Ep. 432 AI in Medicine: Navigating the New Frontier with Confidence with Dr. Matthew Lungren

In this next installment of our Back to the Basics series, Drs. Aaron Fritts and Chris Beck discuss their techniques, considerations, and tips for ensuring safe and high quality renal biopsies. The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/bYgmZk --- CHECK OUT OUR SPONSORS Laurel Road for Doctors https://www.laurelroad.com/healthcare-banking/ RADPAD® Radiation Protection https://www.radpad.com/ --- SHOW NOTES First, the doctors discuss indications and contraindications for biopsy. In the outpatient setting, the doctors have noticed that proteinuria is the most common reason for referral, followed by lupus nephritis. For inpatients, acute unexplained kidney failure is an additional indication. It is important to talk with nephrologists to weigh the risks and benefits of renal biopsy, especially if the patient has a coagulopathy, is experiencing uncontrolled hypertension, or is too unstable to lay prone on the table. The SIR Guidelines app is a useful tool to risk stratify patients. In terms of imaging, CT or ultrasound can be used, although they each have unique advantages. Ultrasound allows for real-time guidance and the ability to use the probe to hold pressure on the kidney to prevent bleeding. On the other hand, CT allows for better imaging in patients with larger body habitus and allows the patients to lay prone. Dr. Fritts emphasizes that the best imaging modality is the one that the operator is most comfortable with, since this will ensure maximal safety for the patient. One helpful tip when planning a biopsy is to avoid needle entry into the paraspinal muscles, since this could change the trajectory of the needle and cause pain. Both doctors prefer to use moderate sedation if the patient can tolerate it. This sedation usually has the added benefit of facilitating an intra-procedural blood pressure dip, which protects against bleeding when biopsying hypertensive patients. Since sedation can alter breathing patterns, starting sedation early (before scanning the patient) can be helpful in establishing a steady breathing pattern before the procedure starts. Dr. Beck also recommends checking blood pressure while the patient is in pre-operative care, in order to predict whether or not they might require additional intra-procedural antihypertensive medications such as hydralazine, labetalol, or clonidine. Since blood pressure control is a cornerstone of a safe procedure, each doctor has their own safety threshold for blood pressure. Then, the doctors discuss different types and sizes of biopsy needles. While a 16G needle can obtain better diagnostic samples, the 18G needle might have a lower risk of bleeding complications. The doctors also share their preferred brands of needles. The episode concludes with tips for surveilling patients in the post-procedural period and dealing with bleeding complications. Dr. Beck describes his protocol for re-scanning patients to check for large hematomas and keeping them under observation for at least three hours. If there is a large hematoma, emergency embolization must be performed. --- RESOURCES SIR Guidelines App: https://apps.apple.com/us/app/sir-guidelines/id1552455529 SIR Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions: https://www.jvir.org/article/S1051-0443(19)30407-5/fulltext 18G BioPince Biopsy Needle: https://www.argonmedical.com/products/biopince-full-core-biopsy-instrument Bard Mission Biopsy Needle: https://www.bd.com/en-us/products-and-solutions/products/product-families/mission-disposable-core-biopsy-instrument Temno Biopsy Needle: https://www.merit.com/peripheral-intervention/biopsy/soft-tissue-biopsy/temno-evolution-biopsy-device/

18 Marras 20221h 11min

On this episode, BackTable VI host Dr. Christopher Beck shares the mic with two Maternal Fetal Medicine (MFM) specialists, Drs. Roxane Rampersad at Washington University and Tony Shanks at Indiana University, to discuss cross-specialty management of postpartum hemorrhage (PPH) between OBGYN and interventional radiology (IR). The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/ASxPdP

