Ep. 591 NSCLC Tumor Board Discussion: Considerations for Oligometastatic Disease with Dr. Karen Reckamp, Dr. Scott Atay, Dr. Scott Oh and Dr. Alan Lee

Vascular Surgeon Daniel Han discusses management of persistent false lumen perfusion in chronic aortic dissection, including the Knickerbocker Technique. --- CHECK OUT OUR SPONSOR Medtronic IN.PACT Admiral Drug-Coated Balloon https://www.medtronic.com/5yeardcb --- SHOW NOTES In this episode, vascular surgeon Dr. Daniel Han and our host Dr. Sabeen Dhand discuss various techniques involved in repairing chronic aortic dissections, including Thoracic Endovascular Aortic Repair (TEVAR), Knickerbocker, and candy plug. Dr. Han starts by reviewing the differences between a true lumen and a false lumen. False lumens are usually formed by a dominant entry tear in the aortic wall with additional fenestrations present. Since the false lumen lacks the three walls of the aorta, it is more easily perfused and compresses the true lumen. He further subdivides aortic dissection into hyperacute, acute, subacute, and chronic dissections, all depending on the chronicity of the tear. With treatment, the goal is to achieve aortic remodeling and fuse the true and false lumens. Dr. Han notes that the more chronic the dissection, the harder it will be to remodel the aorta back to its original state, since it has already started remodeling in the dissected state. The doctors discuss TEVAR and follow-up results in which Dr. Han would choose to re-intervene. He explains the Knickerbocker technique, in which he uses a balloon to selectively rupture the dissected septum. This establishes contact between the stent graft and the other side of the aorta, effectively creating a physical barrier to retrograde flow in the thoracic aorta. Dr. Han also discusses the candy-plug technique, which results in immediate cessation of blood flow into the thoracic aorta. --- RESOURCES BackTable VI Episode 142: Type B Aortic Dissections with Dr. Frank Arko: https://www.backtable.com/shows/vi/podcasts/142/type-b-aortic-dissections Favorable Impact of Thoracic Endovascular Aortic Repair on Survival of Patients with Acute Uncomplicated Type B Aortic Dissection: https://pubmed.ncbi.nlm.nih.gov/29914833/ Outcomes of Thoracic Endovascular Aortic Repair for Chronic Aortic Dissections: https://pubmed.ncbi.nlm.nih.gov/29157682/

1 Marras 202143min

Interventional Cardiologist Behnam Tehrani and Interventional Radiologist Reha Butros from Inova Health System tell us about their team approach to endovascular treatment of chronic thromboembolic pulmonary hypertension (CTEPH) with Balloon Pulmonary Angioplasty (BPA). --- CHECK OUT OUR SPONSOR RADPAD® Radiation Protection https://www.radpad.com/ --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/TCTEY3 --- SHOW NOTES In this episode, interventional radiologist Dr. Reha Butros, interventional cardiologist Dr. Behnam Tehrani, and our host Dr. Michael Barraza discuss chronic thromboembolic pulmonary hypertension (CTEPH) and medical, endovascular, and surgical treatment options for CTEPH. CTEPH affects patients of all different ages and medical histories. While it has been associated with prior pulmonary embolism, it can also arise in patients due to blood clotting disorders and infected pacemakers. Both Dr. Butros and Dr. Tehrani stress the importance of collaborating with pulmonary hypertension experts to identify CTEPH patients before right sided heart failure occurs. CTEPH is diagnosed with dual energy CT, which shows perfusion, and right heart catheterization, which measures blood pressure. The three treatment options discussed are medical management, balloon pulmonary angioplasty (BPA), and pulmonary thromboendarterectomy (PTE). Medical management is discussed as an initial treatment for CTEPH, while PTE can be appropriate for good surgical candidates. Finally, Dr. Butros and Dr. Tehrani present BPA as an appropriate treatment for patients of all ages. BPA over multiple sessions and increasing balloon size has been shown to be effective at promoting pulmonary artery remodeling and dilation. The doctors share their own experiences with learning BPA technique, noting that it has a learning curve, but it is ultimately rewarding when patients’ quality of life is improved.

25 Loka 202136min

Neurosurgeon Dr. Nam Tran from Moffitt Cancer Center talks with us about RF ablation for painful spinal metastases, including patient selection and the importance of a multidisciplinary approach. --- CHECK OUT OUR SPONSOR Medtronic OsteoCool https://www.medtronic.com/us-en/healthcare-professionals/products/spinal-orthopaedic/tumor-management/osteocool-ablation-system-rf.html --- SHOW NOTES In this episode, neurosurgeon Dr. Nam Tran and our host Dr. Michael Barraza discuss minimally invasive procedures to treat both primary spine tumors and spine metastases. Dr. Tran describes the flexibility that kyphoplasty and spinal ablation can grant patients who are not suitable candidates for open surgical decompression. These minimally invasive procedures can reduce hospital stays from 4-5 days to just one night. Dr. Tran views ablation not only from a palliative pain reduction perspective, but also from an oncologic perspective that aims to reduce tumor burden. Dr. Tran says the ideal candidate for ablation is a patient who has isolated disease to the anterior column of the spine. With larger lesions, Dr. Tran relies on his neurosurgical background to take an aggressive approach in treating the entire vertebra. The doctors also discuss research studies that have made ablation more widely accepted and available (all articles are linked below). --- RESOURCES OPuS One Study: https://pubmed.ncbi.nlm.nih.gov/33129427/ CAFE Study: https://www.clinicaltrials.gov/ct2/show/study/NCT00211237

