Wysdom Radio™

This episode breaks down the practice-changing COLLISION Trial (Lancet Oncology, 2025) and explores how the IR community must scale its skills to meet the new standard of care.

The Mic Drop: For decades, surgical resection was the undisputed gold standard for Colorectal Liver Metastases (CRLM). The COLLISION trial randomized patients eligible for both surgery and thermal ablation. The trial was stopped early for benefit, proving that ablation is non-inferior for overall survival (Hazard Ratio 1.05).

The Staggering Cost Difference: While survival was equal, the physical toll was not. Surgery resulted in a 46% adverse event rate and a 4-day median hospital stay. Ablation cut complications to 19%, reduced the hospital stay to just one day, and had a 0% treatment-related mortality rate.

The A0 Margin Mandate: To match surgical success, IRs must achieve an A0 margin—a visible 5mm buffer of ablated tissue surrounding the tumor on post-procedure imaging. Achieving this margin ensures the absence of local progression in 95% of cases.

Scaling the Skillset: We discuss how the platform Wysdom (founded by Dr. Rusty Hoffman) is replacing the outdated "see one, do one, teach one" model. Through bite-sized "Clinical Pearls" and private "Morning Rounds," Wysdom provides just-in-time digital mentorship, allowing community IRs to learn complex techniques (like hydrodissection) necessary to achieve that critical A0 margin.

Tune in to hear why the default question at the tumor board is shifting from "Can we cut it out?" to "Why wouldn't we ablate this first?"

Based on comments from experts, content on Wysdom, and the article cited below.

Puijk RS, Ruarus AH, Vroomen LGPH, et al. Colorectal liver metastases: surgery versus thermal ablation (COLLISION) - a phase III single-blind prospective randomized controlled trial. BMC Cancer. 2018;18(1):821. Published 2018 Aug 15. doi:10.1186/s12885-018-4716-8

The alphabet soup of societies (AHA/ACC/ACCP/ACP) has officially released the 2026 Multi-Society PE Guidelines. These guidelines move the field away from the blunt submassive labels and into a new era of granular, physiology-driven care.

Categories Classifications A–E: The 2011 AHA labels are officially retired. We now use a spectrum from Category A (Subclinical) to Category E (Cardiopulmonary Failure). Key for IR: Advanced therapies are now strictly reserved for Categories D and E, while most Category C patients (even with RV strain) remain on medical management unless they deteriorate.

The "R" Modifier: A new suffix for patients whose primary threat is respiratory failure rather than hemodynamic collapse (e.g., Category C2R), allowing for a more nuanced triage during PERT activations.

Reading Room Mandate: The guidelines emphasize that clot volume does not equal risk. Radiologists must now prioritize reporting RV dysfunction parameters—including RV:LV ratio, McConnell’s sign, and TAPSE—as these are the data points that actually drive the A–E categorization.

IVC Filter Pullback: In a major shift, routine IVC filter placement in anticoagulated patients is now a Class III: Harm recommendation. They are strictly limited to patients with absolute contraindications to anticoagulation or those failing therapy.

The "Clot in Transit" Data Vacuum: For the 2-4% of patients with floating intracardiac thrombus, the guidelines admit a lack of randomized data, mandating a multidisciplinary PERT decision rather than a fixed surgical or interventional algorithm.

Tune in to master the new rules of engagement for the IR suite and ensure your reports meet the 2026 standard.

Based on comments from experts, content on Wysdom, and the guidelines cited below.

Writing Committee Members*, Creager MA, Barnes GD, et al. 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. Published online February 19, 2026. doi:10.1161/CIR.0000000000001415

This episode covers the critical paradigm shift in treating Pulmonary Arteriovenous Malformations (PAVMs) as detailed by Dr. Lynne Martin from Stanford Interventional Radiology. We discuss why the old "block the pipe" method is obsolete and how to achieve durable, definitive occlusion.

The Silent Neurological Threat: We explore why intervention isn't about hypoxia—it's about preventing paradoxical emboli. With stroke risks up to 32% and a 40-50% prevalence of silent brain infarctions, the lung's broken filter puts the brain directly in the firing line.

The Odontogenic Connection: A crucial clinical pearl: routine dental cleanings can cause brain abscesses in PAVM patients because transient oral bacteria bypass the lung filter. Lifetime antibiotic prophylaxis for dental work is mandatory.

The "3mm Myth": The old rule of only treating feeding arteries >3mm is dead. Modern guidelines dictate that any measurable, safely catheterizable PAVM—even 2mm feeders—must be treated, as they still carry significant stroke and abscess risk.

