Experience with Intracept.

[clubdeac]

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any of you got pics of an S1 entry. I've never done that during augmentation so this is the only level I'm uncomfortable with

 

[Ligament]

How do you make money on this procedure?

 

[Taus]

How do you make money on this procedure?

See my post earlier in this thread, from Aug 4th

 

[nvrsumr]

Any chance this ever gets an office code? I'm interested after hearing about the success of others on the forum. Cant be harder than kypho.

 

[drrosenrosen]

How do you make money on this procedure?

Pro fee is like $460-470 (standard two levels, eg L4-5). My very first case I did in 50 minutes, with a 15 minute burn time, so I know I could get it down to just slightly longer than an RFA. Granted it doesn't pay as well as an RFA for a similar amount of time, but lots of procedures don't. So it's not going to be something that makes a ton of money for you. But as long as it makes a little, it's something I'm happy to do, if I can get results as good as I've seen from colleagues.

 

[RoloTomassi]

Any chance this ever gets an office code? I'm interested after hearing about the success of others on the forum. Cant be harder than kypho.

Unlikely, but you could potentially do cash pay in office. Recommend IV conscious, and 2, maybe 3 vertebral bodies max, and in the right patient with high procedure tolerance because you might find yourself needing to hammer pretty hard, may even need hand drill. Not your typical osteoporotic fx bones. And trocar is 8 ga. Even if you get to BVN uneventfully, you can't numb the burn, so make sure it's not a patient that would scream during a 90 sec RFA.

 

[bedrock]

Unlikely, but you could potentially do cash pay in office. Recommend IV conscious, and 2, maybe 3 vertebral bodies max, and in the right patient with high procedure tolerance because you might find yourself needing to hammer pretty hard, may even need hand drill. Not your typical osteoporotic fx bones. And trocar is 8 ga. Even if you get to BVN uneventfully, you can't numb the burn, so make sure it's not a patient that would scream during a 90 sec RFA.

Do u you ever mac them? Or at least for the burn?

 

[RoloTomassi]

Do u you ever mac them? Or at least for the burn?

Done most MAC or general. IV conscious only 2-3 times.

The above was in reference to if done in office, since IV conscious is the highest sedation for office.

 

[BobBarker]

These procedures need MAC/general. The bone is a lot more dense than a kypho.

 

[Taus]

any of you got pics of an S1 entry. I've never done that during augmentation so this is the only level I'm uncomfortable with

I would not worry about that at all. I have never done any vertebral augmentation outside of a couple cases in fellowship. Here is a shot of an S1 I did recently. Slam dunk case. 100% relief.

 

[clubdeac]

I would not worry about that at all. I have never done any vertebral augmentation outside of a couple cases in fellowship. Here is a shot of an S1 I did recently. Slam dunk case. 100% relief.

Nice pics! Looks like great placement. You don’t happen to have a down the barrel pic?

 

[Taus]

Nice pics! Looks like great placement. You don’t happen to have a down the barrel pic?

Thanks. I don’t usually save those- will do next case. Definitely more nuances to S1 access due to iliac crests and getting medial enough without too ventral. Course was very helpful plus rep in OR giving pointers.

 

[epidural man]

My experience has not been great... but I have only done 10 or so.

Neurosurgeon at my hospital is doing a lot of them (probably 100) and he reports excellent pain relief. What he doesn't know is they come to the pain clinic after still complaining of pain. 🙂


He had three cases scheduled but got COVID and asked if I could do them. 1/3 had benefit. The two that didn't get benefit, I would have NEVER offered the procedure to them.

Here is my idea for a study at my place (input welcome).

CT/SPECT patients that have anterior column descriptions. Perform Intracept on the diseased levels. Then try and correlate to see if CT/SPECT findings can be a better predictor for those who respond to this therapy. I don't think MODIC is good enough.

 

[RoloTomassi]

My experience has not been great... but I have only done 10 or so.

Neurosurgeon at my hospital is doing a lot of them (probably 100) and he reports excellent pain relief. What he doesn't know is they come to the pain clinic after still complaining of pain. 🙂


He had three cases scheduled but got COVID and asked if I could do them. 1/3 had benefit. The two that didn't get benefit, I would have NEVER offered the procedure to them.

Here is my idea for a study at my place (input welcome).

CT/SPECT patients that have anterior column descriptions. Perform Intracept on the diseased levels. Then try and correlate to see if CT/SPECT findings can be a better predictor for those who respond to this therapy. I don't think MODIC is good enough.

