Ep. 549 Liquid Embolics: Practical Applications and Techniques with Dr. Gary Siskin

In this episode, host Dr. Chris Beck interviews interventional radiologist Dr. Kush Desai (Northwestern University Feinberg School of Medicine) and vascular surgeon Dr. Steve Abramowitz (MedStar Washington Health Center) about iliofemoral venous stenting. --- CHECK OUT OUR SPONSOR Cook Medical https://www.cookmedical.com/divisions/vascular-division/ --- SHOW NOTES We start this episode by reviewing the evolution of knowledge and treatment of venous disease over recent years. Dr. Desai and Dr. Abramowitz identify referral patterns that connect patients with vascular and interventional physicians, and they emphasize how most patients are diagnosed in primary care pathways rather than in the emergency room. The doctors also underscore the importance of educating referring physicians and patients on the impact of early intervention and how vascular and interventional physicians are well-equipped to provide specialized care and management of venous disease. Dr. Desai and Dr. Abramowitz explain their work-up of patients with deep venous disease. The doctors cover necessary imaging studies and conservative treatments for clinic visits. They also explain their procedural approach, access sites, patient positioning preferences, and more. The doctors share guiding anatomical landmarks and recommendations on tools for crossing, along with their decision-making process in treating post-thrombotic patients. They also discuss best practices in venous stenting and post-operative follow up algorithms. We conclude this episode with important advice on how to avoid dangerous life-threatening outcomes. --- RESOURCES Society of Interventional Radiology Position Statement on the Endovascular Management of Acute Iliofemoral Deep Vein Thrombosis (2023): https://www.sciencedirect.com/science/article/pii/S1051044322013173 A review of the incidence, outcome, and management of venous stent migration: https://www.sciencedirect.com/science/article/abs/pii/S2213333X2100411X

6 Nov 20231h 2min

In this episode, interventional radiologists Dr. Aaron Fritts, Dr. Vishal Kumar, and Dr. Chris Beck discuss types of sedation for IR procedures. --- CHECK OUT OUR SPONSOR Medtronic OBL https://www.medtronic.com/obl --- SHOW NOTES We start the discussion off by dividing the spectrum of patient sedation into three tiers: local anesthesia, moderate sedation with fentanyl and Versed, and deep sedation which encompasses anything beyond fentanyl and Versed. The conversation revolves around the fluidity of this spectrum, underscoring the ease with which patients can transition between these sedation levels, thereby adding layers of complexity to the decision-making process. Chris emphasizes the significance of embracing trauma-informed care, highlighting the potential for IR procedures to be maximally traumatic despite their minimally invasive nature. The doctors emphasize the importance of establishing comprehensive pre-procedural patient education to align expectations about pain management. Procedures that automatically trigger the requirement for an anesthesia team include procedures such as TIPS, tumor ablations, as well as declot procedures more recently. Decisions regarding anesthesia for these procedures are additionally influenced by factors such as the patient's condition, history of methadone exposure, the preference of the IR providers, and the comfort level of nursing staff. Vishal highlights the game-changing concept of having an anesthesia team present for real-time monitoring and the administration of nerve blocks during IR procedures. This collaboration is especially helpful for complex interventions. Vishal advocates for prioritizing patient safety over logistical considerations. He firmly contends IRs should be empowered to decide the level of anesthesia care since they have the most experience with the specific procedures and are best suited to recognize anesthesia needs. The conversation delves into the American Society of Anesthesiologists (ASA) scoring system, which categorizes patients based on their health status from ASA 1 (healthy) to ASA 6 (brain death). While IR procedures usually involve ASA 3 or ASA 4 patients, today’s discussion uncovers the tendency among clinicians to underestimate a patient's ASA classification while overestimating their pain tolerance. The discussion raises critical questions about whether the IR community has grown complacent with moderate sedation in procedures and whether alternative approaches are warranted. --- RESOURCES American Society of Anesthesiologists Classification (ASA) Classification: https://www.ncbi.nlm.nih.gov/books/NBK441940/