17 Marras 202251min

In this episode, host Dr. Aaron Fritts interviews interventional cardiologist Dr. Rohit Amin about his private practice PE response team, including his treatment algorithm, follow-up protocol, and how he believes AI can contribute to PE care. --- CHECK OUT OUR SPONSOR RapidAI http://rapidai.com/?utm_campaign=Evergreen&utm_source=Online&utm_medium=podcast&utm_term=Backtable&utm_content=Sponsor --- SHOW NOTES Dr. Amin trained at Ochsner Clinic in New Orleans, and now works in private practice in Pensacola, Florida. He and a partner decided to start a PE response team (PERT) to better serve patients in the area and expand their practice. It took a lot of groundwork. They had to pitch it to administration and raise awareness, which they did by hosting CME such as grand rounds. They struggled to get a pulmonologist on board in 2013 when there was less clinical data and guidelines. Next, we discuss how the PERT algorithm functions in his private practice. An ER doctor or hospitalist evaluates the patient first. If the CT shows proximal thrombus, the PERT is notified. If it is a massive PE or submassive with clinical severity, he does thrombectomy promptly. If there is no elevated troponin and normal hemodynamics, the patient gets admitted and evaluated with a stat echo and venous doppler. Dr. Amin’s practice prefers an echo with PE protocol to risk stratify RV dysfunction - i.e. RV size, tricuspid annular plane systolic excursion (TAPSE). He also evaluates pulmonary artery (PA) pressure, PA saturation, and cardiac index which are important clinical factors that determine the optimal route of intervention. For patients with submassive PE who get admitted overnight, he gives all patients a heparinoid, preferably lovenox over heparin. He sees the patient in the morning and if the clot is submassive or proximal, he does a thrombectomy that day. Lastly, we cover the importance of treating PE and how Dr. Amin approaches longitudinal follow up. Dr. Amin refers to the ICOPER trial that showed that the 30 day mortality for submassive PE is 15%, higher than that of NSTEMIs. If a PE is left untreated or if treatment is significantly delayed, a patient can develop post-PE syndrome or chronic thromboembolic pulmonary hypertension (CTEPH), which significantly worsen morbidity and mortality. Dr. Amin treats his PE / DVT patients with one week of lovenox before transitioning to a direct oral anticoagulant (DOAC). He sees them in the office in one month and gets an echo at 3 months. He then sees patients semi-annually or annually for 3-5 years. --- RESOURCES BackTable Episode 196: https://www.backtable.com/shows/vi/podcasts/196/building-a-pe-response-team PERT Consortium: https://pertconsortium.org ICOPER Trial: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(98)07534-5/fulltext

14 Marras 202259min

In this episode, host Dr. Ally Baheti interviews interventional radiologist Dr. Luke Wilkins about his approach to the subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) technique for crossing challenging chronic total occlusions (CTO) in critical limb ischemia (CLI) patients. --- CHECK OUT OUR SPONSORS Reflow Medical https://www.reflowmedical.com/ BD Rotarex Atherectomy System https://www.bd.com/rotarex --- SHOW NOTES Dr. WIlkins gives us the basic indication for the procedure, which is when the lesion is unable to be crossed from a purely antegrade approach and other re-entry devices have failed. Dr. Wilkins will always attempt to use an Outback wire and an Enteer balloon before performing the SAFARI technique. There are multiple factors that influence the decision to use SAFARI, such as lesion location, level of calcification, and size of the true lumen at the re-entry point. Next, Dr. Wilkins walks us through a typical SAFARI. He normally establishes retrograde access in the dorsalis pedis or posterior tibial artery using a 4 cm micropuncture needle and an exchange length Nitrex wire. He uses telescoping catheters from the antegrade direction. When the antegrade and retrograde approaches enter the same subintimal plane, the 2 devices can connect and the lesion can be crossed. If it is challenging to achieve the same intimal plane for both devices, the gunsight approach of overlapping snares can be utilized. After the lesion is crossed, normal angioplasty and stenting can occur. Dr. Wilkins gives advice on how to make the procedure efficient. In occlusions that are longer than 1 cm, he always makes sure that the foot is prepped before the case starts. He also emphasizes the importance of knowing when to try a different technique and notes that this intuition comes from experience. Finally, we discuss patency rates for SAFARI patients, which have been relatively high. This technique has made a large impact on limb salvage in a patient population that previously had no other non-surgical options. --- RESOURCES Rotarex Atherectomy System: https://www.bd.com/en-us/products-and-solutions/products/product-families/rotarex-rotational-excisional-atherectomy-system Outback Re-Entry Catheter: https://cordis.com/na/products/cross/endovascular/outback-elite-re-entry-catheter Enteer Re-Entry Catheter/Balloon: https://www.medtronic.com/us-en/healthcare-professionals/products/cardiovascular/chronic-total-occlusion-devices/enteer/indications-safety-warnings.html Nitrex Wire: https://www.medtronic.com/us-en/healthcare-professionals/products/cardiovascular/guidewires/nitrex.html CXI Catheter: https://www.cookmedical.com/products/di_cxi_webds/ Outcome and Distal Access Patency in Subintimal Arterial Flossing with Antegrade-Retrograde Intervention for Chronic Total Occlusions in Lower Extremity Critical Limb Ischemia: https://www.jvir.org/article/S1051-0443(19)31033-4/fulltext