Interesting idea. Do you think SPECT correlates well with Modic 1 and not 2? I've had success with 1, 2 and mixed. I would think that SPECT would not be a sensitive predictor, kind of how it isn't for facet RFA.

 

[epidural man]

Interesting idea. Do you think SPECT correlates well with Modic 1 and not 2? I've had success with 1, 2 and mixed. I would think that SPECT would not be a sensitive predictor, kind of how it isn't for facet RFA.

Probably - but dont' know. I would think that MODIC I response better to Intracept anyway.

I don't think the jury is out with SPECT/CT and RFA.

 

[Taus]

My experience has not been great... but I have only done 10 or so.

Neurosurgeon at my hospital is doing a lot of them (probably 100) and he reports excellent pain relief. What he doesn't know is they come to the pain clinic after still complaining of pain. 🙂


He had three cases scheduled but got COVID and asked if I could do them. 1/3 had benefit. The two that didn't get benefit, I would have NEVER offered the procedure to them.

Here is my idea for a study at my place (input welcome).

CT/SPECT patients that have anterior column descriptions. Perform Intracept on the diseased levels. Then try and correlate to see if CT/SPECT findings can be a better predictor for those who respond to this therapy. I don't think MODIC is good enough.

I agree, I would much prefer a more clear cut prognostic indicator, like mbb - granted, success rate of MB rfa is not 100% even with 2 sets with complete relief on blocks. Modic 1/2 are objective findings on MRI, but saying for certain the pain is “vertebrogenic“ is not. The clinical picture certainly helps to a degree but I’d like more. At this point, in my practice, if history/exam points to anterior column, there is ddd with modic 1/2, Failed proper conservative care, and even just modest focal tenderness or pain on extension, I still rec MBB prior to going ahead with intracept. I think I may decrease the false positive rates in this scenario, when the patient understands there is a next step either way. Positive block goes to repeat MBB and possible facet RFA. Negative block goes to intercept. I have had patients in the past tell me, after failed RFA, that they did not really have a good relief with the blocks as they said, but knew there were no additional options, so told me they did.

Some have advocated for discogram or anesthetic intradiscal injection prior to intracept- I would not at this time. At appropriately low pressures, you’re stimulating disc or anesthetizing disc. Sure, you could crank up the pressure and pressurize end plates perhaps. Why would this be prognostic for intracept? I do not think the ends justify the means. Open to be proven wrong.


Sorry to hear it hasn’t been a good experience for you. Have you gotten post procedure MRIs to check lesion targeting? Would you be open to posting MRI and procedure images? Would definitely be discouraging if seeing a total failure rate more than about 30%. I am still in the honeymoon phase, and I’ve had excellent outcomes so far. I know I absolutely will not always and it will be some failures as I do more cases

 

[epidural man]

I agree, I would much prefer a more clear cut prognostic indicator, like mbb - granted, success rate of MB rfa is not 100% even with 2 sets with complete relief on blocks. Modic 1/2 are objective findings on MRI, but saying for certain the pain is “vertebrogenic“ is not. The clinical picture certainly helps to a degree but I’d like more. At this point, in my practice, if history/exam points to anterior column, there is ddd with modic 1/2, Failed proper conservative care, and even just modest focal tenderness or pain on extension, I still rec MBB prior to going ahead with intracept. I think I may decrease the false positive rates in this scenario, when the patient understands there is a next step either way. Positive block goes to repeat MBB and possible facet RFA. Negative block goes to intercept. I have had patients in the past tell me, after failed RFA, that they did not really have a good relief with the blocks as they said, but knew there were no additional options, so told me they did.

Some have advocated for discogram or anesthetic intradiscal injection prior to intracept- I would not at this time. At appropriately low pressures, you’re stimulating disc or anesthetizing disc. Sure, you could crank up the pressure and pressurize end plates perhaps. Why would this be prognostic for intracept? I do not think the ends justify the means. Open to be proven wrong.


Sorry to hear it hasn’t been a good experience for you. Have you gotten post procedure MRIs to check lesion targeting? Would you be open to posting MRI and procedure images? Would definitely be discouraging if seeing a total failure rate more than about 30%. I am still in the honeymoon phase, and I’ve had excellent outcomes so far. I know I absolutely will not always and it will be some failures as I do more cases

It is likely that some of the failures were from poor placement. I haven’t considered post procedure MRI to evaluate lesion. Hmmm….