3 Nov 202350min

In this episode, host Dr. Ally Baheti interviews vascular surgeon Dr. Steven Abramowitz and interventional radiologist Dr. Angelo Marino on managing venous stent rethrombosis with the RevCore device. Steven is the Chair of Vascular Surgery at MedStar Washington Hospital and Angelo is an Assistant Professor of Interventional Radiology at Yale School of Medicine. --- CHECK OUT OUR SPONSOR Inari Medical RevCore https://www.inarimedical.com/revcore/ --- SHOW NOTES We start this episode with Steven and Angelo’s experience in venous interventions and how venous stent rethrombosis presents. The doctors then tell us more about how stent failure can precipitate, inflow and landing zone considerations, and stenting location. Angelo then goes onto introduce the RevCore device. Both Steven and Angelo share their experience in using the RevCore device in venous stent rethrombosis, and their preferred access site(s) when using this tool. They also discuss specific maneuvers, troubleshooting, and other tools they use alongside the RevCore system. We conclude this episode with the doctor’s overall treatment algorithm for venous stent rethrombosis and follow-up plans. --- RESOURCES Inari Medical RevCore Device: https://www.inarimedical.com/revcore/

30 Okt 202326min

In this episode, host Dr. Chris Beck continues the discussion on managing hepatocellular carcinoma (HCC) with Dr. Tyler Sandow and Dr. Juan Gimenez, interventional radiologists at Ochsner Health in New Orleans, Louisiana. --- CHECK OUT OUR SPONSOR Boston Scientific TheraSphere https://www.bostonscientific.com/therasphere --- SHOW NOTES We continue the conversation where we left off in Part 1. Tyler and Juan share their thoughts on lobar treatment vs. radiation segmentectomy, selection strategies, and their preferred combination of ablation and Y-90. Tyler also reviews the core tenets of Y-90 treatment and references a handful of major landmark trials and studies. Juan highlights more studies that guide their approach to preoperative mapping and intraoperative delivery of Y-90. Juan emphasizes cone-beam CT and how this technique has significantly evolved over the years. We cover dosimetry software, navigation software, and the calculation of treated tumor volumes. Additionally, Tyler and Juan discuss their change in treatment approach for especially complex cases, which can involve factors such as extrahepatic feeders and difficult treatment locations. We also discuss the redistribution of flow and how underlying liver disease may affect treatment plans. We wrap up Part 2 of our discussion by highlighting the doctors’ current research pursuits. Tyler tells us about exciting new developments in the tumor marker arena, the emerging role of albumin in HCC, and the rising popularity of radiation segmentectomy in metastatic disease. Juan shares a few closing thoughts on the extrahepatic applications of Y-90 and the advantages of using AI in interventional radiology. --- RESOURCES LEGACY Trial: https://www.bostonscientific.com/en-US/medical-specialties/interventional-radiology/interventional-oncology/therasphere/clinical-data/legacy-study.html RASER Trial: https://pubmed.ncbi.nlm.nih.gov/35617978/ DOSISPHERE Trial: https://www.bostonscientific.com/en-US/medical-specialties/interventional-radiology/interventional-oncology/therasphere/clinical-data/dosisphere-01.html TARGET Study: https://www.bostonscientific.com/en-US/medical-specialties/interventional-radiology/interventional-oncology/therasphere/clinical-data/target-study.html Radiation Lobectomy: Preliminary Findings of Hepatic Volumetric Response to Lobar Yttrium-90 Radioembolization: https://link.springer.com/article/10.1245/s10434-009-0454-0 Radiation lobectomy: Time-dependent analysis of future liver remnant volume in unresectable liver cancer as a bridge to resection: https://www.sciencedirect.com/science/article/abs/pii/S0168827813004315 ACR–ABS–ACNM–ASTRO–SIR–SNMMI PRACTICE PARAMETER FOR SELECTIVE INTERNAL RADIATION THERAPY (SIRT) OR RADIOEMBOLIZATION FOR TREATMENT OF LIVER MALIGNANCIES: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/rmbd.pdf Clinical, dosimetric, and reporting considerations for Y-90 glass microspheres in hepatocellular carcinoma: updated 2022 recommendations from an international multidisciplinary working group: https://pubmed.ncbi.nlm.nih.gov/36114872/ “Simplicit90y” Boston Scientific Dosimetry Software: https://www.bostonscientific.com/en-US/medical-specialties/interventional-radiology/interventional-oncology/therasphere/dosage-and-administration.html