18 Loka 202118min

Dr. Aparna Baheti talks with Dr. Saher Sabri from MedStar Georgetown University Hospital about his approach to Balloon-occluded retrograde transvenous obliteration (BRTO) for portal hypertension, including advanced tips and tricks. --- CHECK OUT OUR SPONSOR Medtronic Embolization https://www.medtronic.com/embolization --- SHOW NOTES In this episode, Dr. Saher Sabri and our host Dr. Aparna Baheti discuss PARTO, BRTO, and combined TIPS and BRTO procedures. First, they discuss differences between PARTO (Plug-Assisted Retrograde Transvenous Obliteration) and BRTO (Balloon-Occluded Retrograde Transvenous Obliteration). Dr. Sabri walks us through the steps of both, noting that it is important to study the shunt before the procedure to identify its narrowest part. He also emphasizes the need to confirm successful balloon occlusion before starting embolization. This can require minor adjustments to balloon size and positioning. To identify the endpoint for injection, Dr. Sabri tracks sclerosant movement up to the diaphragm and then down to the gastric varix. He confirms that the shunt has been obliterated and prevented from recruiting other outflows in the future. When considering combined TIPS and BRTO procedure, Dr. Sabri focuses on key indications such as bleeding gastric varices, high-risk esophageal varices, and ascites. He prefers to do the TIPS procedure first, then the BRTO, then re-measuring the gradient and deciding if more ballooning of the TIPS is needed. Finally, the doctors discuss post-procedural follow up and imaging. Dr. Sabri aims to have CT imaging within 2-4 weeks after BRTO and an ultrasound within 2 weeks after TIPS.

15 Loka 202149min

Dr. Nainesh Parikh from Moffitt Cancer Center discusses his approach to ablation of small renal masses, including workup, technique, and device selection. He also tells us why he has the best job ever! --- CHECK OUT OUR SPONSOR Medtronic FlowMet https://www.medtronic.com/flowmet --- SHOW NOTES In this episode, Dr. Nainesh Parikh and our host Dr. Michael Barraza discuss tips for renal ablation and multispecialty care for kidney cancers. First, they delve into the decision-making process for choosing between cryoablation and microwave ablation. Dr. Parikh believes that cryoablation is relatively safe to use in lesions near the collection system; however, it can cause a large inflammatory response in surrounding tissues. On the other hand, he prefers to use microwave ablation on exophytic lesions. Both doctors share their experiences with tricky lesions near the spine and various nerves. They also discuss the usage of pre-ablation embolization lesions larger than 5 cm. Throughout the episode, the doctors emphasize the importance of constant communication with urologists, since embolization and ablation can provide significant benefits for patients who are poor surgical candidates. Collaboration can help the medical team better manage recurrences as they arise. Dr. Parikh notes that follow up care for image-guided procedures should occur around four weeks, which is sooner than the conventional urology follow up period. Finally, Dr. Parikh gives pearls of wisdom regarding the advantages of hydrodissection, pneumodissection, and CT fluoroscopy for a safer and more efficient procedure. --- RESOURCES Moffitt Cancer Center IR Page: https://moffitt.org/for-healthcare-professionals/clinical-programs-and-services/radiology-diagnostic-imaging-and-interventional-radiology-program/