11 Marras 202239min

In this episode, host Dr. Michael Barraza interviews interventional radiologist Dr. Doug Hidlay about how he has built a solo IR practice in rural Virginia, including how he got equipment, employees and referrals to build a busy and diverse practice. The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/TOy6WC --- CHECK OUT OUR SPONSORS Accountable Physician Advisors http://www.accountablephysicianadvisors.com/ Accountable Revenue Cycle Solutions https://www.accountablerevcycle.com/ --- SHOW NOTES Dr. Hidlay begins by discussing how he was recruited out of fellowship into a medical group in Virginia. They offered him the opportunity to build an entire IR practice and do the kinds of procedures that he wanted to bring with whatever skills he had from his residency at Brown and fellowship at the University of Washington. He is employed by a hospital group where he does about 30% diagnostic radiology, runs his own clinic and sees consults. He was hired to prioritize IR, and feels very supported by his diagnostic colleagues to do so. We discuss what he learned through this process, and what he wished he would have known. He says the biggest surprises were from his own naivete, having gone straight into this position out of fellowship. The administration was up front with him and told him to expect to have to build this practice from scratch. When he started, he had 6 FTEs including himself, a scheduler, 3 techs and 3 nurses. He started off doing about 10 paracenteses, a couple lung biopsies and some thyroid biopsies per week. He attributes his success to showing up consistently. He asked for time to talk at every local practice and grand rounds. He met with surgeons, hospitalists, and primary care doctors to tell them what he could do, with the idea that even if they didn’t remember, they would have his number and could reach him at any time. What he didn’t realize was how much of a need there was. He soon became overwhelmed by the demand, and realized he was in over his head, doing 12-18 cases daily with the same support staff. As for acquiring equipment to do procedures, Dr. Hidlay feels he was fortunate to have administration who were willing to believe him when he said he needed certain equipment. When it came to training staff, he often worked with them at the backtable and taught them how to use the image intensifier (II) controls to help them ‘learn by doing’. He started out on call 24/7, while his 3 techs and nurses were on call every 3 days. He slowly adjusted this as it was unsustainable for all, and has more staff now. By volume, he still mostly does light IR and feels that if he didn’t accept these cases he would never have built trust and made connections to referring providers. He also has a kyphoplasty service, a venous thromboembolism (VTE) service, and also does a sizeable volume of renal ablations, chemoembolizations, and emergent bleeds. He is hoping to bring on two more IRs to round out his practice and meet the community demand. --- RESOURCES BackTable Episode 221: Building a Musculoskeletal Interventional Oncology Service with Dr. Alan Sag https://www.backtable.com/shows/vi/podcasts/221/building-a-musculoskeletal-interventional-oncology-service Doug Hidlay Twitter: @DHidlayVIR

