Ep. 205 Update on Reimbursement Cuts for the OBL/ASC with Dr. Jim Melton and Dr. Blake Parsons

Dr. Sabeen Dhand talks with Neurointerventionalist Dr. Ansaar Rai from about his approach to posterior circulation strokes, including patient selection, technique and devices, and pitfalls to avoid. --- CHECK OUT OUR SPONSOR CERENOVUS https://www.jnjmedicaldevices.com/en-US/companies/cerenovus --- SHOW NOTES In this episode, neurointerventional radiologist Dr. Ansaar Rai joins Dr. Sabeen Dhand to discuss posterior circulation stroke, including when to treat with thrombectomy, techniques, and advances in stroke research in recent years. They discuss factors to consider when deciding to treat posterior circulation strokes with thrombectomy. Dr. Rai reports that age is the most important factor, followed by comorbidities and severity of clinical symptoms. He discusses the variability in presentation of basilar artery strokes, ranging from mild ataxia to coma. He treats these aggressively with thrombectomy, especially for young patients. For isolated PCA strokes, he often treats with intra arterial TPA only. Dr. Rai next discusses landmark clinical trials, as well as his own research looking at stroke burden. He found that 2% of all acute ischemic strokes occur in the posterior circulation. Importantly, he postulates that there will never be good posterior circulation trials due to lack of equipoise and difficulty in randomizing to a medical treatment only arm. Dr. Rai uses general anesthesia for posterior circulation strokes. He prefers femoral access, and uses an 8Fr femoral short sheath and a guide catheter (ideally 088), rather than a balloon guide catheter. He then uses an 070 or 072 intermediate aspiration catheter navigated over an 024 microwire (Aristotle) or 027 microcatheter (Duo or XT-27) into the basilar. After trying many techniques, he prefers aspiration using the ADAPT technique. If he has to cross clot, he uses a stent retriever such as Trevo, Embotrap or Solitaire. Due to the delicate vasculature and high risk in posterior circulation thrombectomies, Dr. Rai always uses a J wire, biplane imaging and emphasizes that knowing the anatomy on CT is key to decreasing complications such as dissection or distal embolization. --- RESOURCES ASPECTS score: https://www.ahajournals.org/doi/10.1161/STROKEAHA.117.016745 Route 92 Medical SUMMIT MAX Clinical trial: https://evtoday.com/news/route-92-medicals-monopoint-reperfusion-system-studied-in-pivotal-summit-max-trial#:~:text=According%20to%20Route%2092%20Medical%2C%20SUMMIT%20MAX%20is,sites%20in%20the%20United%20States%20and%20New%20Zealand. The Greater Cincinnati Northern Kentucky Stroke Study: https://www.gcnkss.com MR RESUE trial: https://www.ahajournals.org/doi/full/10.1161/strokeaha.113.001443 IMS3 trial: https://evtoday.com/news/ims-3-substudy-shows-delays-in-stroke-treatment-leads-to-worse-outcomes#:~:text=IMS%203%20was%20a%20multicenter%20international%20trial%20in,received%20tPA%20within%203%20hours%20of%20stroke%20onset. SWIFT PRIME trial: https://evtoday.com/news/covidien-commences-enrollment-for-swift-prime-acute-ischemic-stroke-study#:~:text=The%20SWIFT%20PRIME%20study%20will%20evaluate%20acute%20ischemic,will%20also%20include%20an%20extensive%20health%20economics%20analysis. ADAPT technique trial by Turc: https://www.ahajournals.org/doi/10.1161/STROKEAHA.119.025753 BEST trial: https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(19)30395-3/fulltext#:~:text=The%20BEST%20trial%20was%20a%20multicentre%2C%20prospective%2C%20open-label%2C,the%20institutional%20review%20board%20of%20each%20participating%20site. ATTENTION trial: https://pubmed.ncbi.nlm.nih.gov/35102797/

21 Feb 202241min

Dr. Fred Bertino educates us on anticoagulation regimens for patients after deep venous interventions. --- 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/NwME1W --- SHOW NOTES In this episode, pediatric interventional radiologist Dr. Fred Bertino joins our host Dr. Chris Beck to discuss new data on anticoagulation regimes before, during, and after venous stenting and/or mechanical thrombectomy. Dr. Bertino starts by reviewing the difference between the compositions of arterial versus venous clots. Arterial clots are formed as a response to endothelial injury and exposure of von Willebrand factor, so these clots are usually platelet-rich. On the other hand, venous clots are formed due to stasis, and these are usually platelet-poor. Therefore, antiplatelet therapy may not be ideal for venous clots. However, Dr. Bertino notes that stent placement can cause endothelial injury at the apposition points of the stent, so the treatment algorithm can become more complex in these cases. The doctors note that there are non-thrombotic diseases that require venous stenting, such as May Thurner syndrome. Dr. Bertino says that addressing this early in the pediatric population can be a safe way to prevent future DVT, as long as children are monitored carefully. Next, Dr. Bertino walks us through his preferred anticoagulation routine for stent placement. Four hours before the procedure, he starts with a dose of Factor Xa inhibitor (apixaban or rivaroxaban) to prevent in-stent thrombosis. The patient is maintained on heparin during the procedure. After the procedure, anticoagulation varies depending on whether a stent was placed, or solely mechanical thrombectomy was performed. Finally, the doctors discuss preferred anticoagulation for special scenarios such as covered stents (which can be more thrombophilic) and patients with malignancies. Dr. Bertino encourages IRs to reach out to their hematology colleagues to stay updated on anticoagulation research, as well as physical and occupational therapists to help patients form long-term DVT prevention plans. --- RESOURCES Find this episode on backtable.com to see the full library of resources mentioned by Dr. Fred Bertino.

