BackTable Vascular & Interventional

In this episode, host Dr. Sabeen Dhand interviews vascular surgeon Dr. Rami Tadros about advantages and indications for radial access in PAD treatment and the current selection of radial access devices. --- CHECK OUT OUR SPONSOR Surmodics Sublime Radial Access Platform https://sublimeradial.com/ --- SHOW NOTES Dr. Rami Tadros is a vascular surgeon and Site Director of Endovascular Aortic Surgery at Mount Sinai Hospital. Dr. Tadros begins by discussing how often he uses radial access in his practice, how current wire and catheter technology limits the potential of radial access, and how evolution of these devices (such as increased length and improved sizing for transradial tools) is on the horizon. Dr. Tadros also discusses the indications and specific advantages for radial access. He describes his device preferences, workflow, and workarounds for radial access. The doctors then take a deeper dive into lengths and sizing of the tools that are currently on the market. They offer some insight on maximizing distance while still maintaining pushability and taking into account the variety of patient anatomy. There is also a brief discussion on pedal access, risks associated with it, and closure complications. Dr. Tadros covers specific clinical vignettes for treating PAD with radial access. There are limitations of the currently available devices, so it is important to plan for distal embolization and bailout stents. We conclude the episode with some guidance for radial access. We review the required tools, the importance of confirming patency of the palmar arch, and the Barbeau test to inform radial access. Dr. Tadros also highlights the use of verapamil, heparin, and nitroglycerin to minimize the risk of vessel spasm. --- RESOURCES Dr. Rami Tadros Twitter: https://twitter.com/VascMD

10 Jul 202344min

In this episode, host Dr. Aaron Fritts interviews interventional radiologist Dr. Gregg Khodorov about design thinking to improve healthcare outcomes, getting involved with innovation as a trainee, and ways to successfully advocate for idea implementation. --- 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 free AMA PRA Category 1 CMEs: https://earnc.me/88AWhz --- SHOW NOTES Dr. Khodorov was introduced to design thinking when he was pursuing his MBA before medical school. Design thinking revolves around the idea of human-centered design, and it is useful when thinking about healthcare outcomes. The process involves a combination of the scientific process and creative elements. In medical school, Dr. Khodorov led a student organization that taught innovation concepts and encouraged his classmates to explore the entrepreneurship space. The doctors review examples of good and bad designs, such as pill packs instead of orange pill bottles, the confusing EpiPen drug delivery system, the automated voice system on AEDs, and instructions for scrub machines. Then, they focus on design projects that Dr. Khodorov has been working on during his residency. During his intern year, he introduced design thinking to surgical didactic conferences. As an IR resident, he has embarked on collaboration projects with industrial design students to improve the angio suite. One of these improvements was ceiling-mounted lighting that improves visibility during procedures. Dr. Khodorov believes that valuable insights can be offered by people outside of medicine, since they often question the status quo of healthcare and can generate ideas to solve efficiency and safety problems. He notes that it is important to judge two specific characteristics of each idea– effort and impact. The best ideas are the ones with the lowest effort and the highest impact. The next step is to convince stakeholders to accept and invest in the idea. It is helpful to find key performance indicators, forecast numerical outcomes, and identify mentors who will champion the idea. Pitching an idea as a quality improvement initiative is a great way to get dedicated time to work on the project, although it is important to pay attention to institutional policies about intellectual property. Throughout the episode, Dr. Khodorov shares some of his favorite innovation resources, including conferences, workshops and books. --- RESOURCES Health Design Lab: https://www.healthdesignlab.com/ Health Design Thinking: https://www.amazon.com/Health-Design-Thinking-Creating-Products/dp/0262539136 Google Ventures: https://www.gv.com/ This is Service Design Doing: https://www.thisisservicedesigndoing.com/

