Wysdom Radio™

This fundamental episode builds your mental toolbox by outlining the three main categories of embolic agents you'll use every single day.

We break down the core principles, "why," and critical safety rules for:

This episode breaks down the critical differences between the two main endovascular strategies for managing variceal bleeding in patients with portal hypertension:

TIPS (Transjugular Intrahepatic Portosystemic Shunt): A procedure that acts as an internal bypass to lower the overall portal pressure.

New Guidance: Covered stents are now standard, and smaller 8mm stents are preferred to minimize the risk of Hepatic Encephalopathy (HE).

Trade-Off: It reduces the risk of bleeding but increases the risk of HE (brain fog/confusion).

RTO/ATO (Retrograde/Antegrade Transvenous Obliteration): Procedures that physically block and obliterate the specific bleeding veins (varices).

Key Difference: RTO/ATO increases portal pressure but is preferred for patients with pre-existing HE or heart issues, as it often improves liver function and has a lower HE risk.

Technological Leap: Newer methods like PARTO and CARTO (Coil/Plug-Assisted RTO) are replacing older techniques, offering a safer, faster, and more targeted approach that eliminates the need for prolonged ICU stays.

The Clinical Crossroads: We detail how specialists choose between TIPS (pressure-lowering) and RTO (obliteration) based on patient factors like underlying HE, cardiac health, and the location of the bleeding varices.

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

Lee EW, Eghtesad B, Garcia-Tsao G, et al. AASLD practice guidance on the use of TIPS, variceal embolization, and retrograde transvenous obliteration in the management of variceal hemorrhage. Hepatology. 2024;79(1):224-250. doi:10.1097/HEP.0000000000000530

This episode explores Cryoneurolysis, a cutting-edge interventional radiology technique that uses extreme cold to precisely disable nerves and stop chronic pain without addictive opioids.

The "Sweet Spot" of Freezing: We break down the critical science of achieving a Sunderland Grade 2 injury (axonotmesis). This requires freezing the nerve to a precise temperature range (below -20°C but warmer than -100°C) to destroy the pain pathway while preserving the nerve's outer structure, allowing for healthy regeneration and avoiding painful neuromas.

The Role of Advanced Imaging: Learn why CT guidance is essential for deep nerve targets. Unlike ultrasound, which is blocked by the "ice ball," CT allows interventional radiologists to see the entire freeze zone and protect vital organs using techniques like hydrodissection (injecting fluid to create a safety barrier).

Policy Shifts Driving Access: We discuss the landmark 2015 CMS decision to approve new CPT codes for cryoablation, transforming it from a financially unviable procedure into a mainstream option for cancer pain, osteoarthritis, and nerve entrapment.

Beyond Pain Relief: Discover surprising new applications, including trials targeting the vagus nerve for weight loss, where patients saw significant appetite reduction and weight loss.

Tune in to understand how this precise, regenerative therapy is changing the landscape of pain management and beyond.

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

Sag AA, Bittman R, Prologo F, et al. Percutaneous image-guided cryoneurolysis: applications and techniques. RadioGraphics. 2022;42(6):1776-1794. doi:10.1148/rg.220082

This episode of Morning Rounds delivers a direct line to critical research on Bronchial Artery Embolization (BAE), the life-saving procedure used to stop massive hemoptysis (coughing up blood).

CF Patient Effectiveness: We analyze a long-term Stanford study on BAE in adults with Cystic Fibrosis (CF), revealing that while BAE is highly effective at stopping the immediate bleed (89% technical success at 30 days), the patient's underlying disease severity remains a major factor in overall survival.

The Crucial Role of Non-Bronchial Arteries: The CF data highlights the need for optimized BAE procedures, showing that nearly 75% of successful procedures involved targeting abnormal vessels recruited from outside the lung's main supply. This suggests a shift toward mandatory pre-procedure imaging (like CT angiography) is necessary for high success rates.

The Rare but Feared Risk: Spinal Cord Infarction (SCI): We break down a massive 9,000-patient Japanese study focused on the risk of SCI, a devastating complication with a low overall prevalence of 0.19%.

Safety vs. Speed: Material Matters: The key finding reveals a statistically significant, more than tenfold difference in SCI risk based on the embolic agent used.

Coils (mechanically placed, controlled): Lowest SCI risk at 0.06%.

Gelatin Sponge (flow-dependent particles): Medium risk at 0.18%.

N-Butyl Cyanoacrylate (NBCA) (liquid glue): Highest risk at 0.71%.

Tune in to discover how these findings demand a critical appraisal of standard clinical practice, balancing the documented safety profile of embolic agents against perceived speed and ease of use.

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

Ishikawa H, Ohbe H, Omachi N, Morita K, Yasunaga H. Spinal cord infarction after bronchial artery embolization for hemoptysis: a nationwide observational study in Japan. Radiology. 2021;298(3):673-679. doi:10.1148/radiol.2021202500

Lynne N. Martin, Luke Higgins, Paul Mohabir, Daniel Y. Sze, Lawrence V. Hofmann,
Bronchial Artery Embolization for Hemoptysis in Cystic Fibrosis Patients: A 17-Year Review,
Journal of Vascular and Interventional Radiology, Volume 31, Issue 2, 2020, Pages 331-335, ISSN 1051-0443, https://doi.org/10.1016/j.jvir.2019.08.028.

Martin LN, Higgins L, Mohabir P, Sze DY, Hofmann LV. Bronchial artery embolization for hemoptysis in cystic fibrosis patients: a 17-year review. J Vasc Interv Radiol. 2020;31(2):331-335. doi:10.1016/j.jvir.2019.08.028

This episode dives into the STORM PE Randomized Control Trial, which fundamentally shifts how we treat patients with intermediate high-risk Pulmonary Embolism (PE)—those who look stable but have hidden heart strain.

