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.

In this episode, Dr. Kim Scherer, Assistant Professor of Radiology at Weill Cornell and Associate Program Director, shares her top five pieces of advice for navigating the challenges of an Interventional Radiology residency.

You Get Out What You Put In: Residency isn't medical school; there are no weekly tests. Success requires self-guided learning, reading every night, and showing up early to see as much as possible.

Find Balance: It’s a long six years. Decompressing with hobbies and building relationships with co-residents is vital for sustaining your energy.

Earning Autonomy: Don't expect full autonomy on day one. It is earned by mastering smaller cases first and proving you know your patients inside and out.

The Power of Kindness: IR is a team sport involving nurses, techs, and staff. Being nice isn't just polite; it's a requirement for high-quality patient care.

Stay Engaged: Don't drift away during your diagnostic years. Keep your foot in the door by joining research projects, attending social events, and dropping into the angio suite whenever possible.

Tune in for a roadmap to excelling in your training from a program director who’s been there.

This episode investigates the specific, aggressive liver injury that can follow Y-90 Radioembolization—Radioembolization-Induced Liver Disease (REILD)—defining it not as simple radiation necrosis, but as Hepatic Sinusoidal Obstruction Syndrome (SOS), essentially Veno-Occlusive Disease (VOD).

The Clinical Picture: We identify the hallmark presentation appearing 4-8 weeks post-procedure: significant jaundice (Bilirubin >3) and ascites in the absence of tumor progression.

The "Combined Insult" Theory: The discussion highlights that this injury is often synergistic, occurring when the liver is "primed" by prior systemic chemotherapy, making the tissue far more vulnerable to radiation.

The Safety Limit: We detail the critical safety threshold found in the literature: keeping the dose below 0.8 GBq per liter of targeted liver volume significantly drops the risk.

Protocol for Prevention: The episode outlines a proven modified protocol—including strict patient selection (Bilirubin <2), ursodiol/steroid prophylaxis, and a 2-month chemotherapy-free interval—that reduced the rate of severe toxicity from 13.3% down to 2.2%.

Rescue Therapy: We explore why TIPS is often considered for acute management to decompress the portal hypertension caused by the sinusoidal obstruction.

Tune in to learn the dosimetry limits and patient selection criteria that keep your Y-90 practice safe.

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

Ruutu T, Peczynski C, Houhou M, et al. Current incidence, severity, and management of veno-occlusive disease/sinusoidal obstruction syndrome in adult allogeneic HSCT recipients: an EBMT Transplant Complications Working Party study. Bone Marrow Transplant. 2023;58(11):1209-1214. doi:10.1038/s41409-023-02077-2

Sangro B, Gil-Alzugaray B, Rodriguez J, et al. Liver disease induced by radioembolization of liver tumors: description and possible risk factors. Cancer. 2008;112(7):1538-1546. doi:10.1002/cncr.23339

Gil-Alzugaray B, Chopitea A, Iñarrairaegui M, et al. Prognostic factors and prevention of radioembolization-induced liver disease. Hepatology. 2013;57(3):1078-1087. doi:10.1002/hep.26191

This episode provides a deep dive into the management of Acute Porto-Mesenteric Venous Thrombosis (PVT) in non-cirrhotic patients, a condition with a 30-day mortality rate of up to 32% if the clot extends into the mesenteric veins.

The Limitations of Meds: We discuss why systemic anticoagulation often fails, achieving complete recanalization in only 50% of patients due to the sheer volume of clot.

The "Hidden" Drivers: Learn why an exhaustive workup is mandatory, as up to 52% of these patients have an underlying prothrombotic disorder (like JAK2 mutations) alongside local inflammation.

Interventional Strategy: The conversation highlights the shift toward Mechanical Thrombectomy (MT) combined with Catheter-Directed Thrombolysis (CDT), which data shows can reduce the duration of dangerous thrombolytic infusion from 44 hours to just 22.7 hours.

Critical Safety Caveats: We cover the specific management of VITT (Vaccine-Induced Thrombotic Thrombocytopenia), where heparin is strictly contraindicated, and the three "red flags" (Lactate >2, Marshall score >2, Bowel dilation) that signal irreversible necrosis and the need for surgery.

Tune in to master the decision matrix for saving the bowel when medical therapy fails.

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

Lorenz J, Kwak DH, Martin L, et al. Endovascular Management of Noncirrhotic Acute Portomesenteric Venous Thrombosis. J Vasc Interv Radiol. 2025;36(1):17-30. doi:10.1016/j.jvir.2024.09.023