Ep. 592 Comparing Thermal Ablation Techniques for Liver Lesions with Dr. Jason Hoffmann

In this episode, host Dr. Aaron Fritts and interventional radiologist Dr. Alex Pavidapha give a primer on the emerging field of hemorrhoidal artery embolization (HAE), including patient presentations and referrals, treatment algorithms, procedural steps, and follow up care. --- CHECK OUT OUR SPONSOR Boston Scientific Nextlab https://www.bostonscientific.com/en-US/nextlab.html?utm_source=oth_site&utm_medium=native&utm_campaign=pi-at-us-nextlab-hci&utm_content=n-backtable-n-backtable_site_nextlab_1_2023&cid=n10013202 --- SHOW NOTES To start. Dr. Pavidapha describes the typical patient presenting with hemorrhoids. This is a prevalent condition that peaks at the ages of 45-65 and in the pregnant population. There are a variety of treatment options ranging from banding, hemorrhoidectomy, and cryotherapy; however, many patients may experience recurrence after these treatments or they may not be suitable candidates for surgery. Next, we discuss the current landscape of HAE. This treatment is a good option for patients who have failed other treatment options. The majority of Dr. Pavidapha’s patients come from referrals by gastroenterologists, although some come based on their own research on the web. It is important that all patients have a colonoscopy before HAE, to rule out the possibility of colon cancer. Additionally, a full history and rectal exam should be performed, since the choice to treat can be guided by the patient’s symptom severity and the degree of internal hemorrhoid prolapse. It is also advisable to identify extremely painful external hemorrhoids, since these can be addressed with conservative measures. Dr. Pavidapha notes that patient counseling is extremely important, since hemorrhoids have a high risk of recurrence and bowel habits play a large part in this. In terms of procedural risks, he counsels patients about standard risks of bleeding and infection, recurrence, mild pain in the few days after the procedure, and although it is rare, non-target embolization of skin or other organs. During the procedure, Dr. Pavidapha prefers femoral access, since this is the easiest way to select the internal mesenteric artery. He does a base catheter run here to visualize the superior rectal arteries. These vessels are the most commonly involved in internal hemorrhoids, and if they are feeding the hemorrhoid, he will inject 500 micron beads and then follow with embolic coils. Next, he navigates through the internal iliac and pudendal arteries to arrive at the middle rectal arteries for another run. If they also supply the hemorrhoids, he will embolize them. The inferior rectal arteries are usually not involved in hemorrhoid formation, embolization of them carries a high risk of skin necrosis. Treatment of inferior rectal arteries is usually avoided. It is important to know typical anatomy very well so you can determine targets for embolization and recognize whether a patient has variant anatomy. Finally, Dr. Pavidapha sees his patients for follow-up at 1 month, 4 months, and 1 year to check for symptomatic improvement, primarily decreased bleeding. If bleeding has worsened, the patient most likely needs a repeat procedure to identify new blood vessels supplying the hemorrhoid. To IRs who are interested in starting an HAE service line, Dr. Pavidapha advises them to read the existing literature about hemorrhoids and HAE and be able to show clinical outcomes data to gastroenterologists. Overall, patients with recurrent hemorrhoids are typically an underserved population and have the potential to benefit from this novel procedure. --- RESOURCES Ep. 319 - How to Collaborate with GI on a New Outpatient Service Line: https://www.backtable.com/shows/vi/podcasts/319/how-to-collaborate-with-gi-on-a-new-outpatient-service-line Outcomes of Hemorrhoidal Artery Embolization from a Multidisciplinary Outpatient Interventional Center: https://pubmed.ncbi.nlm.nih.gov/36736822/ The STREAM Meeting: ​​https://www.thestreammeeting.com/

