pay next, and Weeks clarifies that an MBA is not a requirement. He says around half of IR sales reps now were previously techs or nurses because they know the procedures well, making them great trainees and knowledgeable reps. Pay is variable, but often starts as a base salary when training, with quotas or other incentives added later on.

Next, the speakers discuss what qualities make a good sales rep and pitfalls to avoid on the job. Weeks notes the importance of emotional intelligence and being able to read the room. He notes that those who are easily frustrated or trying to make a quick sale will not be as successful. The speakers agree that one of the biggest strengths of a good sales rep is knowing their product's limitations and when to step away.

The speakers touch on the difficulties that COVID has placed on the job. Weeks discusses how he stays up to date on current products and techniques being used for the procedures he covers. He says podcasts, virtual society meetings and other digital media outlets have played a key role in this aspect of his job.

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RESOURCES

JVIR Website: https://www.jvir.org

Salesforce Website: https://www.salesforce.com

Cook Medical Website: https://www.cookmedical.com

Aaron Weeks Linkedin: https://www.linkedin.com/in/aaron-weeks-753bb1

In this episode Dr. Kumar and Dr. Bennett discuss various levels of racism found in healthcare, and share allegories of racism as outlined by Dr. Camara P. Jones, including the gardeners tale.

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In this episode, guest host Dr. Vishal Kumar interviews Dr. Ayanna Bennett about how to train ourselves to recognize perpetuated health disparities within the medical system and how we can actively work to dismantle them.

The doctors first talk about understanding racism on an institutional level, which results in a “machine” that selectively delivers better and worse aspects of healthcare to different populations. Dr. Bennett emphasizes that every disease process shows race disparities not because of inherent biological differences in racial groups, but because of unequal frequencies and quality of contact with healthcare systems.

Throughout the episode, they reference the allegories of Dr. Camara Jones, a physician-epidemiologist and civil rights activist. These allegories provide a framework for discussing nature vs. nurture for health outcomes and also privilege defined as the lack of barriers to entry.

In terms of actionable steps that providers can take toward reducing health inequity, Dr. Bennett encourages us to learn and engage with the communities that they serve. She advises us to be “counter-stereotypical” and show interest in patients’ lives outside of the healthcare setting. Finally, she calls us to analyze the impact that our institutions have on maintaining the health of the community as a whole, rather than solely focusing on individual patients.

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RESOURCES

The Gardener’s Tale Allegory by Dr. Camara Jones:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1446334/

Tedx Talk by Dr. Camara Jones:

https://www.youtube.com/watch?v=GNhcY6fTyBM

Dr. Sabeen Dhand talks with Neurointerventionalist Dr. Ansaar Rai from about his approach to posterior circulation strokes, including patient selection, technique and devices, and pitfalls to avoid.

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In this episode, neurointerventional radiologist Dr. Ansaar Rai joins Dr. Sabeen Dhand to discuss posterior circulation stroke, including when to treat with thrombectomy, techniques, and advances in stroke research in recent years. They discuss factors to consider when deciding to treat posterior circulation strokes with thrombectomy. Dr. Rai reports that age is the most important factor, followed by comorbidities and severity of clinical symptoms. He discusses the variability in presentation of basilar artery strokes, ranging from mild ataxia to coma. He treats these aggressively with thrombectomy, especially for young patients. For isolated PCA strokes, he often treats with intra arterial TPA only.

Dr. Rai next discusses landmark clinical trials, as well as his own research looking at stroke burden. He found that 2% of all acute ischemic strokes occur in the posterior circulation. Importantly, he postulates that there will never be good posterior circulation trials due to lack of equipoise and difficulty in randomizing to a medical treatment only arm.

Dr. Rai uses general anesthesia for posterior circulation strokes. He prefers femoral access, and uses an 8Fr femoral short sheath and a guide catheter (ideally 088), rather than a balloon guide catheter. He then uses an 070 or 072 intermediate aspiration catheter navigated over an 024 microwire (Aristotle) or 027 microcatheter (Duo or XT-27) into the basilar. After trying many techniques, he prefers aspiration using the ADAPT technique. If he has to cross clot, he uses a stent retriever such as Trevo, Embotrap or Solitaire. Due to the delicate vasculature and high risk in posterior circulation thrombectomies, Dr. Rai always uses a J wire, biplane imaging and emphasizes that knowing the anatomy on CT is key to decreasing complications such as dissection or distal embolization.

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RESOURCES

ASPECTS score: https://www.ahajournals.org/doi/10.1161/STROKEAHA.117.016745

Route 92 Medical SUMMIT MAX Clinical trial: https://evtoday.com/news/route-92-medicals-monopoint-reperfusion-system-studied-in-pivotal-summit-max-trial#:~:text=According%20to%20Route%2092%20Medical%2C%20SUMMIT%20MAX%20is,sites%20in%20the%20United%20States%20and%20New%20Zealand.

The Greater Cincinnati Northern Kentucky Stroke Study: https://www.gcnkss.com

MR RESUE trial: https://www.ahajournals.org/doi/full/10.1161/strokeaha.113.001443

IMS3 trial: https://evtoday.com/news/ims-3-substudy-shows-delays-in-stroke-treatment-leads-to-worse-outcomes#:~:text=IMS%203%20was%20a%20multicenter%20international%20trial%20in,received%20tPA%20within%203%20hours%20of%20stroke%20onset.

