Ep. 590 Deep Venous Arterialization: Techniques & Outcomes with Dr. Miguel Montero Baker and Dr. Lucas M Ferrer Cardona

In this episode, host Dr. Michael Barraza interviews neurointerventional radiologist Dr. Aaron Bress about transverse sinus stenting for benign intracranial hypertension. --- CHECK OUT OUR SPONSORS MicroVention FRED X https://www.fred-x.com/ RADPAD® Radiation Protection https://www.radpad.com/ --- SHOW NOTES Aaron starts off the discussion by describing his typical patient population that requires stenting. Patients usually present to the clinic experiencing headaches, vision issues, and pulsatile tinnitus. Typically, these patients are female and overweight, and have been referred from headache clinics, neurosurgeons, and ENT specialists. Around 50% of his patients arrive with prior diagnoses and a complete workup already done, and they only require the procedure to be done. For the remaining patients, Aaron starts from scratch, emphasizing meticulous preparation imaging, which includes MRV with contrast. Aaron has a sequential approach for outpatients. He typically conducts diagnostic and treatment processes separately, to ensure that no complicating fistulas are present during interventions. Three months after the procedure, patients are referred for follow-ups with ophthalmologists to verify progress. During the procedure, Aaron starts with a diagnostic angiogram from the groin. During this time, he also obtains pressure measurements using a 27 mm diagnostic microcatheter. He typically measures from superior central sinus and then works his way back. He then obtains an MR venogram, which typically shows bilateral transverse sinus stenosis, and he measures pressure on both sides of the sinus. For him, a significant enough gradient to stent is typically 10 mmHg, however clinical presentation remains a key factor in deciding to stent patients with a lesser gradient. For the treatment procedure, patients are prescribed 75 mg Plavix and baby aspirin for five days before the intervention. On the day of the procedure, general anesthesia is administered, due to its neck-based approach. This approach not only provides better maneuverability, but also avoids complications associated with the heart, given the complexities of navigating the transverse sinus junction. Stent sizing remains highly personalized and tailored to the size of the patient's sinus, with no rigid guidelines in place. Patients typically stay overnight, with clear communication regarding the likelihood of experiencing a headache post-treatment. Following the procedure, they adhere to a six-month regimen of the dual antiplatelet therapy, which improves their recovery and treatment outcomes.

2 Okt 202331min

In this episode, host Ally Baheti interviews Dr. Minhaj Khaja about iliocaval reconstruction. Minhaj is a Clinical Professor of Radiology and Cardiac Surgery and Associate Program Director of Interventional Radiology Residency at the University of Michigan. --- CHECK OUT OUR SPONSOR BD Advance Clinical Training & Education Program https://page.bd.com/Advance-Training-Program_Homepage.html --- SHOW NOTES Minhaj begins by sharing how deep venous disease typically presents, as well as his clinical workup. He emphasizes the importance of gathering prior imaging, taking a thorough history and comprehensive physical exam, and calculating Villalta scale and Venous Clinical Severity Score (VCSS) for deep venous disease. Minhaj then tells us more about his approach to complex cases. We cover his setup and intra-op workflow in patients with good inflow, poor inflow, and prior chronically occluded stents. Minhaj and Ally also discuss anticoagulation, types of stents, crossing devices/sharp recanalization, and treating inflow via tibial vein access. Minhaj also shares his experience with using arterial re-entry devices for crossing long, occluded venous segments, radiofrequency wires for chronically occluded stents, and the new RevCore mechanical thrombectomy device made specifically for venous stent thrombosis. Ally and Minhaj then conclude the episode by highlighting the components of good follow up for patients. --- RESOURCES C-TRACT Venous Trial: https://clinicaltrials.med.nyu.edu/clinicaltrial/536/c-tract-study;-chronic-venous/ RevCore Mechanical Thrombectomy Device for Venous Stent Thrombosis: https://www.inarimedical.com/revcore/ Venovo Venous Stent: https://www.bd.com/en-us/products-and-solutions/products/product-families/venovo-venous-stent-system Zilver Vena Stent: https://www.cookmedical.com/products/f3af274c-42cc-42cd-a0db-e5715ad57cc4/ Abre Venous Stent: https://www.medtronic.com/us-en/healthcare-professionals/products/cardiovascular/deep-venous/abre-venous-stent.html