7 Jul 202342min

In this episode, Dr. Jacob Fleming interviews Dr. Alok Sharan about low back awake spinal surgery. This innovative approach offers patients a more pleasant surgical experience compared to traditional surgery under general anesthesia. Not only does it provide better patient outcomes, but it also reduces the need for opioid pain medication and allows for improved mobility after the procedure. --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/3kWFrM --- SHOW NOTES Dr. Sharan began his career in academic medicine at Montefiore, where he gained valuable experience in caring for individuals with severe back problems requiring spine surgery. During his time at Montefiore, Dr. Sharan recognized the changing landscape of healthcare and decided to pursue a healthcare MBA. This unique combination of medical expertise and business knowledge led him to transition to private practice. Dr. Sharan explains that awake spinal surgery offers several benefits for patients undergoing spine procedures. It enables patients to mobilize and recover from surgery more quickly, leading to faster overall recovery times and decreased risk of delirium. Additionally, patients have the opportunity to return home on the same day as the surgery, promoting a more convenient and comfortable experience. Awake spinal surgery also helps reduce the reliance on narcotics for pain management, with patients typically only needing narcotics for around four days compared to the usual four to six weeks with surgeries performed under general anesthesia. Due to the improvement in patient outcomes and the tremendous cost-efficiency of the procedure, awake spinal surgery is an appealing option for individuals requiring spinal fusions and other procedures. Dr. Sharan's entrepreneurial drive has led him to create a comprehensive preoperative education program. His patients are provided with virtual reality headsets to simulate and experience the day of surgery and the actual surgical procedure. The aim is to alleviate any fears or anxieties the patients may have prior to undergoing surgery by immersing them in a realistic virtual environment. This approach helps to prepare patients mentally and emotionally, ensuring a smoother and more comfortable surgical experience. Dr. Sharan is now sharing his techniques with surgeons around the world and anticipates this technique being implemented in many fields in the future. --- RESOURCES Awake Spinal Fusion: https://awakespinalfusion.com Doc Social: https://doc.social Dr. Sharan’s LinkedIn: https://www.linkedin.com/in/alok-sharan-6a612610/

5 Jul 202349min

In this episode, guest host Dr. Robert Ryu interviews Dr. Warren Clements and Dr. Premal Trivedi about the current state of IVC filter retrievals, obstacles to increasing retrieval rates, and their experiences with implementing programs to increase IVC filter retrieval rates within their respective healthcare systems. --- CHECK OUT OUR SPONSOR Boston Scientific Lab Agent https://www.bostonscientific.com/en-US/customer-service/ordering/lab-agent/contact.html?utm_source=oth_site&utm_medium=native&utm_campaign=pi-at-us-labagent-hci&utm_content=n-backtable-n-backtable_site_labagent_1_2023&cid=n10013205 --- SHOW NOTES Dr. Clements begins the discussion by giving an overview of his recent paper published in CVIR, which explores a novel multidisciplinary approach to IVC filter retrievals. He introduces key features of the Australian healthcare system that contribute to their strengths and challenges with IVC filter retrievals. Dr. Clements emphasizes the positive correlation between maintaining an active database of all IVC filter patients and increased retrieval rates. He discusses the limitations of their previous approach towards IVC filter retrievals, which relied on referring physicians and an automatic retrieval referral system. This passive model posed issues with timing and led to a lower retrieval rate. He also highlights the differences in governmental oversight and filter utilization between Australia and the US, emphasizing the importance of aiming for a 100% retrieval rate. The new approach at his hospital involves a multidisciplinary team, which has resulted in retrieval rates going from 53% to 74% . Next, Dr. Trivedi discusses his recent paper, which is also focused on quality improvement surrounding IVC filter retrieval. He describes his health system’s previous passive approach that relied on a follow-up list of all patients with IVC filters. The list was checked monthly, and letters were sent to patients providing the status of their filters along with educational material. However, since 2016, they have adopted an active methodology, which relies on the IR team actively evaluating the list of patients with an IVC filter and verifying whether retrieval is appropriate in each case. This active approach engages referring doctors and schedules retrievals as needed. Implementing this new methodology has resulted in an increase in IVC retrieval rates from 49% to 61%. The doctors discuss the significant number of filters placed before 2010 that still need to be retrieved. They emphasize the need for a central dedicated team to take responsibility for filter follow-up and retrieval, and they highlight potential role of AI in automating the process and addressing issues related to patients who are lost to follow-up. Finally, they discuss the future of filter retrieval. Both Dr. Clements and Dr. Trivedi stress the importance of knowing the IVC retrieval rate to set goals accordingly. Dr. Clements shares his team's goal of reducing median dwell time to less than 150 days and the benefits of establishing a national registry. Dr. Trivedi emphasizes the need for incremental goals and celebrating small wins on the path towards increasing overall filter retrieval rates. He also discusses the importance of aligning economic and health incentives and leveraging existing AI technology. They all agree that achieving a 100% filter retrieval rate requires a collaborative effort within a multidisciplinary team. --- RESOURCES “Improving the rate of inferior vena cava filter retrieval through multidisciplinary engagement” by Clements et al: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9958400/ “Inferior Vena Cava Filter Retrieval Rates Associated With Passive and Active Surveillance Strategies Adopted by Implanting Physicians” By Trivedi and Ryu et al: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2802524