18 Feb 202251min

Interventional Radiologist Dr. Preston Smith and healthcare attorney Patrick Souter join us to discuss strategies for navigating the legal world of non-compete agreements and exclusive contracts. --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/pAxIn5 --- SHOW NOTES First, we review the vocabulary and examples of each type of agreement. Mr. Souter emphasizes that contrary to popular misconceptions, non-compete agreements are enforceable, as long as they are reasonable in scope, geographic location, and time frame. Additionally, he calls attention to “backdoor noncompetes,” which are clauses that, while not officially called “noncompetes,” still restrict a physician’s ability to practice medicine in a certain location. These include non-circumvention and non-solicitation agreements. Dr. Smith advises listeners to be wary of any terms that seem far-reaching or unreasonable, and to have a legal professional review the terms of the agreement. Next, we discuss exclusive contracts between large radiology practices and hospitals. While they are legal, they cannot be entered into for antitrust purposes of trying to prevent others from entering the marketplace. Exclusive contracts can serve as a barrier for independently practicing IRs to gain hospital privileges. Mr. Souter advises independent IRs to speak with hospital CMOs and provide reasonable explanations for why their services would be efficient and necessary for quality patient care.

14 Feb 202247min

We talk with Interventional Radiologist Dr. Sandeep Bagla about the challenges of clinical research in private practice, and the inspiration behind building a new practice paradigm in collaboration with Urology colleagues. --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/Ogw44h --- SHOW NOTES In this episode, interventional radiologist and entrepreneur Dr. Sandeep Bagla joins our host Dr. Aaron Fritts to discuss the founding and multispecialty focus of Prostate Centers USA, a rapidly expanding network of office based labs (OBLs). Dr. Bagla describes why he decided to shift away from his former private practice and embark on a new venture that would eventually become Prostate Centers USA. Dr. Bagla sought to focus on embolization, a novel area of interventional radiology. He recounts the process of conducting prostate artery embolization clinical trials in a private practice environment, including challenges encountered and lessons learned about changing FDA regulations. Dr. Bagla developed Prostate Centers USA from a vision of collaboration with urologists to provide comprehensive procedural and clinical care. He describes how he pitched his collaborative approach to urologists and how he dealt with pushback. He also describes why the centers’ ownership structures and focused training pathways are attractive to physicians. Finally, Dr. Bagla highlights technologies that allow for ease of communication between the team members, such as task management systems and centralized monitoring systems. --- RESOURCES Ep. 164 Collaborative Approach to Prostate Artery Embolization (PAE) for BPH: https://www.backtable.com/shows/vi/podcasts/164/collaborative-approach-to-prostate-artery-embolization-pae-for-bph Prostate Centers USA: https://www.prostatecentersusa.com/ Outpatient Endovascular and Interventional Society (OEIS) Annual Meeting: https://oeisociety.com/

11 Feb 202255min

Co-hosts Dr. Christopher Beck and Dr. Aaron Fritts discuss cholecystostomy tube placement for acute cholecystitis, including the pros and cons of different techniques, and pitfalls to avoid. --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/QDepym --- SHOW NOTES In this episode, our hosts Dr. Aaron Fritts and Dr. Chris Beck compare their procedural techniques for placing cholecystostomy tubes. They start the conversation by discussing patient workup. Dr. Beck always obtains an ultrasound and sometimes a HIDA scan. He also orders coagulation tests and checks if the patient is on anticoagulation medication in order to stratify the risk of the procedure and counsel the patient accordingly. Next, the doctors discuss pros and cons of transhepatic and transperitoneal approaches. Dr. Fritts usually prefers a transhepatic approach because it minimizes the risk of biliary leaks. He also believes that it is easier to stick the gallbladder in an area where it is affixed to the liver. Dr. Beck emphasizes that the gallbladder is a dynamic organ, so doing this procedure under ultrasound with fluoroscopy will allow real-time visualization of the needle. Finally, they consider different needle and drainage options. There are a variety of needles that can be used, including AccuStick, Yueh, and spinal needles. With drainage, the doctors highlight the differences between drainage bags and JP bulbs, noting that the former relies on drainage of infected bile by gravity, and the latter provides additional vacuum suction.

