Ep. 334 New Balloon Technologies for CLI with Dr. Peter Soukas

Can you manipulate blood flow in the tumor microenvironment to optimize drug delivery? In this episode of the BackTable Podcast, interventional oncologist Dr. Zachary Berman (UC San Diego) joins host Dr. Christopher Beck to discuss real-world applications of pressure-enabled drug delivery in locoregional liver-directed therapies like TACE and Y90.---This podcast is supported by:TriSalus Life Scienceshttp://trinavinfusion.com/---SYNPOSISThe conversation begins with an overview of the tumor microvascular environment, focusing on the abnormal nature of the new vessels that feed tumors. They then discuss the genesis of pressure-enabled drug delivery and the theory behind its efficacy. Dr. Berman explains the TriNav catheter’s micro-valve design, its anti-reflux properties, and how these features enhance tumor drug delivery. He walks through his own procedure technique, comparing and contrasting it to standard embolization, and details the utility of pressure-enabled drug delivery in lobar radioembolization and larger tumors. They also explore the benefits of both balloon occlusion and microvalve catheters.Real-world cases—including neuroendocrine tumors, segmental HCC, and more—illustrate the thought process around when to use specialized technologies. The episode wraps up with a discussion of the future implications for this technology in other pathologies, cost considerations, and the potential for enhancing drug delivery with innovative approaches.---TIMESTAMPS00:00 - Introduction01:39 - The Tumor Microenvironment06:59 - Pressure-Enabled Drug Delivery Explained09:37 - Technical Aspects of Pressure-Enabled Catheters21:48 - Case 1: Grade 3 Neuroendocrine Tumor34:06 - Case 2: Hepatocellular Carcinoma with Tumor and Vein36:01 - Case 3: TACE for Segmental HCC in Decompensated Cirrhosis38:58 - Case 4: Large Heterogenous Cholangiocarcinoma40:40 - Case 5: Lobar Neuroendocrine Tumor42:38 - Case 6: Segmental HCC with Central Necrosis47:52 - Best Practices and Technical Considerations57:52 - Future Directions in Pressure-Directed Embolotherapy59:48 - Conclusion and Final Thoughts---RESOURCESJVIR 2024 Jaroch et al.:https://pubmed.ncbi.nlm.nih.gov/38969336/

12 Aug 202558min

The toolbox for vessel preparation is rapidly expanding. Are you keeping up? In this episode, host Dr. Sabeen Dhand is joined by Dr. Jay Mathews, interventional cardiologist (Manatee Memorial Hospital) and Dr. Michael Siah, vascular surgeon (UT Southwestern), to explore the latest innovations and strategies in vessel prep. --- This podcast is supported by: Cagent Vascularhttps://cagentvascular.com/ --- SYNPOSIS The discussion opens with a look at new additions to their practice over the past few years, including bioresorbable scaffolds for below-the-knee interventions and retrievable stent technologies. Both experts emphasize the role of imaging—particularly CT angiography and IVUS—and discuss how renal disease impacts their use of contrast during diagnosis and intervention. They then walk through how they assess vessels on angiography or IVUS to decide when and where to use specialty tools. From intravascular lithotripsy for managing dense calcification to serration angioplasty, the conversation highlights how the doctors decide to use specialty balloons and devices. The episode also touches on the practical challenges of balancing device cost with treatment effectiveness. The physicians break down the latest specialty balloons and devices and touch on their own experiences with them. To close, the guests share what emerging technologies they’re most excited about and how these devices could change their day-to-day practice. Whether you’re in IR, cardiology, or vascular surgery, this episode offers a valuable roadmap to the current and future state of vessel preparation. --- TIMESTAMPS 0:00 - Introduction4:07 - New Changes in Techniques14:57 - Vessel Characteristics on Angiogram18:10 - Approaches to Above-the-Knee vs. Below-the-Knee Disease23:48 - Latest Specialty Balloons46:14 - New Devices on the Horizon50:58 - Words of Advice and Final Thoughts --- RESOURCES POINT FORCE Registry: ​​https://evtoday.com/news/cagent-initiates-point-force-registry-of-serranator-pta-catheter?c4src=news

5 Aug 202555min

What are the key elements of a robust interventional radiology practice, and how can IRs effectively demonstrate their value to hospitals? Guest, Dr. Harris Chengazi, interventional radiologist at Great Lakes Medical Imaging, joins host Dr. Sabeen Dhand to explore the core strategies behind developing a successful and sustainable clinical IR practice. --- This podcast is supported by: RADPAD® Radiation Protectionhttps://www.radpad.com/ --- SYNPOSIS Dr. Chengazi reflects on formative experiences from the early stages of his career, highlighting the importance of joining a group that shares your vision for a clinical interventional radiology (IR) practice. He underscores the unique value IR offers hospitals—particularly through longitudinal patient care, which not only enhances reimbursement opportunities but also strengthens interdisciplinary collaboration and drives outpatient referrals.He shares insights on balancing complex cases with essential procedures, while underscoring the importance of clear communication and articulating IR’s value to hospital leadership. He also highlights the critical need for physicians to understand the business side of medicine—including coding, billing, and reimbursement—in order to effectively advocate for the specialty. He concludes the episode with a compelling message on the importance of taking ownership of both our patients and the future of our profession. --- TIMESTAMPS00:00 - Introduction and Overview01:55 - Building a Private Practice05:22 - Challenges and Successes24:58 - The Value of Complex Cases in Medical Practice27:00 - Improving Hospital Efficiency Through IR Services29:18 - Involvement of IR in Hospital Administration31:26 - Building a Successful IR Practice36:14 -The Financial Dynamics of IR and DR Practices41:14 -The Essential Role of IR in Hospital Operations