29 Sep 202357min

In this episode, host Dr. Aaron Fritts interviews Dr. Maureen Kohi and Dr. Niten Singh on the VIVA Foundation’s multidisciplinary approach to advancing vascular medicine. --- CHECK OUT OUR SPONSORS Medtronic ClosureFast https://www.medtronic.com/closurefast6f Philips Image Guided Therapy Devices Academy https://resource.philipseliiteacademy.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/PO5TFV --- SHOW NOTES Maureen is an interventional radiologist and Professor and Chair of the Department of Radiology at University of North Carolina - Chapel Hill. Niten is a vascular surgeon and Associate Chief of Vascular Surgery at University of Washington. Both serve on the board of directors at VIVA. We begin with how Maureen and Niten became involved at VIVA. They discuss the history and foundations of VIVA. The duo goes on to describe how VIVA has evolved throughout the years. Maureen speaks on how VEINS has become a comprehensive educational meeting for all things venous disease and interventions, which complements VIVA’s arterial focus. Niten and Maureen then explain how VIVA and VEINS have become more than just meetings. They are conglomerates of multiple initiatives for all things vascular driven by the central question of “What is best for the patient?” The duo also sheds light on the unique inner-workings of VIVA, highlighting the foundation’s speedy, nimble, and inclusive approach to the rapidly advancing landscape of vascular and endovascular surgery. We get a special look of what to expect at VIVA & VEINS Annual 2023 Conference at Wynn Las Vegas (October 28th - November 2nd) from Niten and Maureen. We conclude this episode with Maureen and Niten’s thoughts on how we can improve vascular care for our underserved patient populations and what role OBLs will play in this equation going forward. --- RESOURCES VIVA 2023 Annual Conference Registration: https://viva-foundation.org/viva-programming VEINS 2023 Annual Conference Registration: https://viva-foundation.org/veins-programming VIVA Vascular Leaders Forum on Paclitaxel Safety (2019): https://evtoday.com/articles/2019-mar/highlights-from-the-viva-vascular-leaders-forum-on-paclitaxel-safety

27 Sep 202330min

In this episode, host Dr. Aaron Fritts and Dr. Krishna Mannava engage in a discussion with Dr. Bret Wiechmann about a concerning trend in the field—insurance denials for critical limb ischemia (CLI) interventions. --- CHECK OUT OUR SPONSOR Philips SymphonySuite https://www.philips.com/symphonysuite --- SHOW NOTES Bret is an IR in Gainesville, Florida with over 26 years of experience and is one of the founders of the Outpatient Endovascular & Interventional Society (OEIS). OEIS was started 10 years ago to advocate for the viability of non-hospital IR services. We start the episode with Bret sharing his staff’s firsthand encounters with pre-authorization challenges for atherectomy procedures.The panel discusses how the recent inflammatory NY Times article regarding the use of atherectomy to treat peripheral artery disease has exacerbated these challenges. The doctors delve into the perplexing use of non-scientific articles as evidence by insurance companies, which are often influenced by third-party recommendations. The disconnect between insurance decisions and patients' actual needs becomes evident, as peer-to-peer reviews usually involve physicians unfamiliar with the specific medical speciality. Next, we explore strategies for navigating the intricacies of insurance approvals, a particularly challenging task as each insurance company has its unique set of requirements for procedure coverage. Evaluating these requirements for each patient not only limits the capabilities of the physician, but also decreases the quality of the patient's care. One strategy that is discussed is compiling a list of different payers and their specific requirements for each procedure, but this takes away valuable time away from a patient’s care. Another strategy includes the intriguing notion of physicians noting the names of insurance companies and peer reviewers on medical records as reasons for denying certain procedures. While promising, the effectiveness of this approach remains uncertain. Furthermore, the episode contemplates the possibility of refusing to work with insurance companies that consistently denying coverage— a bold strategy that warrants careful consideration as it may drop patient volumes. To combat the rising tide of insurance denials, the discussion emphasizes the pivotal role played by organizations like OEIS. It highlights the importance of involving referring physicians in various specialties, patients themselves as well as industry stakeholders manufacturing relevant devices to bring about meaningful change in the insurance approval process. --- RESOURCES New York Times Article: https://www.nytimes.com/2023/07/15/health/atherectomy-peripheral-artery-disease.html OEIS: https://oeisweb.com