27 Okt 202352min

In this episode, Dr. Constantinos (Costi) Sofocleous, Dr. Bruno Odisio, and Dr. William Rilling discuss the history of percutaneous liver tumor ablation, takeaways from past and present clinical studies, and the contemporary role of ablation margin confirmation software for optimizing treatment outcomes. --- CHECK OUT OUR SPONSORS NeuWave Microwave Ablation Systems https://www.jnjmedtech.com/en-US/product-family/neuwave-microwave-ablation-systems EDDA Technology https://www.eddatech.com/ --- SHOW NOTES Costi initiates the discussion by highlighting crucial developments in tumor ablation over the last 15 years. He notes that it took time to realize that tumors larger than 3 cm carried higher rates of local failure, primarily due to insufficient margins. Research eventually found that establishing larger margins, preferably 10 mm margins, resulted in significantly lower recurrence rates. In fact, with these margins, ablation outcomes became even more favorable than surgical outcomes. This shift towards personalizing the approach to each tumor has been instrumental in improving patient outcomes. The conversation then transitions to innovation within the realm of ablation. There are fewer prospective studies over ablation as a sole treatment, since ablation is often performed in conjunction with surgery. Additionally, the presence of numerous vendors for ablation technology makes it challenging to conduct comprehensive studies. The doctors also discuss the importance of ablation margins and recurrence. 3D confirmation is correlated with greater control over the procedure. Local recurrence tends to occur in areas where the margin is suboptimal, but the exact standards for what constitutes "suboptimal" margins are yet to be established. Nevertheless, the consensus among experts is that a contrast CT on the day of the ablation and a subsequent 3D evaluation of the images are crucial. This evaluation should be repeated three weeks later to verify the success of the procedure. Costi mentions that at Memorial Sloan Kettering, ablation zone biopsy is an option if necessary, which adds another layer of verification. The discussion also touches on the importance of using a guidance system for ablation. Bruno underlines the significance of always using CT to verify the procedure. He points out that colleagues in Europe have been using stereotactic guidance for many years, revealing that 40% of the time, the ablation application wasn't placed exactly where they thought it would be based on pre-scans. This is where stereotactic technology becomes invaluable. Costi suggests real-time PET as a beneficial tool, but the challenge lies in justifying these additional steps to payers. Minimum imaging requirements and margin confirmation software are essential components of a guidance system.. The episode culminates in a discussion of a significant trial that involves three different industry sponsors - a landmark effort in the field of oncology. The ACCLAIM trial, which began in 2016, sought to conduct a multicenter study but took four years to secure approval and funding. Costi highlights the reasons for its success, emphasizing the potential for reproducible outcomes that could establish ablation as a strong indication in colorectal cancer. The data suggests that margin confirmation software significantly improves margins, and he hopes that this information will lead to increased reimbursement for the use of these crucial software tools. --- RESOURCES ACCLAIM Trial: https://www.sio-central.org/Research-Resources/Research-Grants/ACCLAIM-Trial

25 Okt 202348min

In this episode, host Dr. Chris Beck interviews Dr. Juan Gimenez and Dr. Tyler Sandow. Juan and Tyler are both interventional radiologists in New Orleans, Louisiana who practice at Ochsner Health System - one of the United States’ leading transplant centers. As a result, both doctors have significant experience in Y-90 radiation segmentectomy and other complex procedures for treatment of hepatocellular carcinoma (HCC). --- CHECK OUT OUR SPONSOR Boston Scientific TheraSphere https://www.bostonscientific.com/therasphere --- SHOW NOTES Juan and Tyler start the episode by telling us about how their practice has evolved over the years, their experience on tumor boards, and advice for building strong relations with transplant surgeons. The doctors also tell us about their approach to working-up patients with HCC, the variety of treatment modalities, and overall timeline to transplant. Next we discuss considerations for building an effective interventional oncology service. Taking full ownership at every step of the way is critical to this goal. To conclude the episode, Juan and Tyler discuss the Barcelona Clinic Liver Cancer (BCLC) staging algorithm, their research, and other factors that guide their treatment plan. Stay tuned for Part 2 of this discussion, releasing later this week! --- RESOURCES Premiere and TRACE Trials: https://www.bostonscientific.com/en-US/medical-specialties/interventional-radiology/interventional-oncology/therasphere/clinical-data/premiere-trial-and-trace-trial.html

