Ep. 327 Building a Pain Interventions Service Line with Dr. Stephen Hunt

In this episode, guest host and vascular technologist Jill Sommerset interviews Dr. Kathleen Gibson, vascular surgeon and president of the American Vein and Lymphatic Society, about the role of RVTs and venous ultrasound in the diagnosis and treatment of pelvic venous disorders. --- CHECK OUT OUR SPONSORS Medtronic Abre Venous Stent https://www.medtronic.com/abrevenous Boston Scientific Eluvia Drug-Eluting Stent https://www.bostonscientific.com/en-US/medical-specialties/vascular-surgery/drug-eluting-therapies/eluvia.html?utm_source=oth_site&utm_medium=native&utm_campaign=pi-at-us-de_portfolio-hci&utm_content=n-backtable-n-backtable_site_eluvia_1_2023&cid=n10012337 --- SHOW NOTES We begin by discussing Dr. Gibson's career. She was the first woman to complete a vascular surgery fellowship, which was in 2001. Her training, like most, was very arterial focused at the time. She then moved into the private practice space while still completing clinical research. She began to realize that more of her patients had venous disease than arterial. For example, she saw many more patients with varicose veins than abdominal aortic aneurysms. Pelvic venous disorders (PeVD) in particular, remain poorly studied and understood. She became interested in this patient population because she saw many women present with pelvic pain and varicose veins after multiple targeted saphenous vein treatments. She realized this was because the source of the problem, the pelvic veins, were being left untreated. Dr. Gibson developed a varicose vein classification that is being disseminated around the world, and has been translated into multiple languages. It is called the SVP Classifier (Symptoms-Varices-Pathophysiology). It was developed to be used in conjunction with CEAP (Clinical-Etiology-Anatomy-Pathophysiology) classification for venous disease. There is an app available, as well as a workbook that can be used to claim CME. It is a tool that can aid providers and vascular technologists alike when working up PeVD. Lastly, Dr. Gibson reviews her workup of a patient with pelvic pain. Before undergoing ultrasound and vascular workup, it is important to think of other causes of pelvic pain in women of certain ages. In young women, she always ensures patients have seen a gynecologist, as endometriosis is the most common cause of pelvic pain in this group. If they are post-menopausal and present with new onset pain, she also has the patient see a gynecologist to rule out malignancy. Finally, if the patient is postpartum, she loops in a pelvic floor physical therapist because myofascial pain from pregnancy can mimic pain from PeVD. For the vascular workup, she begins with an ultrasound performed by a vascular technologist. She meets with the patient to discuss symptomatology and impacts on quality of life. If PeVD is found on US but the patient has minimal pelvic symptoms, she does not pursue treatment. She treats the patient, not the imaging. If symptoms are bad enough, she will move forward with stenting (for obstruction) or embolization (for varicosities). For embolization patients, there is no routine follow up unless there is a complaint. For stenting in NIVL (non-thrombotic iliac vein lesion) patients, she follows patients with annual US for a couple years. For post-thrombotic stenting she sees patients for US every 6 months, and then annually, as re-thrombosis is always a concern in these patients. --- RESOURCES American Vein and Lymphatic Society: https://www.myavls.org Society for Vascular Ultrasound: https://www.svu.org SVP Classifier App: https://www.myavls.org/svp-classification.html Pelvic ultrasound technique paper: https://journals.sagepub.com/doi/abs/10.1177/0268355516677135?journalCode=phla UIP 2023: https://www.myavls.org/annual-congress-2023.html Twitter: @JillSommerset @KathleenGibson6