25 Sep 202352min

In this episode, host Dr. Aaron Fritts interviews Dr. Aaron Kovaleski on good old-fashioned TV and radio marketing. Aaron is an interventional radiologist and founder of Endovascular Consultants of Colorado, who has found success in using tried and true methods of advertising to grow his practice. --- CHECK OUT OUR SPONSOR Philips SymphonySuite https://www.philips.com/symphonysuite --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/pL6Ay0 --- SHOW NOTES We begin with Aaron’s initial dive into marketing, tips that he learned, and surprising discoveries during this endeavor. He discusses differences between TV and radio advertising and ideal promotions to run through each medium. He also notes the importance of supplementing these strategies with a physical presence. Aaron also shares advice for building a marketing budget. He breaks down categories and percentage of funds invested towards his OBL’s TV and radio outreach. Aaron then speaks on how his practice measures the success of their efforts through analytics provided to them by TV and radio stations and CRM technology. We also discuss the time investment and step-by-step approaches for newer OBLs that are new to marketing outreach. We conclude this episode with future directions for marketing and a shoutout for next year’s Outpatient Endovascular and Interventional Society (OEIS) Annual Meeting in Las Vegas (April 25th-27th, 2024), which will have a dedicated session on marketing and practice building led by Aaron. --- RESOURCES Outpatient Endovascular and Interventional Society (OEIS) Annual 2024 Meeting: https://oeisweb.com/meetings/2024-annual-meeting/

22 Sep 202332min

In this episode, host Aaron Fritts is joined by Teri Yates, CEO of Accountable Physician Advisors, who offers essential guidance for successfully establishing and managing Office-Based Labs (OBLs). --- CHECK OUT OUR SPONSORS Accountable Physician Advisors http://www.accountablephysicianadvisors.com/ Philips SymphonySuite https://www.philips.com/symphonysuite --- SHOW NOTES Teri started a consulting company after working as a quality and risk officer at a radiology practice for 18 years. As the company rapidly grew, she has worked with many different physician practices and specialities. We start off the discussion by identifying key pitfalls that Teri sees in OBL ventures. First, it is common for physicians to conduct inadequate due diligence about referral sources, which can be a barrier to effective marketing and patient acquisition. Also, it is common for founders to lack a detailed revenue model or a plan for the business. Oftentimes, they will underestimate the capital needed to start the OBL and lack a clear idea about the types of procedures and patients they are catering towards. Another pitfall is not realizing the amount of time investment required. Teri estimates that approximately 10% of a physician's time will be needed to manage the OBL and it is important to take this into account. Finally, a common error is initially hiring individuals not qualified to be administrators, such as family members or trusted individuals. Teri also highlights some of the major reasons physicians consult her company. These challenges often revolve around "people problems," encompassing issues related to both administrative difficulties and employee management. Staffing and retention problems, leading to a significant turnover of employees, are common concerns. She underscores the importance of addressing issues related to physicians themselves, emphasizing that partners must set the tone for the culture within a company. Patient turnover efficiency in OBLs is also a recurring issue. Teri's advice for this issue to closely follow a few patients throughout their entire visit. This will most likely uncover redundancies in the patient experience, many of which the staff might already be aware of, but hesitant to communicate to leadership. As Teri reflects on her experiences, she notes that it typically takes 6-9 months to fully construct and operate an OBL. A comprehensive understanding of healthcare regulations in each state is crucial in the initial development stages. --- RESOURCES Accountable Physician Advisors: https://www.accountablephysicianadvisors.com/