SWIFT PRIME trial: https://evtoday.com/news/covidien-commences-enrollment-for-swift-prime-acute-ischemic-stroke-study#:~:text=The%20SWIFT%20PRIME%20study%20will%20evaluate%20acute%20ischemic,will%20also%20include%20an%20extensive%20health%20economics%20analysis.

ADAPT technique trial by Turc: https://www.ahajournals.org/doi/10.1161/STROKEAHA.119.025753

BEST trial: https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(19)30395-3/fulltext#:~:text=The%20BEST%20trial%20was%20a%20multicentre%2C%20prospective%2C%20open-label%2C,the%20institutional%20review%20board%20of%20each%20participating%20site.

ATTENTION trial: https://pubmed.ncbi.nlm.nih.gov/35102797/

Dr. Fred Bertino educates us on anticoagulation regimens for patients after deep venous interventions.

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In this episode, pediatric interventional radiologist Dr. Fred Bertino joins our host Dr. Chris Beck to discuss new data on anticoagulation regimes before, during, and after venous stenting and/or mechanical thrombectomy.

Dr. Bertino starts by reviewing the difference between the compositions of arterial versus venous clots. Arterial clots are formed as a response to endothelial injury and exposure of von Willebrand factor, so these clots are usually platelet-rich. On the other hand, venous clots are formed due to stasis, and these are usually platelet-poor. Therefore, antiplatelet therapy may not be ideal for venous clots. However, Dr. Bertino notes that stent placement can cause endothelial injury at the apposition points of the stent, so the treatment algorithm can become more complex in these cases.

The doctors note that there are non-thrombotic diseases that require venous stenting, such as May Thurner syndrome. Dr. Bertino says that addressing this early in the pediatric population can be a safe way to prevent future DVT, as long as children are monitored carefully.

Next, Dr. Bertino walks us through his preferred anticoagulation routine for stent placement. Four hours before the procedure, he starts with a dose of Factor Xa inhibitor (apixaban or rivaroxaban) to prevent in-stent thrombosis. The patient is maintained on heparin during the procedure. After the procedure, anticoagulation varies depending on whether a stent was placed, or solely mechanical thrombectomy was performed.

Finally, the doctors discuss preferred anticoagulation for special scenarios such as covered stents (which can be more thrombophilic) and patients with malignancies. Dr. Bertino encourages IRs to reach out to their hematology colleagues to stay updated on anticoagulation research, as well as physical and occupational therapists to help patients form long-term DVT prevention plans.

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RESOURCES

Find this episode on backtable.com to see the full library of resources mentioned by Dr. Fred Bertino.

Interventional Radiologist Dr. Preston Smith and healthcare attorney Patrick Souter join us to discuss strategies for navigating the legal world of non-compete agreements and exclusive contracts.

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First, we review the vocabulary and examples of each type of agreement. Mr. Souter emphasizes that contrary to popular misconceptions, non-compete agreements are enforceable, as long as they are reasonable in scope, geographic location, and time frame. Additionally, he calls attention to “backdoor noncompetes,” which are clauses that, while not officially called “noncompetes,” still restrict a physician’s ability to practice medicine in a certain location. These include non-circumvention and non-solicitation agreements. Dr. Smith advises listeners to be wary of any terms that seem far-reaching or unreasonable, and to have a legal professional review the terms of the agreement.

Next, we discuss exclusive contracts between large radiology practices and hospitals. While they are legal, they cannot be entered into for antitrust purposes of trying to prevent others from entering the marketplace. Exclusive contracts can serve as a barrier for independently practicing IRs to gain hospital privileges. Mr. Souter advises independent IRs to speak with hospital CMOs and provide reasonable explanations for why their services would be efficient and necessary for quality patient care.

We talk with Interventional Radiologist Dr. Sandeep Bagla about the challenges of clinical research in private practice, and the inspiration behind building a new practice paradigm in collaboration with Urology colleagues.

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In this episode, interventional radiologist and entrepreneur Dr. Sandeep Bagla joins our host Dr. Aaron Fritts to discuss the founding and multispecialty focus of Prostate Centers USA, a rapidly expanding network of office based labs (OBLs).

Dr. Bagla describes why he decided to shift away from his former private practice and embark on a new venture that would eventually become Prostate Centers USA. Dr. Bagla sought to focus on embolization, a novel area of interventional radiology. He recounts the process of conducting prostate artery embolization clinical trials in a private practice environment, including challenges encountered and lessons learned about changing FDA regulations.

Dr. Bagla developed Prostate Centers USA from a vision of collaboration with urologists to provide comprehensive procedural and clinical care. He describes how he pitched his collaborative approach to urologists and how he dealt with pushback. He also describes why the centers’ ownership structures and focused training pathways are attractive to physicians. Finally, Dr. Bagla highlights technologies that allow for ease of communication between the team members, such as task management systems and centralized monitoring systems.

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RESOURCES

Ep. 164 Collaborative Approach to Prostate Artery Embolization (PAE) for BPH:

https://www.backtable.com/shows/vi/podcasts/164/collaborative-approach-to-prostate-artery-embolization-pae-for-bph

Prostate Centers USA: https://www.prostatecentersusa.com/

Outpatient Endovascular and Interventional Society (OEIS) Annual Meeting: https://oeisociety.com/