Why Proximal Coiling Fails (The Jailed Nidus): Placing a coil proximally creates a low-pressure, ischemic environment that triggers massive VEGF release, recruiting tiny collateral vessels to feed the sac. This creates a "jailed nidus"—a growing AVM that is now impossible to access and treat.

The New Standard ("Pack the Bucket"): Dr. Martin advocates for complete mechanical occlusion of the nidus itself using soft, high-volume detachable coils ("liquid metal"). We discuss why vascular plugs are contraindicated inside the sac and how to hunt for the hidden systemic feeders (bronchial/intercostal arteries) that cause recurrence.

Tune in to learn why we are moving away from being "catheter plumbers" and how to definitively protect your PAVM patients.

This episode tackles one of the most technically demanding procedures in IR, breaking down Dr. John Louie’s protocol to transform the traditional "blind stick" of a TIPS procedure into a visualized, scientific process.

The Visualization Crisis: Standard iodinated contrast fails to opacify the portal vein 75% of the time because it washes out with flow. We discuss why CO2 digital subtraction angiography is the superior alternative, achieving an 87% visualization rate by using buoyancy to backfill the portal system.

The "Targeted Puncture": How using CO2 turns a missed needle pass into a roadmap, allowing you to correct your angle based on visual feedback rather than guessing.

IVUS as the Great Equalizer: We review data showing that Intravascular Ultrasound (IVUS) significantly reduces radiation and capsular perforations. Crucially, the data shows IVUS benefits inexperienced operators the most, allowing them to match the speed and safety of veterans.

The Anatomy Hack: Dr. Louie solves the "Parallel Vein" illusion (where the Right and Middle Hepatic veins overlap) with one simple move: Check the Lateral View. The RHV will always be posterior.

The "Backdoor" (DIPS): When standard access fails, Direct Intrahepatic Portosystemic Shunt (DIPS) is the alternative. We discuss why it's a last resort due to the risks it poses for future liver transplantation.

Tune in to learn how to stop "poking and praying" and start seeing your target.

This episode breaks down the evolving landscape of benign thyroid management, pitting the two thermal ablation titans against each other and exploring the vascular solution for massive goiters.

The 12-Month Divergence (RFA vs. MWA): A 2025 meta-analysis reveals that while short-term results are similar, Radiofrequency Ablation (RFA) proves superior at one year (83.3% vs 77% volume reduction). The reason? Microwave Ablation (MWA) creates high-heat carbonization ("charring") that the body struggles to resorb compared to the softer coagulative necrosis of RFA.

The "Thermal Overshoot" Risk: MWA is less forgiving, with a steeper thermal gradient that risks injury to the recurrent laryngeal nerve. RFA remains the safer "workhorse" for operators with less than 10 years of experience.

Solving the "Unavoidable" with TAE: For massive retrosternal goiters invisible to ultrasound, Thyroid Artery Embolization (TAE) is the only option. The study showed a 69% volume reduction and critical retraction of the retrosternal mass, restoring the patient's ability to breathe and swallow.

Managing the Hormone Dump: Infarcting a large goiter releases a massive wave of T3/T4. We discuss the critical management protocol: beta-blockers, methimazole, and the "pearl" of using bile acid sequestrants (Cholestyramine) to clear the hormone surge.

The Holy Grail of Euthyroidism: Unlike radioactive iodine or surgery which often lead to lifelong hypothyroidism, TAE showed an 86% success rate in returning hyperthyroid patients to a normal euthyroid state without medication.

Tune in to decide which tool belongs in your thyroid toolkit: the precision of RFA, the power of Microwave, or the vascular reach of Embolization.

Based on comments from experts, content on Wysdom, and the articles cited below.

Lim H, Cho SJ, Baek JH. Comparative efficacy and safety of radiofrequency ablation and microwave ablation in benign thyroid nodule treatment: a systematic review and meta-analysis. Eur Radiol. 2025;35(2):612-623. doi:10.1007/s00330-024-10881-7

Yilmaz S, Habibi HA, Yildiz A, Altunbas H. Thyroid Embolization for Nonsurgical Treatment of Nodular Goiter: A Single-Center Experience in 56 Consecutive Patients. J Vasc Interv Radiol. 2021;32(10):1449-1456. doi:10.1016/j.jvir.2021.06.025

This episode tackles one of the most frustrating clinical challenges in Interventional Radiology: the patient with a recurrent occult GI bleed who has failed endoscopy and standard imaging. We analyze the largest retrospective cohort study to date (22 years of data) on TPA-based Provocative Mesenteric Angiography (PMA) to determine when to use this aggressive diagnostic maneuver.