7 Marras 202245min

In this episode, host Dr. Aaron Fritts interviews Dr. Marc Sapoval about practicing IR in France, the origins of the Global Embolization Oncology Symposium Technologies (GEST) Conference, and an upcoming conference in MSK embolization. The CE experience for this Podcast is powered by CMEfy - click here to reflect and earn credits: https://earnc.me/PX6J62 --- CHECK OUT OUR SPONSORS Global Embolization Oncology Symposium Technologies (GEST) Conference https://thegestgroup.com/ Laurel Road for Doctors https://www.laurelroad.com/healthcare-banking/ RADPAD® Radiation Protection https://www.radpad.com/ --- SHOW NOTES First, Dr. Sapoval gives an overview of the French IR landscape. He outlines the training pathway, which is a four year radiology program with an additional two years of IR specialization. He also describes his role at an academic hospital. Dr. Sapoval says that in his country, collaboration with other endovascular specialists depends on both interpersonal relationships and business incentives. For the remainder of the interview, we talk about how GEST began and where it is today. In 2007, Drs. Marc Sapoval, Jafar Golzarian, and Ziv Haskal started the first GEST conference in Barcelona, after they realized the need for a specific meeting geared towards embolization. This inaugural meeting turned out to be a success, with attendance reaching much higher numbers than they had originally anticipated. Since then, GEST annual meetings have taken place throughout Europe and the United States. In recent years, it has found a permanent home in New York City. Dr. Sapoval introduces a new smaller conference series called GEST Hot Topics. An upcoming conference in this series focuses on MSK interventions, and it will be held in Paris on January 20-21, 2023. He emphasizes that it is an incredible opportunity to be part of a new field of IR. He highlights speakers who currently lead research efforts in MSK embolization and encourages all listeners to register and attend GEST Hot Topics: MSK Embolization. --- RESOURCES GEST Hot Topic: MSK Embolization: https://thegestgroup.com/gest-msk-2023-paris/ GEST Annual Conference 2023: https://annual.thegestgroup.com/GEST23/Public/mainhall.aspx

4 Marras 202233min

In this episode, Dr. Chris Beck interviews Interventional Radiologist Dr. Josh Kuban about his liver tumor ablation practice at MD Anderson Cancer Center, including how it's evolved over time with newer technologies. They also discuss patient workup for liver tumors, treatment with microwave ablation, and post-procedure follow up. Dr. Kuban shares why he uses microwave ablation technology, and the advantages of ablation confirmation software for these procedures. --- CHECK OUT OUR SPONSOR NeuWave Microwave Ablation Systems https://www.jnjmedtech.com/en-US/product-family/neuwave-microwave-ablation-systems --- SHOW NOTES We begin by discussing how Dr. Kuban started to get involved in interventional oncology and tumor ablation. He started off doing a broad base of vascular procedures. When he came to MD Anderson, he began building close relationships with oncologists which led him to become focused on ablation, primarily of liver and lung lesions. For liver tumors, Dr. Kuban primarily uses microwave ablation, while in the lung, he does cryoablation. The benefits of microwave ablation are the efficiency of the procedure compared to the time it takes to perform cryoablation. He generally does multiprobe ablations, which allows him to treat the tumor more aggressively from the beginning. He is able to do this confidently by taking advantage of ablation confirmation (AC) software. He always starts with a pre-procedure CT which he uploads to the AC software. He then compares his pre-image to his probe image which helps target the lesion intraoperatively. After ablating, he does another scan that has arterial and venous phases to look for bleeding. The AC software then takes the pre-scan and post-scan and merges them to show the ablation zone. Lastly, we discuss the impact that AC software has had on Dr. Kuban’s practice. When Dr. Kuban approaches a liver ablation case, his goal is to get the entire tumor in a single procedure, and he believes that he has to be able to see the margins in order to effectively ablate them. The software allows him to see the treatment effect in real time and provide more complete treatment the first time. After using this software, his recurrence rates have been very low, and he is confident that if a recurrence does happen, it is not due to incomplete ablation. He also emphasizes the effects that AC software has had on practice building. Because of this software, he is able to show images of cases to referring providers. --- DISCLAIMER Dr. Josh Kuban is presenting on behalf of Ethicon. The presentation reflects the opinions of the individual presenter, and the steps described may not encompass the complete steps of the procedure. Additionally, other surgeons may prefer different techniques, approaches, etc., as individual surgeon experience in his/her clinical practice, as well as patient needs, may dictate variation in procedure steps. Accordingly, results from any case studies reported in this presentation may not be predictive of results in other cases. Before using any medical device, review all labeling, including without limitation; the Instructions For Use (IFU), and relevant package inserts with particular attention to indications, contradindications, warnings and precautions, and steps for use of the device(s). Dr. Josh Kuban is compensated by and presenting on behalf of Ethicon and must present information in accordance with applicable regulatory requirements. The NeuWave™ Ablation System and Accessories are indicated for the ablation (coagulation) of soft tissue in percutaneous, open surgical and in conjunction with laparoscopic surgical settings, including the partial or complete ablation of non-resectable liver tumors. The NeuWave™ Microwave Ablation System and Accessories are not indicated for use in cardiac procedures. The system is designed for facility use and should only be used under the orders of a clinician.