23 Okt 202324min

In this episode, host Dr. Jacob Fleming interviews Dr. Dana Dunleavy about spinal tumor ablation and vertebral augmentation. Dana is an interventional radiologist and Director of Windsong Interventional & Vascular Services. --- CHECK OUT OUR SPONSOR Stryker Interventional Spine https://www.strykerivs.com --- SHOW NOTES Dana begins the discussion by reflecting on his upbringing in a small country town. His parents, his mother a midwife and his father a contractor, shaped his early experiences. His exposure to medicine began through his mother, particularly in witnessing childbirths. As he navigated his way through medical school, he contemplated various specialties, including orthopedic surgery, interventional radiology, and neurosurgery. He discovered incredible mentors in radiology and ultimately found his place in the field of interventional radiology. During his residency at Johns Hopkins, he sought externships in interventional spine and had the opportunity to immerse himself in this field for one month. He underscores the significance of participating in tumor boards and being a valuable contributor to the team in terms of diagnosis and treatment. He also emphasizes the value of calling consults when performing biopsies and the importance of meeting with the patient face-to-face and engaging in a thorough discussion of the treatment plan. Next, Dana delves deeper into the topics of bone tumor ablation and mechanical augmentation. He notes the importance of having a comprehensive understanding of the patient's anatomy and being well-versed in interventional tools. Cement extravasation is a feared complication of vertebral augmentation, so Dana discusses the role of implants as a means to establish structural support and mitigate the risk of cement leakage. In addition, he talks about his approach in combining ablation with mechanical augmentation so that the augmentation provides a structure after the ablation. Lastly, he discusses the use of advanced technology such as cone beam CT in trajectory planning. He shares his hybrid approach to performing bone biopsies, utilizing fluoroscopy during access and cone beam CT to ascertain accurate trajectory.

18 Okt 20231h 1min

In this episode, host Dr. Ally Baheti interviews Dr. Bill Julien about strategies to secure independent IR hospital privileges. Bill is an experienced vascular interventional physician at South Florida Vascular Associates. --- CHECK OUT OUR SPONSORS BD Advance Clinical Training & Education Program https://page.bd.com/Advance-Training-Program_Homepage.html Siemens Healthineers https://www.siemens-healthineers.com/ Reflow Medical https://www.reflowmedical.com/ --- SHOW NOTES Bill starts the episode by telling us why it is crucial for vascular and interventional physicians to have hospital privileges. We learn about Bill’s career progression. He discusses the growing pains he faced, how he effectively tackled these challenges, and how he became staff at a number of hospitals. Bill and Ally then unfold Bill’s detailed roadmap for how IRs can join hospital staff. They explore different pathways, and Bill shares his anecdotes and advice throughout. The doctors discuss how many contracts leave little opportunity to build longitudinal care practice, since the majority of time can be dedicated to large volumes of diagnostic reading time and consults for non-complex cases. At the conclusion of this episode, Bill emphasizes the need for SIR and other societies to step in and usher change. He also shares his 13-point action list for what SIR can do to accomplish this and help IRs secure hospital privileges (linked in Resources section). --- RESOURCES SIR Strategic Plan: https://tinyurl.com/SIRstrategicplan SIR Policy Statement: https://tinyurl.com/SIRpolicystatement Dr. Bill Julien’s Clinical Practice Position: https://tinyurl.com/clinicalpracticeposition2 ACR Policy Statement: https://tinyurl.com/ACRpolicystatement

16 Okt 202342min