Let’s say lesion doesn’t seem to be in the right place. Would anyone recommend repeating the procedure?

Anyone concerned about future vertebral fractures? I think the company reports one s/p treatment.

Regarding complications, at our institution (not my case), we had a bone fragment break off from the pedicle causing severe leg pain upon waking. They needed surgical correction.

Any reports of an S1 nerve damage? When I look at MRI images, that S1 traverses (in some) very close to the supposed track of the Intracept probe. I’ve thought about putting some dye in the S1 foremen to make sure I stay away from that.

 

[RoloTomassi]

It is likely that some of the failures were from poor placement. I haven’t considered post procedure MRI to evaluate lesion. Hmmm….

Let’s say lesion doesn’t seem to be in the right place. Would anyone recommend repeating the procedure?

Yes but not sure how reimbursement is in this situation. Would go from the other side.

Anyone concerned about future vertebral fractures? I think the company reports one s/p treatment.

Regarding complications, at our institution (not my case), we had a bone fragment break off from the pedicle causing severe leg pain upon waking. They needed surgical correction.

Not worried. Don't see that happening if you have good trajectory and are not cranking on the trocar or breaching medial wall. Can always go extrapedic if skinny pedicles.

Any reports of an S1 nerve damage? When I look at MRI images, that S1 traverses (in some) very close to the supposed track of the Intracept probe. I’ve thought about putting some dye in the S1 foremen to make sure I stay away from that.

Again, you should be able to see the medial pedicle wall and not breach. Map out your trajectory on MRI if it's a narrow path.

 

[Taus]

It is likely that some of the failures were from poor placement. I haven’t considered post procedure MRI to evaluate lesion. Hmmm….

Let’s say lesion doesn’t seem to be in the right place. Would anyone recommend repeating the procedure?

I’m sure I’ll have my fair share of imperfect lesions as time goes on. Was issue on smart trial- multiple misses. Now why teach 30-50% from posterior cortex. Not 40-60. I try to get as posterior as possible, min 1cm from cortex. Tap J lightly, truly 1-2 mm/hit til turning medial.

Anyone concerned about future vertebral fractures? I think the company reports one s/p treatment.

Wasn’t seen in human or animal beyond the one case with some extenuating circumstances. Clearly it can happen and I’m sure they’ll be more as usage rises… but should be exceedingly rare

Regarding complications, at our institution (not my case), we had a bone fragment break off from the pedicle causing severe leg pain upon waking. They needed surgical correction.

Would presume similar rate as vert augmentation. Repeatedly check Ap, lateral and pedicle en-face to confirm not near breaching cortex.

Any reports of an S1 nerve damage? When I look at MRI images, that S1 traverses (in some) very close to the supposed track of the Intracept probe. I’ve thought about putting some dye in the S1 foremen to make sure I stay away from that.

Published transient radiculitis rate about 5%. Again, multiple re-checks AP, lateral and pedicle en-face to avoid breach. If you don’t end up medial enough with cannula you can always use retraction method with J stylet

 

[Tboned]

I’m sure I’ll have my fair share of imperfect lesions as time goes on. Was issue on smart trial- multiple misses. Now why teach 30-50% from posterior cortex. Not 40-60. I try to get as posterior as possible, min 1cm from cortex. Tap J lightly, truly 1-2 mm/hit til turning medial.

Wasn’t seen in human or animal beyond the one case with some extenuating circumstances. Clearly it can happen and I’m sure they’ll be more as usage rises… but should be exceedingly rare


Would presume similar rate as vert augmentation. Repeatedly check Ap, lateral and pedicle en-face to confirm not near breaching cortex.

Published transient radiculitis rate about 5%. Again, multiple re-checks AP, lateral and pedicle en-face to avoid breach. If you don’t end up medial enough with cannula you can always use retraction method with J stylet

I used the retraction method this morning, nice little technique.

So far my outcomes have been really solid, but only n=5. Followup 6 weeks through 6 months for these patients. Average ODI -34.4. Average VAS -7.3. 100% responder rate using MCID criterion (easily surpassed). Improvements have been maintained.
All patients would have been trial candidates.

About twenty more enrolled in prior auth, two approved cases being scheduled. I’ll try to keep posting outcomes with time and increased numbers since I’m tracking outcomes with OBERD. Plan is to publish data without industry funding bias.