11 Loka 202154min

Dr. Christopher Beck talks with Dr. Driss Raissi about his approach to Microwave Ablation of Liver Lesions, including workup, technique, and tips and tricks for a successful ablation treatment. --- CHECK OUT OUR SPONSOR Medtronic Emprint Ablation System https://www.medtronic.com/covidien/en-gb/products/ablation-systems/emprint-ablation-system.html --- SHOW NOTES In this episode, Dr. Driss Raissi and our host Dr. Chris Beck discuss the planning, technique, and follow-up considerations for microwave ablation of liver lesions. First, they talk through the process of mapping out the tumor. Dr. Raissi often attends tumor boards to contribute to the variety of treatment perspectives and gain consensus for microwave ablation from colleagues in different specialties. He also discusses the differences between cirrhotic and steatotic livers because the latter can limit the efficiency of microwave energy delivery. During the procedure, Dr. Raissi appreciates the simplicity of a one-needle device. He offers advice for maneuvering near critical organs: direct the tip of the needle towards the critical structure to gain control. Additionally, he prefers to align the long axis of the needle with the long axis of the tumor and to minimize the number of new liver punctured by overlapping ablation zones. The doctors also discuss the need to balance clean margins with preservation of liver tissue, noting that lesions in different lobes can be treated in different sessions. Finally, they cover telehealth follow-ups and MRI follow-up during the subsequent month. Throughout this episode, we refer to findings about microwave ablation from previous publications, which are linked below. --- RESOURCES Comparison of microwave ablation and radiofrequency ablation for hepatocellular carcinoma: a systematic review and meta-analysis: https://pubmed.ncbi.nlm.nih.gov/30676100/ Liver microwave ablation: a systematic review of various FDA-approved systems: https://pubmed.ncbi.nlm.nih.gov/30506218/ Early Outcomes with Single-antenna High-powered Percutaneous Microwave Ablation for Primary and Secondary Hepatic Malignancies: Safety, Effectiveness, and Predictors of Ablative Failure: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7110402/

4 Loka 20211h

In Part II of our Lung Biopsy Series Dr. Fred Lee and Dr. Christopher Beck discuss Pleural and Parenchymal Blood Patching to prevent Pneumothorax, including results of the recent JVIR article from Sept 2021. --- CHECK OUT OUR SPONSOR RADPAD® Radiation Protection https://www.radpad.com/ --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/0lTQ87 --- SHOW NOTES In this episode, Dr. Fred Lee and our host Dr. Chris Beck discuss the use of parenchymal and pleural blood patches to reduce the rate of lung biopsy re-interventions. First, Dr. Lee describes why he has incorporated parenchymal blood patching at the end of most biopsies, noting that it is a straightforward procedure that only adds on a few extra minutes to the overall biopsy, and it can reduce the rate of re-intervention. Both doctors agree that minimizing the need for chest tubes can greatly improve the patient experience. Pleural blood patches are used as a salvage technique in the event of a pneumothorax. Dr. Lee walks through his process of re-inflating the lung, finishing the biopsy, and using a three-way stopcock to inject blood onto the pleural surface and along the needle track. He notes that there are other valid ways of treating intraprocedural pneumothoraces (saline, fibrin plug, etc); however, he prefers the pleural blood patch because of its liquid-to-solid clotting transition, minimal time, minimal cost, and relatively low risk. Throughout this episode, we cite data from Dr. Lee’s previous publications, which are cited below. --- RESOURCES Percutaneous Lung Biopsy with Pleural and Parenchymal Blood Patching: Results and Complications from 1,112 Core Biopsies: https://www.jvir.org/article/S1051-0443(21)01202-1/fulltext CT-Guided Lung Biopsies: Pleural Blood Patching Reduces the Rate of Chest Tube Placement for Postbiopsy Pneumothorax: www.ajronline.org/doi/full/10.2214/AJR.10.6324 Pulmonary Intraparenchymal Blood Patching Decreases the Rate of Pneumothorax-Related Complications following Percutaneous CT–Guided Needle Biopsy: www.jvir.org/article/S1051-0443…6)32178-9/fulltext

28 Syys 202144min

We start off Part 1 of a 2 part series with Dr. Fred Lee discussing Percutaneous Lung Biopsy Technique, with tips and tricks to help your daily practice. --- CHECK OUT OUR SPONSOR RADPAD® Radiation Protection https://www.radpad.com/ --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/QD39HM --- SHOW NOTES In this episode, Dr. Fred Lee and our host Dr. Chris Beck discuss tips for achieving safe and successful percutaneous lung biopsies. They start by discussing the increasing popularity of core biopsy (as opposed to fine needle aspiration), since an adequate amount of specimen is needed for genetic testing and personalized medicine. Dr. Lee emphasizes that knowing the goals of lung biopsy for each individual patient helps him decide how much specimen to collect and how the specimen should be handled. Next, Dr. Lee walks through his lung biopsy technique. He outlines the difference between conventional CT and CT with fluoroscopy. While CT with fluoroscopy can be more efficient, it poses radiation risk to the patient and the physician. To minimize radiation risks, he advises IRs to intermittently tap the foot pedal and stand lateral to the CT scanner. The doctors also discuss some of the trickiest lung regions to biopsy and ways to avoid pneumothorax. Finally, Dr. Lee comments on the choice between percutaneous lung biopsies and electromagnetic navigation bronchoscopy, noting that each procedure has different advantages and risks. He encourages interventional radiologists and interventional pulmonologists to explore these options and take evidence-based approaches. Throughout this episode, we cite data from Dr. Lee’s previous publications, which are cited below. --- RESOURCES Percutaneous Lung Biopsy with Pleural and Parenchymal Blood Patching: Results and Complications from 1,112 Core Biopsies: https://www.jvir.org/article/S1051-0443(21)01202-1/fulltext

27 Syys 202148min