3 Jul 202347min

In this episode, host Dr. Aparna Baheti interviews Dr. Kuldeep Singh who breaks down the three stages of lymphedema, their respective medical and surgical treatment options, all while sharing key insights he has developed through years of experience in treating and caring for patients with lymphedema at a high level throughout the episode. --- CHECK OUT OUR SPONSORS Medtronic HawkOne Directional Atherectomy System https://www.medtronic.com/hawkone Philips SymphonySuite https://www.philips.com/symphonysuite --- SHOW NOTES Dr. Kuldeep is a Vascular Surgeon, the Director of Limb Salvage Surgery, and Program Director at Zucker School of Medicine at North Wall Hospital in Staten Island. He begins by recounting the first time he was approached by a patient suffering from Stage 3 lower extremity lymphedema, along with his initial thought process/treatment plan for the patient. He then goes on to speak on several similarities/challenges he has encountered through treating a number of patients with lymphedema, including managing/treating psychological body dysmorphia in most patients after successful surgical treatment of lymphedema. Kuldeep underscores the gravity and risks associated with moving forward with the Charles procedure (which is also known as lymphedema debulking operation), how such a surgical option should only be considered for patients with Stage 3 lymphedema, and how to encourage and promote consistent pre-operative care. Kuldeep goes onto discuss the operation itself in detail - explaining how the surgery is best done as a team (Vascular (dissecting soft tissue and placing Wound VAC for 1 week to promote formation of granulation tissue), Plastics (skin grafting/reconstruction after 1 week), and Pathology), working within the fascial plane (differentiating fascia, muscle, and fat), dealing with calcified fat effectively, difficulty of identifying fascia in setting of lymphedema, and working near the ankle (avoiding iatrogenic injury of anterior and posterior tibial arteries and achilles tendon). We wrap up the episode by discussing postoperative course: admitting the patient into Burn ICU after each step of the procedure, reapplying Wound VAC after Vascular and Plastic portions, and only discharging the patient from Burn ICU to a rehab facility after evidence of good graft uptake. --- RESOURCES Limb Salvage for “Hopeless” Lymphedema: Reviving the Charles Procedure by Singh et al. DOI: https://doi.org/10.1016/j.jvs.2019.01.021