20 Feb 202340min

In this episode, Dr. Chris Beck interviews vascular access surgeon Dr. Ari Kramer about his management of arteriovenous (AV) access for dialysis patients. We cover his preferred imaging for identifying and deciding to treat stenoses, the protracted angioplasty technique, and the evolution of research in drug coated balloons (DCB) and stent grafts. --- CHECK OUT OUR SPONSORS Medtronic Chocolate PTA Balloon https://www.medtronic.com/peripheral BD Rotarex Atherectomy System https://www.bd.com/rotarex --- SHOW NOTES Dr. Kramer starts by describing his vascular access practice. He is the sole operator within a hospital-based practice where he creates and maintains AV access. When evaluating a patient for possible intervention, duplex ultrasound, physical exam findings, patient history, and information from the dialysis center all play roles in determining whether the patient is eligible for a fistulagram. Dr. Kramer offers fistulagram tips: he obtains access above the arterial anastomosis in order to avoid occlusion of outflow, and he first shoots contrast into the venous tract first and works his way up to the arterial system. Depending on the findings of the fistulagram, stenotic lesions in the venous outflow tract can be treated. Dr. Kramer generally treats the lesion if the stenosis limits flow by more than 50%. Additionally, he treats any lesion resulting in a luminal diameter of 2mm or less. In an AV fistula circuit, Dr. Kramer describes his procedure, which is largely informed by the most current clinical trials. He first employs the FLEX Vessel Prep system to reduce circumferential fibromuscular tension. Next, he performs protracted plain old balloon angioplasty (POBA) for 90 seconds. This helps Then, he re-images the vessel to ensure there was no injury and utilizes a DCB to deliver paclitaxel. We discuss the clinical trials outcomes of the two current DCBs that have been approved for use in AV management, IN.PACT and Lutonix. Dr. Kramer also notes the significant cost of DCBs and lack of access to treatment for the most at-risk patients. He encourages clinicians to unite to advocate for increased reimbursement for this treatment that has been proven to show the highest standard of care. Additionally, we address treatment of non-autogenous AV circuits with stent grafts. Dr. Kramer prefers self-expanding covered stents, such as Viabahn or Covera, since they are conformable and resistant to kinks. Overall, Dr. Kramer emphasizes the importance of the operator staying up to date on clinical trials that show data for diverse tools with various indications, knowing their own skill and comfort, and incorporating the best treatments based on their patient and practice context. --- RESOURCES Ep. 139 AV Fistula Graft Management: https://www.backtable.com/shows/vi/podcasts/139/av-fistula-graft-maintenance FLEX Vessel Prep System: https://www.venturemedgroup.com/ KDOQI Clinical Practice Guideline for Vascular Access, 2019 Update: https://www.ajkd.org/article/S0272-6386(19)31137-0/fulltext Fahrtash, F., Kairaitis, L., Gruenewald, S., Spicer, T., Sidrak, H., Fletcher, J., Allen, R., & Swinnen, J. (2011). Defining a significant stenosis in an autologous radio-cephalic arteriovenous fistula for hemodialysis. Seminars in dialysis, 24(2), 231–238. Haskal, Z. J., et al. (2010). "Stent graft versus balloon angioplasty for failing dialysis-access grafts." New England Journal of Medicine 362(6): 494-503. Bard Peripheral Vascular. Covera vascular covered stent instructions for use. Rev.4 / 08-18. http://www.bardpv.com/eifu/uploads/BAWB05872R4-Covera-Vascular-Covered-Stent-IFU.pdf. The Fight Doctors: https://thefightdoctors.com/about/ Find this episode on BackTable.com for all resources mentioned in this podcast, including references to journal articles.