31 Loka 202223min

In this episode, guest host Dr. Nicholas Fidelman interviews Dr. Michael Solen, a key player in the development and widespread adoption of transarterial chemoembolization (TACE). The doctors discuss how TACE became a major therapeutic option for liver tumors, his preferred method of TACE dosage and management, and exciting new frontiers in chemoembolization. --- CHECK OUT OUR SPONSOR Varian, a Siemens Healthineers company https://www.varian.com/ --- SHOW NOTES Dr. Soulen recalls his first ever TACE patient, who was a patient self-referring for a rare neuroendocrine tumor. As an IR fellow at the University of Pennsylvania, Dr. Soulen recognized the opportunity to incorporate clinic time into his IR practice. His push for clinical management of IR patients resulted in successful medical and financial outcomes, which also led his hospital to establishing an interventional oncology clinic. He emphasizes that a clinic presence is crucial to participating in tumor boards and being able to accept outside referrals. Next, we delve into the history of the CAM (cisplatin, adriamycin, mitomycin) conventional TACE cocktail, which Dr. Soulen developed alongside medical oncologists and pharmacists. These chemotherapeutics, combined with lipiodol and followed by particle embolics, make up the most widely used TACE protocol in the United States. Dr. Soulen reviews his preferred ratios and mixing method for maximal efficacy. He discusses his current RETNET trial that directly compares treatment of neuroendocrine tumors with conventional TACE versus bland embolization in terms of progression free survival, toxic side effects, and patient quality of life. Additionally, we address the high prevalence of post-embolization syndrome and SIR consensus guidelines for its management. Since chemoembolization is a highly emetogenic therapy, Dr. Soulen uses an oncology evidence-based combination of Benadryl, Zofran, and Decadron. He administers PRN pain medication on an individual patient basis. Furthermore, we discuss post-TACE management, specifically length of hospital stay. While all patients used to be admitted for overnight monitoring, this has shifted to mostly same-day discharges. This change has allowed the hospital to conserve resources and decrease costs. Finally, Dr. Soulen shares his perspective on new developments in interventional oncology. He highlights a need to identify TACE drugs that specifically target intratumoral hypoxic response mechanisms. He also compares transarterial radioembolization (TARE) to TACE, noting that the former has not shown superiority to systemic therapy in research trials. However, there are possibilities that TARE or TACE could be useful to slow tumor progression in radiation lobectomy or as immunostimulants for combination therapy with immune checkpoint inhibitors and CAR-T cell therapy. --- RESOURCES RETNET Trial: https://clinicaltrials.gov/ct2/show/NCT02724540 Transcatheter oily chemoembolization of hepatocellular carcinoma: https://pubmed.ncbi.nlm.nih.gov/2536946/ Prospective Randomized Study of Doxorubicin-Eluting-Bead Embolization in the Treatment of Hepatocellular Carcinoma: Results of the PRECISION V Study: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2816794/ Randomised controlled trial of doxorubicin-eluting beads vs conventional chemoembolisation for hepatocellular carcinoma: https://pubmed.ncbi.nlm.nih.gov/24937669/ Treatment of Liver Tumors with Lipiodol TACE: Technical Recommendations from Experts Opinion: https://pubmed.ncbi.nlm.nih.gov/26390875/ Outpatient Transarterial Chemoembolization of Hepatocellular Carcinoma: Review of a Same-Day Discharge Strategy: https://pubmed.ncbi.nlm.nih.gov/29478795/ Phase I Trial on Arterial Embolization with Hypoxia Activated Tirapazamine for Unresectable Hepatocellular Carcinoma: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8139681/

28 Loka 202255min