30 Jun 202343min

In this episode, host Dr. Ally Baheti interviews interventional radiologist Dr. Brooke Spencer about management of pelvic venous disease, endovascular therapies for pelvic varices, and important considerations for treating patients with complex and chronic pain. --- CHECK OUT OUR SPONSOR Boston Scientific Drug Elution https://www.bostonscientific.com/en-US/medical-specialties/vascular-surgery/drug-eluting-therapies.html?utm_source=oth_site&utm_medium=native&utm_campaign=pi-at-us-de_portfolio-hci&utm_content=n-backtable-n-backtable_site_portfolio_1_2023&cid=n10012334 --- SHOW NOTES Dr. Spencer serves as the CEO and medical director of Minimally Invasive Procedure Specialists in Denver, CO. Her patients commonly get referred from OB/GYNs for chronic pelvic pain that is refractory to laparoscopic surgery and undiagnosed. She notes that collaborative relationships with women's health specialists and pelvic pain physical therapists are necessary for adequate patient outreach. Classifying cases by the location and nature of the vessel abnormality (i.e. compressive, obstructive, varicose, reflux, congenital) allows her to think about the best treatment for each patient. Targeting proximal veins can improve back and groin pain, dyspareunia, and heavy periods. Iliac vein stenting can improve compressive symptoms 50% of the time. On the other hand, isolated labial pain is best treated by directly targeting labial varices. Perineal ultrasound is a helpful way to locate some varicosities, but Dr. Spencer prefers MRI and digital subtraction venography to get a comprehensive venous picture and correlate symptoms with imaging. Next, the doctors discuss embolization and foam sclerotherapy. Through her experience, Dr. Spencer has seen sclerotherapy work better in varices with slower outflow and coil embolization work better for varices with more rapid flow. She prefers oversized floppy coils to minimize the risk of migration. With both treatments, there can be significant insurance barriers. It is important to utilize preauthorization specialists and be aware of what the patient’s insurance will cover, in order to better frame a conversation about treatment options. After the procedure, maximal pain relief can be achieved anywhere between 3 to 6 months. During this period, it is important to counsel patients over adjunct therapies such as pelvic floor therapy, steroids, and puncture aspiration to remove trapped blood. Overall, Dr. Spencer wants IRs to keep in mind that the chronic pain population has faced many misdiagnoses and insurance barriers, so they might harbor mistrust of the healthcare system. It is crucial to acknowledge their feelings and understand their anatomy in order to manage their expectations. --- RESOURCES Pelvic Guru: https://pelvicguru.com/ Efficacy of Endovascular Treatment for Pelvic Congestion Syndrome: https://pubmed.ncbi.nlm.nih.gov/27318059/ International Pelvic Pain Society: https://www.pelvicpain.org/ “The Way Out” book: https://www.amazon.com/Way-Out-Revolutionary-Scientifically-Approach/dp/059308683X

26 Jun 202343min

In this episode, host Dr. Christopher Beck interviews Dr. Peter Soukas about his algorithm for below the knee (BTK) critical limb ischemia (CLI) interventions as well as his implementation of new evidence-based guidance. --- CHECK OUT OUR SPONSOR Medtronic HawkOne Directional Atherectomy System https://www.medtronic.com/hawkone --- SHOW NOTES Dr. Soukas serves as the director of vascular medicine, the interventional peripheral vascular lab, and the endovascular medicine fellowship at Brown University in Providence, RI. In addition, he holds the position of associate professor of medicine at The Warren Alpert Medical School at Brown University. Dr. Soukas began his career as an interventional cardiologist. Over the course of his 13-year tenure in Providence, he has dedicated his career to the treatment of CLI and BTK disease. Prior to any interventional work, Dr. Soukas follows a comprehensive work-up including an ankle-brachial index (ABI), arterial duplex, and evaluating kidney function for safe administration of contrast. For a majority of cases, he uses the common femoral artery as the access point, but prefers to prep multiple access sites in the event of needing both anterograde and retrograde, or pedal, access. He discusses the use of the chronic total occlusion crossing approach based on plaque cap morphology (CTOP) classification on angiogram in determining the need for a retrograde approach. The type I morphology is characterized by the convexity of the plaque pointing away and is often treated successfully by an anterograde approach alone, as CTOP types II, III, and IV benefited from the addition of retrograde tibiopedal access. Once access is gained and the plaque morphology is evaluated using angiography, it becomes crucial to address any issues with the inflow to the affected vessel. This step ensures proper blood flow and provides a stable foundation for further interventions. Intravascular ultrasound is then used to assess the size and extent of the plaque, and then depending on the amount of calcification, either intravascular lithotripsy or calcium modifying technology can be used. Scoring balloons with low pressure may also be used for vessels that are moderately calcified and have been shown to have low rates of recoil and dissection. The main initiative of the procedure is to provide blood flow to the target angiosome which is dependent on the location of the wound. During his last remarks, Dr. Soukas comments on the future of BTK interventions, including Paclitaxel vs Sirolimus eluting stents, the use of self-expanding stents, and LimFlow, a minimally invasive technology that creates a channel between an artery and vein allowing the vein to provide blood flow to the foot. With the increasing prevalence of critical limb-threatening ischemia (CLTI) and high 12-month mortality rates in patients with amputations, Dr. Soukas ends the discussion by emphasizing how revascularization should be the preferred initial approach in treating CLTI due to the potential benefits it offers in terms of limb preservation and mortality reduction, urging practitioners to educate patients in being aggressive in their care. --- RESOURCES CTOP article: https://evtoday.com/articles/2018-may/using-plaque-cap-morphology-to-determine-cto-crossing-approach Disrupt PAD III Observational study: https://pubmed.ncbi.nlm.nih.gov/34380334/ PRELUDE BTK Study: https://pubmed.ncbi.nlm.nih.gov/34802313/ Intravascular Ultrasound study: https://www.jacc.org/doi/10.1016/j.jcin.2022.01.001 Intravascular US in Medicare Beneficiaries: https://pubmed.ncbi.nlm.nih.gov/35998803/ PROMISE II study: https://limflow.com/us/clinical-evidence/promise-ii-study-results/