18 Sep 202342min

En este episodio de BackTable, la Dra. Sara Lojo Lendoiro entrevista a la Dra. Eva Criado, radióloga intervencionista del Hospital Parc Taulí de Sabadell, Barcelona, sobre el manejo de las estenosis benignas en vía biliar y los stents biodegradables. --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/zVailz --- SHOW NOTES En primer lugar la Dra. Criado explica la clasificación de las estenosis biliares y las diferentes etiologías de las estenosis benignas, como causas iatrogénicas, procesos autoinmunes, inflamatorio-infecciosos, isquémicos o post-transplante hepático. Es crucial saber reconocer este tipo de estenosis y diagnosticar su etiología, ya que su no reconocimiento, o su tratamiento inadecuado deriva en complicaciones con riesgo vital para los pacientes. Las pruebas de imagen como la ecografía, el TC o la RM y colangioRM juegan un papel importante para la detección de estenosis biliares, su precisión diagnóstica y por tanto para su manejo y la planificación prequirúrgica A continuación la Dra. Criado resume las diferentes alterativas terapéuticas para la estenosis biliar benigna, como la cirugía y los tratamientos mínimamente invasivos, tanto endoscópicos como percutáneos, como son la dilatación y la colocación de stents. Ella enfatiza que la decisión sobre qué método utilizar debe de ser valorada de manera individualizada en función de la etiología, tipo y localización de la estenosis y factores de riesgo de cada paciente. Ambas doctoras destacan el hecho de que no existen unas guías de consenso entre las distintas sociedades que faciliten el manejo estandarizado con protocolos para el manejo de esta patología, lo cual sería muy Valioso. Adicionalmente, la Dra. Criado explica las posibilidades terapéuticas que ofrece la radiología intervencionista: la bilioplastia percutánea o dilatación, así como sus resultados y complicaciones, como la alta tasa de re-estenosis. Posteriormente pasa a evaluar los distintos tipos de stents, y específicamente los stents biodegradables, comentando las tasas de éxito técnico en su colocación, su permeabilidad primaria y la baja tasa de complicaciones que han demostrado en estudios multicéntricos a largo plazo, uno de los cuales es el registro Biella, un registro multicéntrico en el que han participado 11 centros españoles. También realiza un resumen de los diferentes tipos de stents biodegradables que hay hoy en día en el mercado y comenta las principales características mecánicas de los mismos. La Dra Criado concluye el episodio comentando su experiencia personal en el tratamiento de estenosis biliares benignas con stents biodegradables dando una serie de consejos prácticos para la liberación de estos stents y para prevenir complicaciones, así como las principales contraindicaciones y el tipo de seguimiento recomendado. También destaca la importancia de valorar cada caso individualmente y tomar decisiones bajo el marco de un equipo multidisciplinar. Finalmente comparte sus predicciones para el futuro de los stents biodegradables.

15 Sep 202343min

In this episode, host Dr. Sabeen Dhand interviews vascular surgeon Dr. Sean Lyden about percutaneous transarterial bypass (PTAB) with DETOUR, a new therapy for treating occlusive / stenotic superficial femoral artery (SFA) disease. --- CHECK OUT OUR SPONSOR Endologix https://endologix.com/ --- SHOW NOTES Dr. Sean Lyden serves as the Chairman of Vascular Surgery at Cleveland Clinic. Sean starts off the discussion by conveying the severity of SFA chronic total occlusion (CTO) and walks us through what PTAB therapy is. We then cover the steps and general principles of using the DETOUR technology. Throughout the episode, Sean and Sabeen discuss the structure and key takeaways of both the DETOUR 1 and DETOUR 2 trials, held in Europe and the United States respectively. They also cover major questions, such as DVT and PE risk, patency of femoral vein following DETOUR intervention, and overall device cost. We conclude the episode with future directions of the now FDA-approved DETOUR device, and when and how vascular and interventional physicians can incorporate the new technology into their practice. Sean and Sabeen also contrast prior treatment options with the recent DETOUR trials to highlight how longer calcified / occluded SFA lesions now have a viable, effective, and safe endovascular treatment option. --- RESOURCES PTAB with DETOUR System: https://endologix.com/ptab/detour/ DETOUR 1 Trial: https://pubmed.ncbi.nlm.nih.gov/29327570/ DETOUR 1 Trial, 1 year follow-up results: https://pubmed.ncbi.nlm.nih.gov/32276015/ DETOUR 2 Trial, 12 month results: https://www.jvascsurg.org/article/S0741-5214(22)01274-5/fulltext DETOUR 2 Trial, 24 month results from Vascular Annual Conference Presentation: https://www.dicardiology.com/content/endologix-announces-24-month-results-detour-2-study-2023-vascular-annual-meeting Voyager Trial: https://www.nejm.org/doi/full/10.1056/nejmoa2000052 Compass Trial: https://www.nejm.org/doi/full/10.1056/nejmoa1709118

11 Sep 202334min