The Safety Surprise: Despite intentionally provoking bleeding with TPA and Nitroglycerin, the study revealed zero major bleeding adverse events, thanks to "first-pass hepatic metabolism" clearing the drugs before they hit the systemic circulation.

The "Secret Sauce" for Selection: We identify the two independent predictors that increase the odds of a positive study by nearly sevenfold:

Hematochezia (bright red/maroon stool).

A Prior Positive Radiologic Study (CTA or Tagged RBC), even if the bleed appeared to stop.

The Hard Stop: The data provides a clear exclusion criterion: zero patients with Melena (black tarry stool) and negative prior imaging had a positive PMA result, suggesting these procedures are likely futile.

Technical Mastery: Success relies on super-selectivity. Injecting from a distal, third-order vessel yielded a 63.6% positivity rate, compared to just 21.5% from a proximal injection.

Tune in to learn how to safely provoke the bleed on your terms and identify the source when all other methods fail.

Based on comments from experts, content on Wysdom, and the article cited below.

Benvenuti TA, Chisholm M, Cline B, et al. Provocative Mesenteric Angiography for Obscure Gastrointestinal Hemorrhage: An Update on Outcomes, Safety, and Predictors of Success. J Vasc Interv Radiol. 2025;36(10):1558-1566. doi:10.1016/j.jvir.2025.06.022

We are honored to include exclusive commentary from the study’s senior author and Chief of IR at Duke, Dr. Charles Kim. Dr. Kim provides a candid look at the last-ditch nature of this procedure and the future of the field:

A Last-Ditch Essential: Dr. Kim argues that while we may have reached the limit of what retrospective TPA data can tell us, PMA remains a vital tool for "desperate patients" that every major hospital IR team should be comfortable performing.

Navigating the TPA Paradox: He acknowledges the "referral friction" IRs often face, as TPA is technically contraindicated in patients with recent GI bleeding. Understanding the safety profile is key to managing these inter-departmental relationships.

The CO2 Frontier: Dr. Kim highlights the potential of CO2 Provocative Angiography. While his team currently uses it in their sequence, he notes that the extremely high positivity rates reported in some literature have been difficult to replicate—leaving the door open for future CO2 experts to refine the technique.

Tune in to learn how to safely provoke the bleed on your terms and identify the source when all other methods fail.

Dr. Rusty Hofmann, Professor of Interventional Radiology and founder of Wysdom, drops essential night-call wisdom after 25+ years of taking call: when & why to come in, how residents/fellows should present cases, and his famous 6 Cs mnemonic to never forget critical prep at 2–3 AM.

Key takeaways:

This quick, practical framework has saved countless chaotic night cases. A must-watch for every IR resident, fellow, APP, and attending who takes call.

#IRCall #NightCall #InterventionalRadiology #RustyHofmann #IRtips #6Cs #EmergencyIR #TIPS #GIBleed #StanfordIR #IRad #IRfellow #IRresident #IRcommunity #MedicalEducation #OnCall #Wysdom #IRpearls

This episode is inspired by Professor of Interventional Radiology Dr. John Louie from Stanford IR and moves beyond the standard safety guidelines to provide a practical "playbook" for managing the high lung shunt patient, focusing on how to prevent fatal Radiation Pneumonitis (RP) without canceling the case. 

The Hidden Threat: We define the stakes of Radiation Pneumonitis—a rare (0.1%) but highly lethal (40-60% mortality) complication with a delayed onset of 1-2 months.

Predicting the Shunt: Learn to spot the "Phasic CT Sign"—early venous streaming during the arterial phase—which signals a massive tumor fistula before you even order the MAA scan.

Mitigation Strategy A (Balloon Occlusion): We detail how placing a compliant balloon in the hepatic vein can reduce shunting by an order of magnitude (e.g., 20% down to 2%), effectively converting a contraindicated patient into a candidate. Pro Tip: Don't forget to occlude the accessory Inferior Right Hepatic Vein.

Mitigation Strategy B (Embolization Trap): The discussion reveals a critical counter-intuitive rule: Never use small particles to plug a shunt. This actually increases the shunt percentage by increasing resistance in healthy tissue. You must use large embolics (Gelfoam, large coils) to physically plug the fistula.