1 Aug 202554min

When is Y90 the right treatment for metastatic disease? Join Drs. Tyler Sandow, Zach Berman and host Kavi Krishnasamy in the conclusion of Dosimetry University where they discuss the complexities of treating different variations of metastatic disease and review how they’ve approached complicated cases with Y90. --- SYNPOSIS The interventional oncologists first outline the types of metastases that they treat, including colorectal, lung, cholangiocarcinoma, breast, gastric, RCC, and melanoma. The doctors then discuss the potential for Y90 to provide palliative relief by reducing tumor-related pain. The conversation also covers key differences between treating liver-dominant and liver-only disease, along with their algorithm for patients not on systemic chemotherapy.The episode then covers advanced concepts in Y90, such as sub-ablative dosing, the possibility of creating an abscopal effect, and how radiation thresholds change depending on treatment goals. They outline their approach to partition dosimetry, using SPECT/CT to calculate tumor-to-normal ratios, and explain how they modify particle counts and microsphere activity, using flow augmentation based on tumor vascularity. Additional discussion includes the impact of mutation status, prior lines of chemotherapy, and tumor response criteria like RECIST 1.1 and mRECIST. The experts conclude with a case series that illustrates decision-making around when to consider Y90, thermal ablation, TACE, or alternative approaches—even in complex cases like sphincter of Oddi dysfunction. The session underscores the nuanced nature of advanced dosimetric techniques and the evolving landscape of interventional oncology. --- TIMESTAMPS 00:00 - Introduction 01:30 - Types of Metastases Treated with Y9002:50 - Liver-Dominant vs. Liver-Only Disease 07:20 - Sub-Ablative Dosing and the Abscopal Effect09:55 - Tips for Partition Dosimetry 15:30 - Clinical Factors in Treatment Planning23:50 - Choosing Ablation, Resection, or Y90 for mCRC30:27 - Case Series: Colorectal Metastases, Biliary Complications, and more46:00 - Final Thoughts: The Evolving Field --- RESOURCES RECIST 1.1 and mRECIST Criteria:https://pmc.ncbi.nlm.nih.gov/articles/PMC9161105/ COLLISION Trial:https://ascopubs.org/doi/10.1200/JCO.2024.42.17_suppl.LBA3501 BackTable Episode on COLLISION Trial:https://www.youtube.com/watch?v=NQLKcv1BRVM FOXFIRE, SIRFLOX, FOXFIRE-Global:https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(17)30457-6/fulltext

29 Jul 202548min

Symptomatic gallstones that can’t be treated with surgery? Interventional radiology can help. In this episode of BackTable, Dr. John Smirniotopoulos, IR at MedStar Health, joins Dr. Michael Barraza to share the latest advancements and techniques in biliary endoscopy. --- SYNPOSIS Dr. Smirniotopoulos reflects on his early work with cholangioscopy at Cornell, highlighting ongoing innovation and evolving tools. The conversation covers the practical aspects of patient selection, procedural steps, and overcoming technical challenges. Dr. Smirniotopoulos shares his personal experiences managing small and large biliary stones, emphasizing the important role of selecting appropriate equipment to navigate procedural challenges. Dr. Smirniotopoulos also highlights the collaborative role of surgeons and gastroenterologists throughout patient management. He also provides insights into the management of biliary strictures and emphasizes the importance of accurate billing and coding. The episode concludes with advice for clinicians seeking to integrate these techniques into their practice. --- TIMESTAMPS 00:00 - Introduction01:09 - Early Experiences with Biliary Endoscopy03:35 - Procedure Techniques and Tools05:36 - Patient Selection and Case Studies11:01 - Advanced Techniques and Equipment14:02 - Patient Management and Follow-Up18:21 - Technical Considerations and Best Practices20:14 - Managing Stones in the Gallbladder35:42 - Collaborating with Surgeons and GI Teams37:59 - Advice for New Practitioners