⚡ Key Findings

Rapid Decompression: The trial compared standard anticoagulation (AC) alone to AC plus Computer-Assisted Vacuum Thrombectomy (CAVT).

Superior Efficacy: CAVT was significantly superior to AC alone, resulting in:

A greater than twofold reduction in deadly right ventricular (RV) strain within 48 hours.

A threefold higher chance of RV normalization.

A 100% resolution of high heart rate (tachycardia) in the CAVT group within 48 hours, compared to 56.5% in the AC group.

Safety Profile: The decisive finding was that this aggressive intervention achieved superior clinical results without increasing the rate of major adverse events (like bleeding).

💡 Clinical Impact

This is the strongest evidence to date supporting mechanical thrombectomy as a first-line consideration for intermediate high-risk PE, safely preventing clinical collapse and stabilizing patients far faster than traditional methods.

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

Lookstein RA, Konstantinides SV, Weinberg I, Dohad SY, Rosol Z, Kopeć G, Moriarty JM, Parikh SA, Holden A, Channick RN, McDonald B, Nagarsheth KH, Yamada K, Rosovsky RP; STORM-PE Trial Investigators. Randomized Controlled Trial of Mechanical Thrombectomy With Anticoagulation Versus Anticoagulation Alone for Acute Intermediate-High Risk Pulmonary Embolism: Primary Outcomes From the STORM-PE Trial. Circulation. 2026 Jan 6;153(1):21-34. doi: 10.1161/CIRCULATIONAHA.125.077232. Epub 2025 Nov 3. PMID: 41183181.

This episode dives into the high-stakes management of Parastomal Variceal Bleeding (PVB), a rare but life-threatening complication of portal hypertension, often seen in patients with significant comorbidities (like metastatic cancer) where a TIPS procedure is initially contraindicated.

The Clinical Dilemma: We explore a case study of a patient ruled out for TIPS due to metastatic disease, shifting the entire burden of hemorrhage control to local embolization techniques like Percutaneous Antegrade Transhepatic Venous Obliteration (PATVO).

Technical Mastery: The episode breaks down the critical need for a multimodal embolic approach—combining mechanical coils, sclerosing foam (STS/Gelfoam), and a final "cap" to ensure immediate and durable stasis against high portal pressures (mean 33 mmHg in our case).

The Recurrence Reality: While technical success for embolization is high (88-100%), the recurrence rate is stubbornly high, reaching up to 50% within the first year due to the recruitment of new collaterals.

TIPS vs. Embolization: We review data showing that TIPS—which treats the underlying portal hypertension—reduces recurrence risk by a staggering 78.5% compared to embolization alone.

The Provocative Question: We end by challenging the consensus: In cases of catastrophic, life-threatening bleed, when is a palliative TIPS justified purely for hemorrhage control, even in patients with poor oncologic prognoses?.

Tune in to master the technical nuances of PATVO and understand the critical decision matrix for treating these complex, high-pressure bleeds.

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

Romano J, Welden CV, Orr J, McGuire B, Shoreibah M. Case Series Regarding Parastomal Variceal Bleeding: Presentation and Management. Ann Hepatol. 2019 Jan-Feb;18(1):250-257. doi: 10.5604/01.3001.0012.7934. PMID: 31113601.

Nadeem IM, Badar Z, Giglio V, Stella SF, Markose G, Nair S. Embolization of parastomal and small bowel ectopic varices utilizing a transhepatic antegrade approach: A case series. Acta Radiol Open. 2022 Jul
5;11(7):20584601221112618. doi: 10.1177/20584601221112618. PMID: 35833193; PMCID: PMC9272059.

Pabon-Ramos WM, Niemeyer MM, Dasika NL. Alternative treatment for bleeding peristomal varices:
percutaneous parastomal embolization. Cardiovasc Intervent Radiol. 2013 Oct;36(5):1399-404. doi:
10.1007/s00270-013-0588-0. Epub 2013 Mar 13. PMID: 23483282.

Pennick MO, Artioukh DY. Management of parastomal varices: who re-bleeds and who does not? A systematic review of the literature. Tech Coloproctol. 2013 Apr;17(2):163-70. doi: 10.1007/s10151-012-0922-6. Epub 2012 Nov 14. PMID: 23152077.

This episode unpacks the long-awaited results of the CREST-2 Trial, a landmark study that challenges the standard of care for treating asymptomatic carotid stenosis (narrowing of the carotid artery without recent stroke symptoms).

The Big Question: Does adding invasive revascularization (Endarterectomy or Stenting) to Intensive Medical Management (IMM) prevent more strokes than medication and lifestyle changes alone?

The Clear Verdict: After 10 years of research, the trial was stopped early for "futility," meaning the results were conclusive: there was no significant difference in stroke or death rates between the surgery/stenting group and the medication-only group.

The Power of Medical Therapy: The study proves that modern medical management—including tight blood pressure control (target <130/80) and high-intensity statins—is incredibly effective on its own, rendering the risks of procedural intervention unnecessary for asymptomatic patients.

The Procedure Gap: While Endarterectomy (surgery) matched the safety of medical management, Carotid Stenting (CAS) performed worse, showing a higher rate of immediate, non-disabling strokes compared to medication alone.

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

Brott TG, Howard G, Lal BK, Voeks JH, Turan TN, Roubin GS, et al. Medical management and revascularization for asymptomatic carotid stenosis. N Engl J Med. Published online November 21, 2025. doi:10.1056/NEJMoa2508800