Glass vs. Resin: We explore real-world data suggesting the standard "30 Gray limit" may be too strict for Glass (which tolerates higher doses) and potentially too loose for Resin (where RP is more common).

Tune in to learn the specific techniques that let you safely treat the "untreatable" shunt.

This episode synthesizes the latest CIRSE standards and DRAGON trial findings to guide Interventional Radiologists in maximizing the Future Liver Remnant (FLR) and minimizing Post-Hepatectomy Liver Failure (PHLF).

The Limitation of Standard PVE: We discuss why Portal Vein Embolization (PVE) alone often isn't enough, with a sobering 15-20% failure rate where patients never reach resection due to insufficient hypertrophy or tumor progression.

The "Combined" Solution (DVE/LVD): The discussion explores why adding Hepatic Vein Embolization (HVE) to block outflow prevents collateral formation ("the enemy of hypertrophy"), creating a faster, more robust regenerative signal.

DRAGON 0 Results: The retrospective data is a game-changer: combined embolization achieved a 92% resectability rate (compared to just 68% for PVE alone) and significantly better long-term survival.

The Paradox of Speed: While the prospective DRAGON 1 trial showed massive growth speed (Kinetic Growth Rate of 8.3% per week), it revealed a critical warning: 22% of patients still developed liver failure despite hitting volume targets.

The New Standard: The takeaway is clear—Volume does not equal Function. To prevent failure in these rapidly regenerated livers, we must move beyond simple volume ratios and demand functional assessments like KGR and mebrofenin scintigraphy before surgery.

Tune in to understand why "making volume" isn't enough and how functional assessment is the new safety frontier.

Based on comments from experts, content on Wysdom, and the articles cited below.

Bilhim T, et al. CIRSE Standards of Practice on Portal Vein Embolization and Double Vein Embolization/Liver Venous Deprivation. Cardiovasc Intervent Radiol. 2024 Aug;47(8):1025-1036. doi: 10.1007/s00270-024-03743-8. Epub 2024 Jun 17. PMID: 38884781; PMCID: PMC11303578.

Korenblik R, et al., DRAGON collaborative study group. Safety and efficacy of combined portal and hepatic vein embolisation in patients with colorectal liver metastases (DRAGON1): a multicentre, single-arm clinical trial. Lancet Reg Health Eur. 2025 Apr 10;53:101284. doi: 10.1016/j.lanepe.2025.101284. PMID: 40255933; PMCID: PMC12008670.

 Korenblik R, et al., DRAGON trials collaborative. Liver regeneration after portal and hepatic vein embolization improves overall survival compared with portal vein embolization alone: mid-term survival analysis of the multicentre DRAGON 0 cohort. Br J Surg. 2024 Apr 3;111(4):znae087. doi: 10.1093/bjs/znae087. PMID: 38662462; PMCID: PMC11044894.

This episode explores the first-in-human trial of Sakura, a novel resorbable alginate microsphere designed specifically to solve the safety trade-offs of Genicular Artery Embolization (GAE) for knee osteoarthritis.

The Problem with Current Agents: We discuss why Interventional Radiologists have been stuck between using permanent particles (risk of skin ulcers/long-term pain) and off-label temporary agents (unpredictable resorption, antibiotic resistance).

The Bio-Innovation: This new device features an "internal timer"—an enzyme trapped inside the bead that activates upon hydration, ensuring predictable degradation within just 1 to 2 hours.

Safety Game-Changer: The trial showed zero serious adverse events. Crucially, non-target skin redness resolved in just 2 hours, compared to weeks with traditional agents, drastically improving the safety profile.

Efficacy vs. Speed: Despite the rapid resorption, patients achieved a 77% reduction in pain at 3 months, and 93% stopped taking pain medication entirely, suggesting that a brief ischemic "reset" is all that is needed to stop the pain cycle.

Tune in to see how this "self-destructing" particle could redefine the standard of care for chronic knee pain.

Based on comments from experts, content on Wysdom, and the article cited below.

Little MW, Agarwal S, Khikmatovich IM, McCabe J, Pandey M, Lewis AL, Farrissey L, Iskhakov SA. First-in-Human Evaluation of a New Resorbable Microspherical Embolic Agent for Genicular Artery Embolization to Treat Pain Secondary to Knee Osteroarthritis. J Vasc Interv Radiol. 2025 Nov;36(11):1658-1666. doi: 10.1016/j.jvir.2025.07.010. Epub 2025 Jul 18. PMID: 40685121.