 

[RoloTomassi]

I used the retraction method this morning, nice little technique.

So far my outcomes have been really solid, but only n=5. Followup 6 weeks through 6 months for these patients. Average ODI -34.4. Average VAS -7.3. 100% responder rate using MCID criterion (easily surpassed). Improvements have been maintained.
All patients would have been trial candidates.

About twenty more enrolled in prior auth, two approved cases being scheduled. I’ll try to keep posting outcomes with time and increased numbers since I’m tracking outcomes with OBERD. Plan is to publish data without industry funding bias.

Nice! Hopefully more data will help it surpass "investigational" status by insurances.

 

[Taus]

What are people doing with aspirin for this? I understand most are treating anticoagulation same as vertebral augmentation. I do not do vert augmentation, looked at Asra app recs- says hold asa 6 days. Differentiate 325 vs 81? Differentiate purely prophylactic vs had prior MI/CVA?

Thanks

 

[lobelsteve]

I do not hold ASA for anything, including SCS implant and gasserian RFA.

 

[epidural man]

I do not hold ASA for anything, gasserian RFA.

I tip my hat to you! Not for not holding the ASA - but for actually doing this block.

 

[Taus]

Realized another advantage of the seven minute burn in case this week. Getting the cannula out of the way while I am going back-and-forth AP and lateral on fluoro for my next access point was very helpful. Pita w how far it sticks out of patient when add electrode. Tech has been sliding whole machine to head or feet before going lateral to avoid hitting it. That plus the burn time itself significantly improved my procedure time. I think I can get a standard single level case, two vertebral bodies, in 30 minutes routinely unless patient has f’d up anatomy/scoli, hardware. Lesion is only 1 mm smaller in radius. 5 verses 6 mm.

 

[RoloTomassi]

Realized another advantage of the seven minute burn in case this week. Getting the cannula out of the way while I am going back-and-forth AP and lateral on fluoro for my next access point was very helpful. Pita w how far it sticks out of patient when add electrode. Tech has been sliding whole machine to head or feet before going lateral to avoid hitting it. That plus the burn time itself significantly improved my procedure time. I think I can get a standard single level case, two vertebral bodies, in 30 minutes routinely unless patient has f’d up anatomy/scoli, hardware. Lesion is only 1 mm smaller in radius. 5 verses 6 mm.

Keep us posted on whether your results stay consistent with 15 min. It's funny though it's 7 min @ 70 C vs 15 min @ 85. You would think for the shorter burn they would increase or at least keep the same temp not decrease. Haven't heard the rationale.

 

[Taus]

Keep us posted on whether your results stay consistent with 15 min. It's funny though it's 7 min @ 70 C vs 15 min @ 85. You would think for the shorter burn they would increase or at least keep the same temp not decrease. Haven't heard the rationale.

You sticking with standard 15 for all lesions regardless of placement for now? I am well aware they did this due to physician complaints about procedure time versus reimbursement, but that would be truly stupid on their part if results don’t hold up despite perfect placement with seven minute burn. It will go the way of idet.

I will ask my rep for the data.

That said, I presume it is similar to medial branch RF studies, diminishing returns with increasing time and temperature. Kind of like cooled RF, larger lesion, lower temperature, more forgiving on placement. As long as this temperature is just as neurolytic on this target and only 1 mm less radius, then all good if placement is on par.

 

[RoloTomassi]

You sticking with standard 15 for all lesions regardless of placement for now? I am well aware they did this due to physician complaints about procedure time versus reimbursement, but that would be truly stupid on their part if results don’t hold up despite perfect placement with seven minute burn. It will go the way of idet.

I will ask my rep for the data.

That said, I presume it is similar to medial branch RF studies, diminishing returns with increasing time and temperature. Kind of like cooled RF, larger lesion, lower temperature, more forgiving on placement. As long as this temperature is just as neurolytic on this target and only 1 mm less radius, then all good if placement is on par.

My plan is to just stick with 15, and if I get done before 7, I'll wait till 7 then stop, otherwise I'll just let it go to 8, 9, however long it takes for me to be ready to remove. So I'll have minimum 7 min @ 85. I'll see what rep says about that plan Friday.

 

[BobBarker]

It is easier for the rad tech if you do the left side first and then the right side.

 

[RoloTomassi]

Did my first extrapedicular at L2 today. Would've been impossible to go transpedicular given narrow, sagittal oriented pedicles and wide facets.

