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

In this episode, guest host Dr. Jacob Fleming interviews Dr. Jason Cox about musculoskeletal interventions and how he uses ultrasound for diagnosis and intervention in his full spectrum musculoskeletal practice. --- CHECK OUT OUR SPONSOR Laurel Road for Doctors https://www.laurelroad.com/healthcare-banking/ --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/ZHCWxF --- SHOW NOTES We begin by discussing Dr. Cox’s path to MSK intervention. During his interventional training at University of Missouri, the musculoskeletal radiology program was rebuilt, and ultrasound was incorporated heavily. He used his ultrasound skills from vascular intervention in IR to learn musculoskeletal anatomy on ultrasound. He was drawn to MSK radiology due to the mechanical aspect of MSK work and the integration of visual spatial awareness and hand eye coordination involved in MSK ultrasound. He started out by learning steroid injections for sports injuries, commonly rotator cuff injuries. He now does around 20 diagnostic or interventional ultrasound procedures each day in his clinic. He opened his clinic with a partner, and did it slowly while still working at his prior job. He started working at his new clinic on his vacation days until he could build up the clientele to leave his prior job. One of the biggest challenges in opening his MSK radiology clinic was finding a sonographer able to do the complex MSK cases he was doing. The most common procedure Dr. Cox does at his clinic is ultrasound guided carpal tunnel release. He also does tendon barbotage for hydroxyapatite deposition disease for the rotator cuff tendons. His practice has grown largely due to the number of patients that are referred because they cannot get an MRI. He reads his ultrasound exams like an MRI report, with a high level of detail, differential diagnosis and recommendations. --- RESOURCES Institute for Advanced Medical Education: https://www.iame.com Linked In: https://www.linkedin.com/in/jasoncoxmd Ultrasound First Clinic: https://ultrasound-first.com European Society of Musculoskeletal Radiology: https://www.essr.org

26 Sep 20221h 1min

In this episode, host Dr. Ally Baheti interviews Dr. Jayson Brower about building a Y90 service line in his outpatient based lab (OBL). --- CHECK OUT OUR SPONSOR Boston Scientific Lab Agent https://www.bostonscientific.com/en-US/customer-service/ordering/lab-agent.html --- SHOW NOTES First, Dr. Brower describes the IR/DR makeup of his practice and partnerships with surrounding hospitals. Inland Imaging’s collaboration with the Providence healthcare system was formed to provide quality outpatient imaging and avoid duplication and competition of services. Over time, they added interventional services, including interventional oncology procedures, to their joint venture. The decision to move Y90 from the hospital to the outpatient setting was spurred by the need in the community, availability of more modern imaging equipment, and patient convenience. In 2019, it was not very common to perform Y90 in an OBL. Dr. Brower outlines the steps he took to move these services, starting with building consensus within the group. Next, he explained the benefits of the OBL to the hospital administration, which include freeing up time in the hospital for true emergencies and providing care for patients who prefer the OBL setting. Then, the group proactively reached out to payers and secured written agreements that they would provide coverage. After securing these agreements, they drafted pro formas, searched for adequate sites, and contacted vendors. Since each state has different regulations for “hot labs” that use radioactive materials, Dr. Brower recommends working with your radiation safety officer to help walk you through the regulations. His OBL has a “mini hot lab” that allows him to draw up the Sirtex dose that he prescribes. Nuclear medicine technicians assist in transporting the radioactive material. Patients have pre-Y90 SPECT mapping close by, at another center. --- RESOURCES Inland Imaging Interventional Radiology: https://interventional.inlandimaging.com/ OEIS: https://oeisweb.com/ Radioactive Material (RAM) License: https://dpbh.nv.gov/Reg/RAM/dta/Licensing/Radioactive_Material_Program_(RAM)_-_Licensing/