17 Feb 20231h 4min

In this episode, host Dr. Sabeen Dhand interviews Dr. August Ysa, vascular surgeon in Spain, about distal deep venous arterialization, including indications, patient selection, and how to perform his gunsight technique. --- CHECK OUT OUR SPONSORS Viz.ai https://www.viz.ai/ BD Rotarex Atherectomy System https://www.bd.com/rotarex Reflow Medical https://www.reflowmedical.com/ --- SHOW NOTES We begin by discussing his training and background. Initially trained in Barcelona before moving to Bilbao as a young vascular surgeon. He came to the US briefly to train at Montefiore and Houston Methodist. When attending the LINNC in Europe one year he saw a live endovascular case, which is when he decided to devote his career to peripheral arterial disease (PAD), specifically below the knee (BTK) and below the ankle (BTA) interventions. He currently works with Dr. Marta Lobato, and they have done around 25 combined deep venous arterializations (DVAs) in their practice. They love this technique because it gives someone previously faced with amputation a new chance. It is a technique to reroute blood flow to get oxygen to a wound and promote wound healing. There are two types of DVA: proximal DVA, which is done closer to the origin of the posterior tibial artery (PTA), and distal DVA, which is at the level of the ankle, and usually also involves the PTA. Thus far, it is unknown which technique is better in terms of limb salvage, and data shows both techniques yield 60-70% limb salvage rates. One advantage to distal DVA is lower rates of post-DVA storm, a type of ischemic steal syndrome. Availability of devices and lower cost also make distal DVA more appealing. DVA is never the first option, traditional recanalization techniques are always explored first. Wounds that are not candidates for DVA are large infected wounds or areas of necrotic tissue. This is because it takes 6-8 weeks to establish the newly created connection, and if the wound is already past the point of healing, DVA will not help. Other reasons DVA can fail is due to choosing the wrong candidates. Mean wound healing time after DVA is 4-7 months, so patients need to be able to commit to close follow up and wound care, and they must have the social support to be compliant with frequent clinic visits. Finally, Dr. Ysa explains his venous arterialization simplification technique (VAST). Before the procedure, he always does a venous ultrasound to rule out prior DVT and evaluate the status of the main veins of the foot. He uses two snares via the gunsight approach, which most IRs are familiar with from TIPS procedures. It involves overlapping two snares and then performing a through and through puncture from the PTA to the posterior tibial vein (PTV). The PTA is generally used over the anterior tibial or the peroneal artery due to its robust connections with the lateral plantar and the plantar arch. He then performs balloon angioplasty (BA) on the PTV. He initially uses the PTA for sizing, but generally goes bigger, between 4-5mm. For valves, he usually does regular BA but will sometimes use a cutting balloon. Two weeks post-DVA he gets an ultrasound, and at one month he gets an angiogram to evaluate the new tract. He has his patients take a single antiplatelet and a blood thinner after the procedure. He considers DVA to have failed if there is progression of wound necrosis. --- RESOURCES Dr. Ysa LinkedIn: https://www.linkedin.com/in/august-ysa-56a99a174/ YouTube DVA Webinar with Dr. Ysa and Dra. Lobato: https://www.youtube.com/watch?v=kDW5Rg5g49I Ep. 93 - DVA for CLI with Dr. Fadi Saab: https://www.backtable.com/shows/vi/podcasts/93/deep-venous-arterialization-for-cli Live Interventional Neuroradiology, Neurology and Neurosurgery Course (LINNC): https://www.linnc.com Patterns of Failure in DVA Paper: https://www.clijournal.com/article/patterns-failure-deep-venous-arterialization-and-implications-management

13 Feb 202359min

In this episode, Dr. Aaron Fritts interviews interventional radiologist Dr. Abdulaziz Alharbi of the Ministry of National Guard Health Affairs in Saudi Arabia. They discuss Dr. Alharbi’s approach to planning and performing sharp recanalization of the superior vena cava (SVC) for dialysis, transplant, and cancer patients. --- 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/sJLY3K --- SHOW NOTES Dr. Alharbi starts by describing how patients get referred to him, mainly due to end stage renal disease, chronic obstruction, and the need for dialysis access. Additionally, some patients seek access for central lines, and others have acute obstructions due to malignancies. Depending on the patient’s clinical condition, comorbidities, upcoming medical procedures, and anatomy, he will then decide if the patient is an appropriate candidate for SVC recanalization and obtain a CT scan. This imaging guides further decision-making on whether to access the obstruction from the internal jugular or brachiocephalic vein. The CT also helps him think about potential complications, such as cardiac tamponade in an obstruction close to the heart and pulmonary edema in all recanalizations. These risks are communicated to each patient accordingly. Prior to starting the procedure, Dr. Alharbi ensures that there are multiple access sites prepared, including neck, bilateral arms, and femoral access. He also ensures that there are tools that he is comfortable using and a support team in place. A colleague will usually help him by obtaining femoral access and placing a target snare distal to the obstruction. Dr. Alharbi walks us through a typical case. First he slowly advances a Chiba needle towards the target. His choice in sheath length depends on the length of the occlusion and the access point. A longer occlusion accessed through the brachiocephalic vein requires a longer sheath than a short occlusion accessed through the internal jugular vein. Next, we discuss stent sizing. Dr. Alharbi notes that it is preferable to oversize, to prevent stagnation of flow. In short occlusions, he uses bare self-expandable stents. In longer occlusions or cancer patients, he uses covered stents since there is more precise deployment. The post-procedure anticoagulation regimen usually includes heparin and an antiplatelet agent for 2-3 weeks. Then, patients are switched to apixaban for 6 months. Beyond this, patients are either taken off of anticoagulation if they are asymptomatic and there is good SVC inflow, or reverted back to their preexisting anticoagulation regimen that they had due to other comorbidities. --- RESOURCES PAIRS 2023: https://pairscongress.com/ Dr. Abdulaziz Alharbi Twitter: https://twitter.com/DrAlHarbiA_Aziz