7 Feb 202241min

In this episode, our host Dr. Eric Keller interviews his longtime mentor, interventional radiologist Dr. Bob Vogelzang about the evolution of their mentor mentee relationship overtime and ways to create benefits for both mentors and mentees. --- 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/3QPBiv --- SHOW NOTES A common idea throughout this episode is that no single definition of mentorship exists. Dr. Vogelzang highlights the importance of a flat structure, in which the mentee and the mentor feel comfortable to ask questions and explore an area of shared interest. Dr. Keller emphasizes the reality that mentoring relationships will grow and change with career development and geographic relocation. Overall, both doctors agree that an effective mentoring relationship should be driven by feasible projects that motivate both parties.

4 Feb 202234min

Interventional Radiologist Dr. Chris Ingraham discusses his approach to treating solid organ and pelvic trauma, including embolization technique and IR's role in workflow efficiency for better trauma care. --- CHECK OUT OUR SPONSOR Boston Scientific IOE https://www.bostonscientific.com/ioe --- SHOW NOTES In this episode, interventional radiologist Dr. Chris Ingraham and our host Dr. Michael Barraza discuss the role of IR in the trauma setting and approaches to embolization for trauma to the spleen, liver, kidneys, and pelvis. Dr. Ingraham outlines Harborview Medical Center’s workup of trauma patients and describes the collaboration between the emergency, trauma surgery, and interventional radiology departments. Although CT provides more comprehensive imaging, Dr. Ingraham says that taking a patient directly to an angiogram could address the trauma quicker and prevent more complications. He also speaks about empiric embolization, noting that extravasation can be intermittent and not visible on imaging. Overall, Dr. Ingraham recommends over-sizing coils, since patients are usually hypotensive and vasoconstrictive during active bleeding. Vessel diameter will eventually increase as patients are resuscitated. When embolizing the spleen, Dr. Ingraham emphasizes that the goal is to prevent the need for splenectomy, especially in young patients, because of its role in immunologic responses. He advocates for proximal embolization in order to decrease the blood flow into the spleen and allow for splenic lacerations to clot and heal. In liver embolization, Dr. Ingraham notes that there could be a laceration to the liver’s venous system, and embolization of the arterial system could reduce the dual blood supply of the liver. In these patients, there can be a higher risk of necrosis and biliary injury. Finally, we discuss follow up care with pulse exams and monitoring of hemodynamic stability. --- RESOURCES Balloons Up: Reduced Time to Angioembolization: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7903099/ SIR Trauma Guidelines, 2020: https://www.jvir.org/article/S1051-0443(19)30952-2/fulltext

31 Jan 202258min

Dr. Aparna Baheti talks with Dr. Timothy Huber about performing thyroid nodule ablation procedures, including patient selection, technique pearls and pitfalls, and how to incorporate the procedure into your practice. --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/QZ9TpA --- SHOW NOTES In this episode, interventional radiologist Dr. Tim Huber and our host Dr. Ally Baheti discuss the process of thyroid nodule radiofrequency ablation, including patient selection, workup, procedural technique, and follow up. Dr. Huber describes the most common indication for ablation, which is the presence of benign thyroid nodules that cause compressive symptoms. These can affect quality of life when they restrict a patient’s ability to swallow, breathe, and speak. He recommends ablation for symptomatic nodules that are over 2 cm in diameter. Dr. Huber also mentions functional nodules as more challenging cases, but still treatable with ablation. Though ablation for thyroid malignancies is rare, it is a field of active and growing research. In his workup, Dr. Huber uses ultrasound to assess nodular composition, vasculature, size, and nearby enlarged lymph nodes. Next, he obtains two benign fine needle aspiration samples and checks TSH levels before proceeding with ablation. During the procedure, he anesthetizes the skin of the neck with lidocaine, and periodically checks in with patients about pain level. Dr. Huber describes his “trans-isthmic approach” that keeps the needle as stable as possible. He exercises caution when ablating near the “danger triangle” containing the recurrent laryngeal nerve which innervates the vocal cords. While ablating posterior to anterior, Dr. Huber tracks echogenic changes on ultrasound. After the procedure, patients are monitored for one hour and then followed up in one month, and then three months over the next year. Dr. Huber warns interventionalists that post-ablation zones may look disfigured on ultrasound, but this will revert back to normal within 3-6 months. --- RESOURCES European Thyroid Association Guidelines: https://www.eurothyroid.com/guidelines/eta_guidelines.html Korean Society of Thyroid Radiology Guidelines: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6005940/

28 Jan 202231min