23 Jun 20231h 2min

In this episode, host Dr. Jacob Fleming interviews one of his attendings Dr. Bhavya Shah about the remarkable features of focused ultrasound technology and its applications. They discuss its dynamic nature, allowing for a wide range of applications. --- SHOW NOTES Dr. Bhavya Shah is a neuroradiologist at UT Southwestern in Dallas, TX and the director of their transcranial-focused ultrasound lab. While in residency at Boston MIT, he studied the radiology applications for nerve regeneration and expanded his scope of practice during his fellowship at Stanford. Dr. Bhavya Shah explains the use of low intensity focused ultrasound (LIFU) and high intensity focused ultrasound (HIFU), particularly in the context of movement disorders including essential tremor and Parkinson’s disease. LIFU is used to identify the appropriate targets in the brain in relation to the disease and may be used to alter how neurons behave. In contrast, high intensity focused ultrasound (HIFU) is utilized to ablate and destroy tissues typically after the localization of the intended treatment area. Dr. Shah developed a way to identify targets in the brain for treatment with focused ultrasound with the use of four-tract tractography in cadavers. Using this technology, the brain can be thinly sliced into sections which could then be registered off an MRI back to the path using block face photography, allowing the identification of white matter tracts that enter and leave the thalamus. With these tracts identified, neuroradiologists can first stimulate the localized area with LIFU to confirm the location, then ablate using HIFU. The procedure lasts approximately 30-45 minutes as the patient remains awake. Remarkably, patients with essential tremor usually experience benefit immediately following the procedure as patients with Parkinson’s have symptom improvement within days to weeks. After two hours of observation, patients are discharged assuming no side effects. Side effects are uncommon but can include numbness and tingling around the mouth or fingertips as well as muscle weakness. Beyond its use for movement disorders, the adaptable nature of focused ultrasound technology shows promise for a broad range of applications, particularly for the use of neuropsychiatric conditions. Dr. Shah offers the potential for the use of HIFU as a wearable device that delivers constant stimulation modulated by biofeedback, potentially eliminating the need for MRI for the procedure. Dr. Shah and Dr. Fleming end the discussion with how radiology has evolved over the years and the importance of keeping an open mind working in a multidisciplinary team. They emphasize the gravity of patient engagement and the central goal of medicine and improving the standard of care should always be aimed at benefiting the patient. --- RESOURCES MRI–Guided Focused Ultrasound Thalamotomy for Essential Tremor: https://thejns.org/view/journals/j-neurosurg/138/4/article-p1028.xml Trial of Globus Pallidus Focused Ultrasound Ablation in Parkinson’s Disease: https://www.nejm.org/doi/10.1056/NEJMoa2202721 Long-term effects of bilateral subthalamic nucleus deep brain stimulation on gait disorders in Parkinson's disease: a clinical-instrumental study https://pubmed.ncbi.nlm.nih.gov/37208527/ Magnetic Resonance Image Guided Focused Ultrasound Thalamotomy. A Single Center Experience With 160 Procedures: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8894664/

21 Jun 202346min