23 Sep 202241min

In this episode, host Dr. Aaron Fritts interviews Dr. Ali Alikhani about his solo outpatient IR practice, how he leveraged his sales background in the OBL setting, and marketing advice for IRs in an outpatient practice. --- CHECK OUT OUR SPONSORS Medtronic IN.PACT 018 DCB https://www.medtronic.com/018 Boston Scientific Nextlab https://www.bostonscientific.com/en-US/nextlab.html?utm_source=oth_site&utm_medium=native&utm_campaign=pi-at-us-nextlab-hci&utm_content=n-backtable-n-backtable_site_nextlab_1&cid=n10008040 --- SHOW NOTES Dr. Alikhani started working at an OBL three years out of fellowship. He became the solo practitioner at an outpatient center that had recently lost its physician to retirement. The practice is OBL based, and had a medical director and staff that flew him around to get trained for his first role. This OBL was part of a company that owns around 70 labs around the country. He primarily does embolization; his favorite procedures include uterine fibroid, prostatic artery, and genicular artery embolization. He works as a W2 employee, but there are 1099 locums IRs who are able to cover him for vacation. Due to his background in marketing, he had a strong interest in building up this OBL and diversifying its services. He works with a marketing team including one employee who has worked at this company for 10 years and is very comfortable going to marketing meetings on her own. She helps plan which meetings he needs to attend, and gives Dr. Alikhani weekly reports on who she has met with during the past week. Together, they are building up the practice. Despite this strong marketing team, Dr. Alikhani still only works 60% at this OBL and has to work 40% at a separate OBL due to lack of patients. It takes time to build relationships with referring providers and build a large patient base. Dr. Alikhani speaks on the responsibilities of being a solo IR at an OBL. It is a great responsibility that requires planning, teamwork and a willingness to make mistakes and learn. It is a stressful adjustment from hospital work, but it can also be a very rewarding shift with the right team in place. He recommends early career IRs to start out at an established OBL that knows how to run the business. Learn from this, and then open your own center if this is something you find yourself capable of and willing to do.

19 Sep 202251min

In this episode, our hosts Drs. Michael Barraza and Aaron Fritts interview Dr. John Pavlus about his methods of drain placement, monitoring, and removal, as well as his vision to design an ideal drainage system. --- CHECK OUT OUR SPONSOR Medtronic Abre Venous Stent https://www.medtronic.com/abrevenous --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/5KfOLv --- SHOW NOTES In this episode, our hosts Drs. Michael Barraza and Aaron Fritts interview Dr. John Pavlus about his methods of drain placement, monitoring, and removal, as well as his vision to design an ideal drainage system. Dr. Pavlus became interested in abscess drains when he noticed that across different institutions had very different indications, types, and methods of putting in drains. Dr. Pavlus prefers to place drains under ultrasound guidance, and he will also obtain a CT image afterwards to ensure the drain is in place. The doctors discuss their favorite guidewires to use: Dr. Pavlus prefers the Coons wire and Dr. Barraza prefers the Amplatz wire. For deep pelvic cul-de-sac abscesses, Dr. Pavlus describes how he obtains transgluteal access and uses a Hawkins needle. Liver abscesses can be challenging, due to their variety of drainage contents (hematoma, bile, necrotic material), and increased time of drainage. We also discuss the debate between suction bulbs and gravity drainage bags, noting that research studies and personal experiences have not shown significant differences in the rate of fistula formation with either method. One exception is post-operative spinal drainage, where using suction could confer the risk of removing CSF. To assess when a drain needs to be removed, Dr. Pavlus monitors the output and obtains a CT. He prefers to take ownership of drain care and remove drains that he originally placed, but if needed, he also collaborates with trauma surgeons to ensure that drains and sutures are removed properly. Dr. Pavlus also recognizes the need to standardize follow up care for drains. Dr. Barraza describes a workflow for drain checks at his fellowship site, which included daily rounds and a standardized checklist for each patient. Finally, Dr. Pavlus speaks about his ongoing mission to design an ideal drainage system for various dwell times, viscosity of contents, and catheter sizes.