19 Touko 202340min

En los confines de la medicina, a veces es necesario un espíritu intrépido para desafiar las prácticas establecidas y abrir nuevos horizontes. El reconocido doctor Francisco Carnevale, una figura emblemática en el campo de la radiologia intervencionista, personifica a la perfección esta audacia. Su historia es la epopeya de un hombre que tuvo la inquietud de explorar la embolización de la próstata, un enfoque innovador en el tratamiento de la hiperplasia prostática. --- CHECK OUT OUR SPONSOR RADPAD® Radiation Protection https://www.radpad.com/ --- SHOW NOTES Como un faro de curiosidad intelectual, el Dr. Carnevale se aventuró en el mundo desconocido de la embolización de la próstata. Con pasión y determinación, navegó a través de los océanos de investigación médica, desafiando la ortodoxia y enfrentando el escepticismo. Fue un viaje lleno de obstáculos y dificultades, pero cada paso que dio fue impulsado por la convicción de que estaba abriendo puertas a nuevas posibilidades de tratamiento. Su dedicación inquebrantable dio frutos. El Dr. Carnevale no solo superó los desafíos técnicos asociados con la embolización de la próstata, sino que también cosechó resultados impresionantes. Sus intervenciones se convirtieron en un éxito rotundo, aliviando el sufrimiento de muchos pacientes y mejorando su calidad de vida. Sus habilidades quirúrgicas y su enfoque innovador se ganaron el reconocimiento de sus colegas, quienes lo consideran un líder en el campo de la urología.Además de sus logros clínicos, el Dr. Carnevale ha dejado una huella imborrable en la comunidad médica a través de sus numerosas investigaciones y publicaciones. Sus contribuciones han ayudado a sentar las bases científicas de la embolización de la próstata, inspirando a otros profesionales a seguir su ejemplo y continuar expandiendo los límites del conocimiento médico. En resumen, la historia del Dr. Francisco Carnevale es una historia de coraje, determinación y éxito. Su viaje desde la inquietud inicial hasta convertirse en un modelo a seguir en investigación y publicaciones es un testimonio de la pasión y el espíritu de vanguardia que impulsa la medicina moderna. Su legado perdurará, iluminando el camino para las generaciones futuras de profesionales de la salud y dejando un impacto duradero en la comunidad médica.

17 Touko 202349min

In this episode, host Dr. Chris Beck interviews Dr. Nima Kokabi about renal trauma embolizations, including imaging workup, embolization technique, and a warning on renal biopsies. --- CHECK OUT OUR SPONSOR Boston Scientific Embold Fibered Coils https://www.bostonscientific.com/en-US/products/embolization/embold-detachable-coil-system.html --- SHOW NOTES Dr. Kokabi was born in Iran, then moved to Canada where he grew up. He attended medical school in Australia due to the shortage of English speaking medical schools in Canada. After his medical training, he was interested in IR, and came to Yale for a fellowship. He then joined Emory as an attending, where he serves one of the largest trauma hospitals in the country. IR and trauma surgery have a close relationship at Emory, and Dr. Kokabi notes they rely more and more on IR for trauma management, even for things such as penetrating trauma, which is traditionally handled by surgery. Most IR consults for kidney injury are iatrogenic from non-target renal biopsies in a nephrology office. The rules for getting access to a kidney that IRs are trained in are generally not followed by nephrology, and only some have ultrasound guidance for their biopsies. Other consults for bleeding from kidney injury are post-op from a partial nephrectomy or from blunt trauma. To work it up, he gets a 2 phase arterial and venous CT. All kidney injuries are evaluated and reported using the American Association for the Surgery of Trauma (AAST) grading scale. If there is an active bleed, they will go to IR for embolization. If the injury is severe, and there is no parenchymal enhancement, this indicates either the artery or both the artery and vein were transected, and this patient requires surgery. In cases where there is only a small pseudo-aneurysm or a perinephric hematoma, these patients can be monitored with repeat imaging. For the embolization, Dr. Kokabi uses radial access. For his microcatheter, he likes the True Select. He always uses coils in the kidney, while in the liver, he uses gel foam. Some of his colleagues use glue for the kidney. He prefers detachable Embold coils, which are fiber coils with a nitinol pusher, so they don’t kink when being pushed very fast, and can be adjusted if positioning is unsatisfactory. When he is finished, he injects first through the microcatheter and then again through the base catheter to ensure he hasn’t missed any bleeding. He generally follows patients in the hospital for 1-2 days, before signing off. His parting advice to trainees and anyone doing kidney biopsies is to exercise caution, because although it is just a biopsy, it can cause life-threatening bleeding. --- RESOURCES AAST Kidney Injury Scale: https://radiopaedia.org/articles/aast-kidney-injury-scale