10 Feb 202357min

In this episode, host Dr. Michael Barraza interviews Dr. Rehan Quadri, interventional radiologist, about the definition, indications and techniques for treating clot in transit.  We begin by defining and describing when to treat clot in transit. Traditionally, the definition is the washing machine mobile clot in the right atrium (RA) or right ventricle (RV). In these situations, the next place for the clot to travel is the pulmonary artery (PA). Mortality in these cases can reach as high as 30%, which is why these cases are considered emergencies. There is another category of clot in transit where a clot is partially adhered to a vessel wall, catheter, or heart valve. They are most commonly diagnosed via an echocardiogram, or found incidentally on a CT angiogram. They commonly present as catheter malfunction with symptoms resembling SVC syndrome. Dr. Quadri explains his usual method for retrieving clot in transit, though he notes each case is complex and different depending on the etiology and the overall status of the patient. In general, unless there is a massive PE, he treats the clot in transit before the PE. He always ensures with the preoperative echocardiogram that there is no interatrial shunt or patent foramen ovale (PFO). At the beginning of the case he checks PA and RA pressures.  He uses a 24 French Inari Flowtriever with FLEX technology, which helps with tough angles. He uses ICE guidance in all clot in transit cases. To help with orientation when using the ICE catheter, he recommends pointing it anteriorly while entering the RA, then using the Eustachian ridge, an echogenic line in the RA, to confirm you are in the RA and indicating that you should see the tricuspid valve as you advance. He uses the FlowSaver device, and always has 2 units of blood in the room just in case. At the end of the case, he remeasures the PA pressures, then injects through the Inari sheath to verify that there is no residual before finally doing a pulmonary arteriogram. He sends all the clots to pathology, and has seen that the morphology is usually mixed, with some organized fibrin in addition to acute thrombus.

6 Feb 202333min

In this episode, our host Dr. Ally Baheti interviews interventional radiologist Dr. Nikki Keefe about safety considerations for pregnant and breastfeeding IR patients. Dr. Keefe’s personal experience with pregnancy during her IR training sparked her interest in this topic. A lot of IR patients are pregnant or breastfeeding, so it is important to be cognizant of radiation and medication exposures and how they should be altered. She emphasizes the importance of establishing a protocol when these patients present. We review radiation doses of various IR procedures and risk stratification based on gestational age. At each stage of pregnancy, there are different risks of disruptions in organogenesis, effects on neural tube development, and predisposition to cancer. Elective procedures should usually be deferred until after delivery. The most common and necessary procedures performed in pregnant patients are PICC line placement, nephrostomy tube, and treatment of postpartum hemorrhage. Dr. Keefe also shares her tips for minimizing fluoroscopy time and deciding between different diagnostic imaging modalities that present both maternal and fetal radiation risks. Next, we discuss medication safety. Iodinated contrast is safe to give during pregnancy, while gadolinium is not. Sedation with opioids is generally safe, but their sustained use or administration around the perinatal period can cause neonatal withdrawal symptoms. Benzodiazepines can also be used for amnesia and anxiety reduction, and midazolam has a good safety profile and long half life. However, abnormally extended use of benzodiazepines can cause floppy infant syndrome (sedation, muscle laxity, failure to suckle). Dr. Keefe notes that pregnant patients have to start on higher doses than the standard, since they have higher blood volume and increased renal clearance of these medications. Lovenox is the safest known anticoagulant for pregnant women. Additionally, fetal heart monitoring should be performed before and after the procedure. Finally, we talk about specific cases of patient positioning when placing nephrostomy tubes, transhepatic access for gallbladder tubes, treatment of visceral artery aneurysms before pregnancy, and selection of  imaging modalities to detect pulmonary embolism.