 

[Taus]

Did my first extrapedicular at L2 today. Would've been impossible to go transpedicular given narrow, sagittal oriented pedicles and wide facets.

Nice! How do you think that approach compares in speed and difficulty to traditional approach? I thought the case I did around a pedicle screw, coming in similarly at L4, was actually somewhat easier and faster than transpedicular.

 

[RoloTomassi]

Nice! How do you think that approach compares in speed and difficulty to traditional approach? I thought the case I did around a pedicle screw, coming in similarly at L4, was actually somewhat easier and faster than transpedicular.

I liked it. I still think going TP for L3-5 is probably easier given the size and obliquity of the pedicles, straight shot to your target, but will probably go EP more routinely at L1/2. A bit higher risk of hematoma and nerve root irritation I suppose.

 

[DrMDAware]

What key questions do you ask to determine vertebrogenic vs facetogenic pain? I know what the literature says but I’m not sure how to apply this in the real world. Maybe just start with MBB then progress to Intracept if no improvement provided Modic changes are present.

What do you do with multiple levels of Modic changes when they are higher lumbar vs lower lumbar? Bring the patient back on another day? Start with the best guess level?

 

[10KHertz]

Why are two levels mandatory?So if you are targeting a young patient with discogenic pain, endplate/modic changes at L4-5 , what levels are recommended? L4 and L5 vertebral body sinovertebral nerve input 50/50 from above and below ?

 

[Taus]

Why are two levels mandatory?So if you are targeting a young patient with discogenic pain, endplate/modic changes at L4-5 , what levels are recommended? L4 and L5 vertebral body sinovertebral nerve input 50/50 from above and below ?

Correct. Same reason as 2 nerves to a facet joint.

 

[Taus]

What key questions do you ask to determine vertebrogenic vs facetogenic pain? I know what the literature says but I’m not sure how to apply this in the real world. Maybe just start with MBB then progress to Intracept if no improvement provided Modic changes are present.

Same as you would with facet vs disc pain.

If mixed picture clinically... mbb

If no tenderness or extension pain and modic present … intracept

What do you do with multiple levels of Modic changes when they are higher lumbar vs lower lumbar? Bring the patient back on another day? Start with the best guess level?

 

[RoloTomassi]

What key questions do you ask to determine vertebrogenic vs facetogenic pain? I know what the literature says but I’m not sure how to apply this in the real world. Maybe just start with MBB then progress to Intracept if no improvement provided Modic changes are present.

What do you do with multiple levels of Modic changes when they are higher lumbar vs lower lumbar? Bring the patient back on another day? Start with the best guess level?

Pain Location and Exacerbating Activities Associated with Treatment Success Following Basivertebral Nerve Ablation: An Aggregated Cohort Study of Multicenter Prospective Clinical Trial Data - PubMed

This study demonstrates that midline LBP correlates with BVN RFA treatment success in individuals with VEP. While none of the regression models demonstrated strong predictive value, the pain location and exacerbating factors identified in this analysis may aid clinicians in identifying patients...

pubmed.ncbi.nlm.nih.gov

 

[Tboned]

Why are two levels mandatory?So if you are targeting a young patient with discogenic pain, endplate/modic changes at L4-5 , what levels are recommended? L4 and L5 vertebral body sinovertebral nerve input 50/50 from above and below ?

Technically, two levels are not “mandatory”, you should just target the levels with modic changes. If there’s only
Modic changes at the inferior endplate of L4, I’m not doing L5. It’s just more common to see modic surrounding a disc level.

 

[Tboned]

Pain Location and Exacerbating Activities Associated with Treatment Success Following Basivertebral Nerve Ablation: An Aggregated Cohort Study of Multicenter Prospective Clinical Trial Data - PubMed

This study demonstrates that midline LBP correlates with BVN RFA treatment success in individuals with VEP. While none of the regression models demonstrated strong predictive value, the pain location and exacerbating factors identified in this analysis may aid clinicians in identifying patients...

pubmed.ncbi.nlm.nih.gov

This article comes out of the recently released Pain Medicine supplement. I’m sure a lot of folks who are interested in Intracept would find the articles in this supplement beneficial.

 

[Tboned]

What key questions do you ask to determine vertebrogenic vs facetogenic pain? I know what the literature says but I’m not sure how to apply this in the real world. Maybe just start with MBB then progress to Intracept if no improvement provided Modic changes are present.