15 Touko 202343min

In this episode, host Dr. Aaron Fritts and interventional radiologist Dr. Kevin Henseler discuss his treatment algorithm and new technologies for embolization of GI bleeds. --- CHECK OUT OUR SPONSOR Boston Scientific Obsidio Embolic https://www.bostonscientific.com/obsidio --- SHOW NOTES Dr. Henseler starts by differentiating between lower and upper GI bleeds. Upper GI bleeds tend to be more life-threatening and are most commonly caused by esophageal varices or duodenal ulcers, and many of these consults come from the endoscopy suite. These upper GI bleeds also have a higher risk of recurrence. On the other hand, lower GI bleeds can be more indolent. CTA is the most efficient way to assess the source of GI bleeding. It provides valuable information about the vascular territory, including localization of bleeding, planning where to inject during angiography, and variant anatomy. If CTA is negative for bleeding, Dr. Henseler does not move onto angiography. He monitors the patient for further signs of intermittent bleeding and may re-image or intervene the following day. If CTA does show bleeding, Dr. Henseler moves onto angiography and embolization. He finds that there are few contraindications to angiography. Relative contraindications include renal insufficiency, which is a small tradeoff for a lifesaving procedure, and contrast allergy, which can be addressed with a preprocedural steroid dose. When it comes to methods of embolization, detachable coils have been a mainstay. While they are more expensive than pushable coils, detachable coils allow for more exact placement and increased safety and more IRs are being trained to use these now. Dr. Henseler also discusses the use of embolic particles, which carry risks of end-organ damage and ischemia, as well as embolic glue, which can be difficult to use if the operator does not have sufficient training. Then, we shift gears to discuss Obsidio, a new injectable solid that is soon to be commercially available. It exists as a liquid when it is in its pressurized form within the microcatheter; however, it immediately solidifies in the vessel as soon as the injection ceases. Obsidio is made of radio-opaque tantalum so it is visible on CT, stays permanently in the vessel, and can be used in conjunction with coils if desired. Additionally, its cohesive properties decrease the risk of abdominal extravasation and it can be used with any catheter. --- RESOURCES Dr. Kevin Henseler LinkedIn: https://www.linkedin.com/in/kevin-henseler-364832231/ CTA for Lower GI Bleeds: https://www.youtube.com/watch?v=UWEf_sAUGKU Ep. 179- Happiness is a Warm Coil: Treating GI Bleeds: https://www.backtable.com/shows/vi/podcasts/179/happiness-is-a-warm-coil-treating-gi-bleeds Ep. 216- Stick It: Glue Embo: https://www.backtable.com/shows/vi/podcasts/216/stick-it-glue-embo

12 Touko 202348min

In this episode, host Dr. Sabeen Dhand interviews interventional cardiologist Dr. Eric Secemsky about the role of intravascular ultrasound in lower extremity interventions, and how he published a consensus document to standardize its use across specialties and provide a framework for new users. --- CHECK OUT OUR SPONSORS Philips Image Guided Therapy Devices Academy https://resource.philipseliiteacademy.com Philips SymphonySuite https://www.philips.com/symphonysuite --- SHOW NOTES Dr. Secemsky practices at BIDMC in Boston. His passions are pulmonary embolism intervention and intravascular ultrasound (IVUS) for peripheral vascular disease. He began using IVUS for coronary interventions, and then began incorporating it in arterial and venous peripheral interventions. The goal is to make procedures durable in the endovascular world, and IVUS is key for that. In the coronaries, there is a standardized way that all cardiologists use IVUS for. First, they cross the lesion with the wire, then use IVUS to measure lesion length and vessel diameter for stent sizing. They also evaluate plaque composition, which informs whether to use a plaque modifying device before stenting. They then balloon, stent, and use IVUS again to evaluate stent position and check for dissections. Dr. Secemsky measures an arterial lumen by identifying the 3 layers of the vessel wall, and finding the black stripe behind the intima, which corresponds to the elastic membrane. Dr. Secemsky tells us about a consensus article he published in the Journal of the American College of Cardiology. He collaborated with some colleagues to form a 12 person steering committee composed of interventional cardiology, interventional radiology, vascular surgery and vascular medicine specialists. The goal was to consolidate information from all these specialties to provide a single standardized document. This document can be used for those wanting to incorporate IVUS into their practice, but don’t know where to begin. They established levels of evidence regarding where IVUS is most appropriate. They found that tibial arterial intervention has the highest support for use of IVUS across specialties. Furthermore, they established that the best practice for IVUS is to use it three times per case, for pre-intervention, middle-run and post-run. Using IVUS is safe, and offers so much information to make case a more efficient. In addition, you cut down on device utilization, contrast use and radiation exposure, while improving patient outcomes by getting better luminal gain and improved durability of your intervention. --- RESOURCES JACC Consensus Article: https://pubmed.ncbi.nlm.nih.gov/35926922/