3 Feb 202326min

In this episode, host Dr. Aaron Fritts interviews Dr. Jim Melton, vascular surgeon, and Dr. Blake Parsons, interventional radiologist, about progress in the OBL and ASC space, including reimbursement updates, partnering with a private equity firm, and value based care. --- CHECK OUT OUR SPONSOR Surmodics Pounce Thrombectomy https://pouncesystem.com/ --- SHOW NOTES We begin by discussing new developments in Dr. Melton’s and Dr. Parson’s practice. Over the past year, they have partnered with a private equity firm, Assured Healthcare Partners to create Heart and Vascular Partners (HVP). They now cover Oklahoma City, Colorado Springs, Denver, Pueblo, and parts of Illinois and Indiana. They employ mostly hospital based physicians’ ready to start their own office based lab (OBL) or ambulatory surgery center (ASC). The physicians under HVP are cardiologists, vascular surgeons, and interventional radiologists. The two discuss the advantages of aligning with a private equity firm. For them, it provided the scale and capability to provide value-based care when it becomes widely adopted. Additionally, the payer has a much lower cost for the service in the outpatient space versus the hospital. All the physicians in HVP maintain local control over their practices, which was one of their main goals when they decided to partner with a firm. Next, we cover reimbursement cuts and the trends in OBLs and ASCs. On the arterial side of business, they are seeing that OBLs are down 10-15% in reimbursement rates, whereas ASCs are up 3-30%. For iliac interventions in the ASC, they have seen a 30-50% increase in balloon angioplasty and stenting, and up to a 60% increase for Shockwave. On the embolization side, arterial and venous reimbursement has dropped in the OBL by 7-8% and increased in the ASC by 3-30%. Alternatively, the CPT code for embolization for end organ ischemia (UFE, PAE) is still well reimbursed in the OBL. They caution listeners on genicular artery embolization and cryoneurolysis due to the risk of not getting it reimbursed and having to pay money back. --- RESOURCES Heart and Vascular Partners: https://heartandvascularpartners.com

30 Jan 202335min

In this episode, our host Dr.Michael Barraza interviews Drs. Jawad Hussain and Alan Sag about how they implemented thyroid artery embolization into their respective private and academic practices. --- CHECK OUT OUR SPONSOR Medtronic Chocolate PTA Balloon https://www.medtronic.com/peripheral --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/GXgzcZ --- SHOW NOTES Dr. Hussain discusses how he started doing thyroid embolizations. It was born out of a need to replace thyroid RFA, since the thyroid RFA generator was not yet approved in his health system. At Duke, Dr. Sag collaborated with endocrinologists and endocrine surgeons to address a need to treat non-surgical candidates with bulk symptoms. These symptoms can include supine dyspnea, dysphagia, and aspiration risk. Together, they developed an institutional protocol for post-procedural management. Dr. Sag emphasizes that everything an IR needs to perform a goiter embolization is probably already available to them. Next, the doctors describe how they implemented thyroid embolization in their respective practices. Dr. Sag approached his institution’s weekly tumor board of endocrine specialists to introduce the concept. When talking to non-surgical patients, he offers thyroid embolization as a palliation alternative to tracheostomy and percutaneous gastrostomy as airway protection for patients with aspiration risks. Dr. Hussain describes patients with TR-3 and TR-4 nodules who require repeat FNA. Embolization can be a valuable option for them, since it is a quick outpatient procedure with minimal side effects. Additionally, he communicates to patients that IRs have experience with applying transcatheter embolizations in different spaces in the body and sets the expectation that shrinkage will be a gradual process. Both doctors emphasize the importance of informed consent in a relatively new palliative procedure. In terms of the research landscape for thyroid embolization, Dr. Hussain says that publishing a large retrospective multicenter study would revolutionize the procedure, since it could show efficacy and safety. Dr. Sag believes that RFA and embolization are complementary technologies that can be used in different scenarios. Dr. Hussain shares his treatment algorithm, which includes getting a CTA after each consultation, to map out variable anatomy and select hypertrophied vessels. Deep cannulation is key to preventing reflux and non-target embolization. Additionally, he does a two week follow up for post-procedural symptoms and a 2 month imaging appointment. Dr. Sag describes a joint clinic with endocrine surgeons. Every patient gets a visit from each service on the same day, and the doctors are able to convene and make joint decisions based on patient and goiter factors. He recommends getting a cone beam CTA to rule out anastamoses to aerodigestive structures and the cervical spinal cord. In his embolization, he uses 300-500 micron Embospheres and leaves at least one quadrant untreated to spare some thyroid and parathyroid glands. He also administers decadron and a medrol dose pack. Lab follow-up happens at day 7, when most thyroid hormone peaks occur. If patients are still experiencing symptoms after two months, Dr. Sag will consider repeating the embolization. --- RESOURCES Thyroid Embolization for Nonsurgical Treatment of Nodular Goiter: A Single-Center Experience in 56 Consecutive Patients (Yilmaz et al): https://pubmed.ncbi.nlm.nih.gov/34256121/ ACR TI-RADS: https://www.acr.org/Clinical-Resources/Reporting-and-Data-Systems/TI-RADS 2017 Thyroid Radiofrequency Ablation Guideline: Korean Society of Thyroid Radiology: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6005940/

27 Jan 202344min