What do you do with multiple levels of Modic changes when they are higher lumbar vs lower lumbar? Bring the patient back on another day? Start with the best guess level?

I saw a patient this week with axial LBP and modic 1/2 change L2-S1, referred for possible Intracept. I felt She wasn’t a candidate, but I thought about this very question. How many levels would I do? All 5 vs staged, maybe do L4-S1 then L2,L3 if still having pain?
I think in her case (70s, other medical comorbidities, somewhat frail, not a buff 40 year old bro) I’d opt for the staged approach. For the bro, I’d probably do all 5. I think it’s patient dependent. I did a 4 level case in a healthy 50 yo F nurse, and she crushed the recovery, really impressive. I have been pleasantly surprised by the recovery on my patients after this procedure so far.

 

[MD87]

Is the procedure currently covered for above L3?

 

[Taus]

.

I saw a patient this week with axial LBP and modic 1/2 change L2-S1, referred for possible Intracept. I felt She wasn’t a candidate, but I thought about this very question. How many levels would I do? All 5 vs staged, maybe do L4-S1 then L2,L3 if still having pain?
I think in her case (70s, other medical comorbidities, somewhat frail, not a buff 40 year old bro) I’d opt for the staged approach. For the bro, I’d probably do all 5. I think it’s patient dependent. I did a 4 level case in a healthy 50 yo F nurse, and she crushed the recovery, really impressive. I have been pleasantly surprised by the recovery on my patients after this procedure so far.

I don’t know that there’s a right answer on that. Total judgment call. I’ve had a couple like that. Modic L1 down. One had pain clinically at lumbosacral junction. Worst ddd at 45. I did L4-s1. Other more diffuse pain. Did ‘em all

 

[RoloTomassi]

I don’t know that there’s a right answer on that. Total judgment call. I’ve had a couple like that. Modic L1 down. One had pain clinically at lumbosacral junction. Worst ddd at 45. I did L4-s1. Other more diffuse pain. Did ‘em all

Same. Usually will do them all, only have done partial once when Modic was significantly worse at a particular level, and they weren't the healthiest, wanted to limit trauma and OR time. We know how low upper lumbar/ thoracic compression fx pain can refer, so I think it's hard to do best guess. I'll usually do MBB first on these folks because L1-S1 is a lot of work.

Is the procedure currently covered for above L3?

I'll bill for L2 when it's part of L2-3 but I don't bill L1. Have only done it a few times, and now it's a 7 min freebie.

 

[DrMDAware]

Pain Location and Exacerbating Activities Associated with Treatment Success Following Basivertebral Nerve Ablation: An Aggregated Cohort Study of Multicenter Prospective Clinical Trial Data - PubMed

This study demonstrates that midline LBP correlates with BVN RFA treatment success in individuals with VEP. While none of the regression models demonstrated strong predictive value, the pain location and exacerbating factors identified in this analysis may aid clinicians in identifying patients...

pubmed.ncbi.nlm.nih.gov

Thanks for sharing that. Seems like pain with activity is quite ubiquitous and non specific. I wonder if there are specific activities? I get the lumbar extension ones.

Maybe my midline vs paraspinal exam isn’t good enough but I feel the patients I treat wouldn’t get that granular. I could be missing a good way to tease this out.

Open to learning.

 

[RoloTomassi]

I have a candidate on Plavix who cannot hold. Would you all be comfortable doing L4-5 Intracept? Would appreciate any feedback from those who have done a lot of kypho on blood thinners. Intracept is an 8 ga trocar, 11 blade stab incisions.

 

[Ducttape]

could he transition to lovenox temporarily?

 

[RoloTomassi]

could he transition to lovenox temporarily?

Hmm not sure, never done that. I'd have to ask his cardio about that. Extensive cardiac history.

 

[Ducttape]

so 5-6 days before procedure, stop plavix. start lovenox that day, twice daily dosing. have to wait 24 hours after last dose so day before procedure, last dose would be the morning dose.

have the cardiologist write for this.

 

[RoloTomassi]

so 5-6 days before procedure, stop plavix. start lovenox that day, twice daily dosing. have to wait 24 hours after last dose so day before procedure, last dose would be the morning dose.

have the cardiologist write for this.

Great, really appreciate this

 

[drrosenrosen]

Saw my first patient back yesterday, 3 week follow up. 90% relief, she was thrilled with how much better she feels, "hasn't felt this good in years". That's some pretty good positive reinforcement for wanting to do more