8 Touko 202329min

5 Touko 202330min

In this episode, Dr. Isabel Newton hosts a panel discussion on updates about Road2IR, an international consortium aimed at increasing access to IR procedures and education in East Africa and beyond. She is joined by Drs. Fabian Laage Gaupp, Judy Gichoya, and Janice Newsome. --- CHECK OUT OUR SPONSORS Reflow Medical https://www.reflowmedical.com/ RADPAD® Radiation Protection https://www.radpad.com/ --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/SuvZJb --- SHOW NOTES We start by reviewing the origin story of Road2IR. In 2017, Dr. Laage Gaupp had been a second-year diagnostic radiology resident when he traveled to Tanzania for an IR readiness assessment. He found that most of the infrastructure to support IR procedures were already in place; however, there was no formal training program. From there, he and other Road2IR co-founders launched East Africa’s first IR training program, as a collaborative effort between Muhimbili University of Health and Allied Sciences (MUHAS), Yale Radiology, Emory Radiology, and many other partner institutions. Since then, graduates of the training program have gone on to become professors of IR in Tanzania as well as other countries. The early years of the program required a lot of flexibility and patience, due to the limited amount of resources. It was necessary to start with simple procedures like core needle biopsies, abscess drainages, and nephrostomy tubes. Additionally, Dr. Gichoya emphasizes that these ordinary procedures can make a drastic difference in a patient’s life and even impact entire families. Being able to perform and teach a full spectrum of minimally invasive, life-saving procedures energizes her and other faculty members who donate their time and energy. Dr. Newsome has served as the program director for the MUHAS IR program, and she speaks about the challenges that arose during the COVID pandemic, in terms of healthcare policy in Tanzania, as well as restrictions for university faculty travel in the United States. Through the height of the pandemic, the training program persisted with virtual oral examinations, meetings, and lectures. The logistics of travel, equipment, and education are still major challenges today, and they are addressed by a dedicated team of individuals with common goals. Finally, we cover the concept of reverse innovation, aspects of healthcare in under-resourced settings that can inform the U.S. healthcare system. These include lessons in building local service lines, avoiding turf wars, and embracing technology. --- RESOURCES Road2IR: https://www.road2ir.org/ Ep. 104- Bringing IR to East Africa: The Road2IR Story with Dr. Faabian Laage Gaupp: https://www.backtable.com/shows/vi/podcasts/104/bringing-ir-to-east-africa-the-road2ir-story

3 Touko 20231h 5min

In this episode, guest host Dr. Peder Horner interviews Dr. Harold Coons about the history of IR, his contributions to the field, where the field is headed, and his advice for trainees and early career IRs. --- CHECK OUT OUR SPONSORS BD Advance Clinical Training & Education Program https://page.bd.com/Advance-Training-Program_Homepage.html Philips SymphonySuite https://www.philips.com/symphonysuite --- SHOW NOTES Dr. Coons attended Pomona College, where he studied math. He then realized he didn’t want to be a nuclear scientist in the Sputnik era, which was where most opportunities were at the time. He decided to attend medical school at UCLA instead. As a medical student, he saw how happy the radiologists were, so he decided to choose it as a specialty. He had the opportunity to do a carotid arteriogram one day when everyone else was busy. He considered himself a maverick and someone who was always ready to take on a challenge. He then experienced a moment that changed his life, when Czech radiologist Josef Rösch came to UCLA to visit from the University of Oregon where he was working with Charles Dotter. Dr. Coons saw Dr. Rösch direct puncture the spleen for a spleen portogram, and it took him only 15 seconds. This was incredible to him, and after that, Dr. Coons followed him around whenever he did procedures. They teamed up, Dr. Coons volunteering to be the nurse, because no nurses liked working with Rösch. Coons shaped catheters for him at a steam kettle, watched him do the first TIPS on a dog, and did the first arterial embolization with clotted venous blood under the direction of Dr. Rösch. After his stint in the Airforce at a hospital in San Antonio, where he honed his embolization skills, he returned to San Diego. He was then working in private practice as the only IR in San Diego. One year, he heard about a meeting at Massachusetts General, so he submitted 6 papers on things he had been doing recently. All his papers were accepted, so he went to the meeting. At his first presentation, the leader of the meeting announced to the audience that he had accepted these papers to expose Coons as a fraud, because these techniques were nothing any academic had ever heard of. He did his presentation, and everyone in the audience, including the meeting leader, believed what he was doing was indeed real. He apologized to Coons and invited him to the speakers dinner, where he sat next to Kurt Amplatz and Plinio Rossi. Rossi convinced him to start publishing his ideas to get the credit he deserved, and to have something to show his children. Dr. Coons was forced to retire early in 1996 due to radiation exposure, but has been an avid innovator, educator, and international speaker since then. His passion for IR and excitement for the future of the field is contagious to all who have the pleasure of hearing him speak.

1 Touko 202352min