16 Sep 202248min

In this episode, guest host Dr. Jacob Fleming interviews Dr. Dan Nguyen about MSK and neurologic pain interventions, specifically how he evaluates and treats different types of headaches at his practice. --- CHECK OUT OUR SPONSORS Athletic Greens https://www.athleticgreens.com/backtablevi 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/Lt1TRq --- SHOW NOTES Dr. Nguyen left academia and the East Coast 6 years ago, where he trained in neurointerventional radiology and pain intervention to open his own practice in Oklahoma City after visiting Dr. Beall. He now has a clinic where he sees musculoskeletal and neurologic pain patients. He enjoys the long term relationships he has built with many patients in his practice. He still does a degree of diagnostic work so as not to lose his skills. Next, Dr. Nguyen discusses how he evaluates and treats headaches as a neurological pain interventionalist. Understanding the neuroanatomy of the face is key. He tries to understand the presentation of the patient’s headaches, whether it is located above the eyebrow, near the ear or at the jaw. He treats cervicogenic headache, trigeminal neuralgia and occipital neuralgia with a diagnostic block, radiofrequency ablation and neuromodulation. He also treats migrainous headaches. After determining whether the pain is musculogenic or neurogenic, he does a trigger point injection or a test injection of the nerve, followed by RFA and neuromodulation. Dr. Nguyen tells us his approach to trigeminal neuralgia workup. There are three branches, and the Gasserian ganglion (trigeminal ganglion) lies deep to the foramen ovale. To approach it, he usually tries to target the most peripheral nerve branch. For V1, he evaluates the supraorbital, supratrochlear nerves, which you can see with ultrasound. For V2, he evaluates the infraorbital with ultrasound. The foramen rotundundum requires CT guidance to access. For V3 he evaluates the mental and alveolar nerves or the foramen ovale. He does diagnostic blocks, and if this provides relief to the patient they discuss radiofrequency ablation. He advises operators to take the longest path to the nerve to ensure the ablative needle is fully buried under the skin to avoid burns. He also discusses the rare outcome of anesthesia dolorosa which can cause facial numbness and pain after ablation of the Gasserian ganglion. He says that for most of his patients, they accept this potential risk due to the more likely possibility of relief from the excruciating pain they experience with trigeminal neuralgia. --- RESOURCES Dr. Nguyen Twitter: @neuroradiology Narouze: Interventional Management of Head and Face Pain https://link.springer.com/book/10.1007/978-1-4614-8951-1 American Society of Spine Radiology: https://assrannualmeeting.org American Society of Neuroradiology: https://www.asnr.org/annualmeeting/

12 Sep 202257min

In this episode, guest host Jill Sommerset interviews vascular surgeon Dr. Miguel Montero-Baker about his evolving use of ultrasound throughout his career in caring for critical limb-threatening ischemia (CLTI) patients. --- CHECK OUT OUR SPONSOR Boston Scientific Eluvia Drug-Eluting Stent https://www.bostonscientific.com/en-US/medical-specialties/vascular-surgery/drug-eluting-therapies/eluvia/eluvia-clinical-trials.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&cid=n10008043 --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/BK45bf --- SHOW NOTES Dr. Montero-Baker starts by outlining his journey from training in Costa Rica, Germany, and Arizona, to building a multidisciplinary limb salvage center at Methodist Houston. Despite his geographic relocations, he is still very involved in endovascular education in Latin America through HENDOLAT, an online community and annual conference. Next, we delve into the uses for ultrasound during the workup stages for CLTI. Dr. Montero-Baker highlights the information that ultrasound can provide: locating the region and extent of disease, pursuing an open versus endovascular treatment approach, and the tools you will need. He points out that a lot of institutions currently only rely on pulse volume recording (PVR), ankle brachial index (ABI), and toe brachial index (TBI), and do not have access to a robust vascular lab for full ultrasounds. Dr. Montero-Baker discusses some hurdles preventing the widespread implementation of ultrasound, such as additional cost and variability in operators. However, he believes that ultrasound can be a phenomenal tool if practices can invest the time to train vascular technologists and implement its use. We frame the ultrasound conversation around incentives for each party: the technologist can achieve higher job satisfaction and further subspecialize, the treating physician can have a better understanding of each patient’s disease and management, and the institution can minimize extended stays and readmissions. Additionally, ultrasound is very useful when institutions are facing the global contrast shortage or treating patients with renal disease. Finally, we look at the pathophysiology of diabetic and chronic renal failure patients who have extreme below the knee and below the ankle disease. These patients with medial artery calcification patterns have very few treatment options and high limb loss rates. Dr. Montero-Baker describes a new method of pedal venous access for deep vein arterialization. --- RESOURCES BackTable en Espanol- Enfermedad Arterial Periférica y Salvamento de Extremidades en la Comunidad Latino Americana: https://www.backtable.com/shows/vi/podcasts/%20v/enfermedad-arterial-periferica-y-salvamento-de-extremidades-en-la-comunidad-latino-americana Dr. Miguel Montero-Baker’s Twitter: https://twitter.com/monteromiguel HENDOLAT: https://hendolat.com/ Society for Vascular Ultrasound:

9 Sep 202250min

In this episode, guest host Dr. Donald Garbett interviews Drs. Geogy Vatakencherry, Zaeem Billah, and Kartik Kansagra about the IR integrated residency, how it’s evolving, and what students should be doing to prepare for this rigorous training program. --- CHECK OUT OUR SPONSOR Medtronic IN.PACT 018 DCB https://www.medtronic.com/018 --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/5RwqRC --- SHOW NOTES We begin by discussing the VIR program at Kaiser LA. As the program director, Dr. Vatakencherry discusses how he built his residency program and how it has evolved since the inception of the integrated iR residencies. One integral part of this program is weekly continuity clinic, starting in your first year. Dr. Kansagra brought up the idea to Dr. Vatakencherry after noticing that other surgical specialties and interventional cardiology were doing this. This model allows residents to develop longitudinal relationships with patients, understand disease progression and the importance of preventive care and nonoperative management. Next, Dr. Billah discusses his training at Kaiser LA, as a resident in the first year of the new integrated IR residency. They have a categorical program, with a surgery intern year included. He highly suggests that all IR residents should do a surgery year due to its similarity to IR and the skills it provides you. Whether on DR, ICU or IR, all IR residents have daily IR conferences. ICU training begins in the first year, which includes MICU, SICU and CCU rotations. In the PGY-5 year, they get consecutive rotations in stroke neurology and neurointervention. Finally we discuss the future of the VIR integrated residency. Dr. Vatakencherry believes that clinic time is quintessential during IR residency to understand the nuances of “should vs. could” when it comes to operative intervention. In clinic, not only do you see what you do well but more importantly, you see what you don't do well and how you can fix that. This clinical experience cannot be replicated in a year of fellowship. Lastly, Dr. Vatakencherry gives some extremely pertinent advice to fourth year medical students applying to IR integrated residency.

5 Sep 20221h 5min

In this episode, our host Dr. Aaron Fritts and Dr. Jason Iannuccilli dive into the history, science, and future directions of medical cannabis. We discuss Dr. Iannuccilli’s founding vision for PureVita Labs, a company focused on developing standardized testing for cannabis products and ensuring consumer safety. --- CHECK OUT OUR SPONSOR Athletic Greens https://www.athleticgreens.com/backtablevi --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/A8oPKA --- SHOW NOTES Dr. Iannuccilli starts by describing his former interventional oncology practice in Rhode Island. His interest in medical marijuana grew as he frequently found himself in conversations with terminal cancer patients who sought his medical advice to navigate the variety of products. As he learned more about this craft industry, he realized that there could be significant variations between each product type, brand, and even within each batch. With co-founders Dr. Jonathan Martin and Dr. Stuart Procter, he started the entrepreneurial journey of building a laboratory that uses innovative techniques to test and label products with accuracy. The team hopes to continue growing their services and eventually through artificial intelligence, build a platform that can recommend products to each individual consumer that will ensure them a predictable experience based on their desired therapeutic outcome. Throughout this episode, we discuss social stereotypes and political challenges that the cannabis industry has faced in the past decades. We move past the mistaken idea that active ingredients of marijuana always cause mental dullness and lethargy, and we bring the conversation down to a molecular level to discuss CB1 receptors and anti-inflammatory benefits, and pain relief. Finally, the doctors discuss fundraising for a nontraditional business pursuit. Dr. Iannuccilli shares how the vape crisis was a pivotal point– it served as a wake-up call for consumers and investors, leading to higher recognition of the importance of more stringent and standardized product testing. PureVita Labs has started to fundraise through friends and family with convertible notes, which are structured loans with set interest rates that allow the investor to either pull out their initial investment plus interest, or roll that value into equity once the company has established its valuation. --- RESOURCES Pure Vita Labs: https://purevitalabs.com/ The Bartholomewtown Podcast- Ep. 101, “Inside RI Cannabis” https://btown.buzzsprout.com/163601/11221697-inside-ri-cannabis-presented-by-purevita-labs-cannabis-101-part-1 WHOOP: https://www.whoop.com/ The Peter Attia Drive Podcast: https://peterattiamd.com/podcast/

2 Sep 20221h 11min