25 Jul 202543min

The balance between targeting tumor and sparing healthy liver is delicate. How do the experts do it? In this case-based review, Drs. Zach Berman (UC San Diego) and Tyler Sandow (Ochsner Health) join host Dr. Kavi Krishnasamy to walk us through real-world scenarios and share how they approach Y90 dose optimization. --- This podcast is supported by: Sirtexhttps://www.sirtex.com/ Medtronic Emprinthttps://www.medtronic.com/emprint --- SYNPOSIS First, the doctors review a case of HCC and discuss key lab values, like albumin, and their role in planning. They also break down how they manipulate variables like microsphere activity, perfusion density, and total dose to deliver a tumor dose of around 1,100 Gy. The doctors also challenge the standard perfused dose of 400 Gy for large tumors and share when they feel comfortable pushing beyond it. Next, they discuss nuances in treating portal vein tumor invasion and what decides which Vp classifications can be treated with Y90 or combination immunotherapy. A subsequent case involving a large central HCC tumor explores the risks of biliary stricture from high radiation and the challenge of missing tumor margins with overly selective catheterization. In the last case, the doctors discuss different scenarios in multifocal HCC liver lesions. Overall, the conversation explores different approaches based on tumor size, location, and patient liver function, and highlights the importance of multidisciplinary collaboration in optimizing patient outcomes. --- TIMESTAMPS 00:00 - Introduction and Case Overview01:28 - Patient Case Study - Hep C and Alcoholic Cirrhosis02:05 - Evaluating Liver Function and Treatment Approach04:50 - Tumor Dose and Perfusion Density15:49 - Portal Vein Tumor Invasion21:42 - Case Study: Large Central HCC Tumor Treatment22:19 - Challenges in Treating Large Central Tumors22:48 - Dosimetry Considerations and Biliary Strictures27:24 - Case Study: Assorted Multifocal HCC Lesions Scenarios

22 Jul 202538min

Are your current stroke interventions in line with the latest clinical data? Dr. Blaise Baxter, interventional radiologist at Sutter Health, and Dr. Jim Milburn, interventional neuroradiologist at the Ochsner Health, join host Dr. Michael Barraza to discuss the latest advancements in stroke interventions. --- This podcast is supported by: Imperative Carehttps://imperativecare.com/stroke/zoom-stroke-solution/ --- SYNPOSIS The episode begins with a discussion on the different pathways to becoming a neurointerventionalist, emphasizing why interventional radiologists are uniquely equipped for this transition. They dive into cutting-edge stroke interventions, sharing key takeaways from major trials on large core and medium vessel occlusions. Dr. Baxter and Dr. Milburn highlight the HERMES trial, which showed that endovascular thrombectomy led to beneficial effects on patients with anterior circulation occlusion. They then cover the BAOCHE trial, which showed better functional outcomes with thrombectomy over medical therapy. Milburn and Baxter also share their perspectives on the shifting role of perfusion imaging and why the field may be moving beyond it. To close the discussion, the doctors underscore the powerful impact of rehabilitation in driving patient recovery, and stress the ongoing need for innovation and improved training in the field of neurointerventional radiology. --- TIMESTAMPS 00:00 - Introduction06:18 - Training and Certification in Neurointervention13:11- Large Core Trials and Their Impact19:42 - CT Perfusion and Treatment Decisions29:45 - Understanding Stroke Scale Scores and ICAD30:31 - Thrombectomy Trials and Treatment Strategies34:48 - Challenges in Randomizing Patients for Trials44:25 - Advancements in Robotics and Stroke Treatment51:37 - Future Directions in Stroke Rehabilitation53:11 - Global Thrombectomy Adoption and Training --- RESOURCES Hermes trial: Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387(10029):1723-1731. doi:10.1016/S0140-6736(16)00163-X BAOCH trial: Jovin TG, Li C, Wu L, et al. Trial of Thrombectomy 6 to 24 Hours after Stroke Due to Basilar-Artery Occlusion. N Engl J Med. 2022;387(15):1373-1384. doi:10.1056/NEJMoa2207576

18 Jul 202558min

How can interventional radiologists turn their unique capabilities into revenue? Dr. Matt Hawkins, interventional radiologist and Health Policy and Economics councilor at the Society of Interventional Radiology (SIR), joins host Dr. Ally Baheti to discuss how interventional radiologists can prove (and get paid for) the value that they bring to hospitals. --- This podcast is supported by: Medtronic Emprinthttps://www.medtronic.com/emprint RADPAD® Radiation Protectionhttps://www.radpad.com/ --- SYNPOSIS The doctors discuss key physician reimbursement models, including the Hospital Outpatient Prospective Payment System (HOPPS) for hospital outpatient and Diagnosis-Related Groups (DRGs) for hospital inpatient, as well as strategies for negotiating subsidies. Dr. Hawkins covers key strategies for proving the value of IR to hospitals, emphasizing the importance of moving beyond work RVUs and focusing on the technical revenue generated for hospitals. The discussion underscores the critical role that IR plays in trauma, transplant, and cancer care. Lastly, Dr. Hawkins highlights SIR’s economic initiative emphasizing the importance of accurate documentation and coding in order to turn our clinical impact into measurable value. --- TIMESTAMPS 00:00 - Introduction01:58 - Understanding Professional and Technical Reimbursement04:49 - Hospital Reimbursement Structures07:59 - Quantifying Value and Negotiating Contracts15:55 - Economic Arguments for IR in Trauma, Transplant, and Cancer23:01 - The Importance of IR Leadership in Mixed IRDR Groups25:13 - Challenges and Strategies for Independent IR Practices28:41 - Maximizing Revenue Through Evaluation and Management (E&M)36:40 - Navigating Coding and Documentation for Better Negotiation38:54 - Financial Literacy and Business Strategies

15 Jul 202542min