Guys I have an idea for IR growth what you guys think?

[Tman507]

-I think in future IR group start ups should employ like 2 vascular surgeons(depend on group size) to be part of their group for standby....That way it'll be easy for IR and vascular to flourish at what they do best

-also DRs part of their group could recommend IR treatment(if applicable) on their reports to increase work as well

IRs just need to be more aggressive like Cardio and NPs at getting their way

What you guys think?

Edit:
- increase in pcp awareness of IR and what it can do

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[UChicagoIR]

Both have been done already.

There are groups that have partnered with surgeons. From what I hear it tends to only work with older vascular surgeons who dislike endovascular work, prefer open surgery, and are no longer interested in growing their practice. Otherwise how do you divide endovascular PAD work between an IR and a vascular surgeon? The reality is that neither one needs the other.

When I was in private practice the DRs would regularly recommend IR consultations in the impressions. In my experience it worked well.

In my opinion, being more "aggressive" was part of the reason IR created it's own residency and pseudo-separated from DR. I also think that the integrated IR/DR residency will siphon off some of the "aggressive" medicine residents who went into IM residencies in pursuit of interventional cardiology.

 

[Tman507]

Both have been done already.

There are groups that have partnered with surgeons. From what I hear it tends to only work with older vascular surgeons who dislike endovascular work, prefer open surgery, and are no longer interested in growing their practice. Otherwise how do you divide endovascular PAD work between an IR and a vascular surgeon? The reality is that neither one needs the other.

When I was in private practice the DRs would regularly recommend IR consultations in the impressions. In my experience it worked well.

In my opinion, being more "aggressive" was part of the reason IR created it's own residency and pseudo-separated from DR. I also think that the integrated IR/DR residency will siphon off some of the "aggressive" medicine residents who went into IM residencies in pursuit of interventional cardiology.

I hear that vascular keeps saying that they control complete patient care so they win the turf war and even have to fix cardio and IR messes, that's why i thought vascular should be a standby, or is vascular overselling it?.... However IR can easily learn pre and post op care which they probably are already.
I agree, i don't think its worth going through IM and cards to want to do PAD intervention, they should stick to the heart, thats what they know best. Cards are practically radiologists with clinic. They have a very strong presence so they get what they want.

-i think pcps should be more educated on IR and what it can do, that way your referral base will skyrocket

*Question- i know what things IR can do that vascular cannot...But what all can vascular do that IR cannot do?

Thanks for the reply, much appreciated

 

[UChicagoIR]

Don't believe everything you hear. There's a lot of egos and hurt feelings involved. A significant portion of my career has been devoted to treating complications resulting from surgery. By the same token, there are instances where complications happen in IR and need to be fixed by surgery. In my experience the latter is much less common, however.

IR cannot do any open surgery.

 

[Tman507]

Don't believe everything you hear. There's a lot of egos and hurt feelings involved. A significant portion of my career has been devoted to treating complications resulting from surgery. By the same token, there are instances where complications happen in IR and need to be fixed by surgery. In my experience the latter is much less common, however.

IR cannot do any open surgery.

Thanks soo much!

 

[deleted950463]

Thanks soo much!

IR cannot do bypasses in the realm of PAD for example. That’s why we should continue to push the frontier for endovascular bail out techniques.

I would not be surprised if in our life time endovascular peripheral bypasses become a reality.

Also a lot of those turf issues come from the way Americans practice medicine. In many countries, clinicians stick with clinical medicine. Surgeons stick with surgery and IRs do IR work. Here it’s more like people divide up their turf by organs and people who own the organ try to do everything in their organ system. It’s a money thing.

As far as why you can’t have VS on standby, it’s because the economy doesn’t make sense. I know of hybrid groups where IR and VS work side by side (even with younger VS). A lot of VS now days are no longer comfortable with open procedures and prefer endovascular as well.

 

[Tman507]

IR cannot do bypasses in the realm of PAD for example. That’s why we should continue to push the frontier for endovascular bail out techniques.

I would not be surprised if in our life time endovascular peripheral bypasses become a reality.

Also a lot of those turf issues come from the way Americans practice medicine. In many countries, clinicians stick with clinical medicine. Surgeons stick with surgery and IRs do IR work. Here it’s more like people divide up their turf by organs and people who own the organ try to do everything in their organ system. It’s a money thing.

As far as why you can’t have VS on standby, it’s because the economy doesn’t make sense. I know of hybrid groups where IR and VS work side by side (even with younger VS). A lot of VS now days are no longer comfortable with open procedures and prefer endovascular as well.

"I would not be surprised if in our life time endovascular peripheral bypasses become a reality. "
This would be a dream, hope IRs are experimenting if not already...it would change alot.

I know that people are generally greedy for money and excited that another procedure could be theirs, but at what quality? And how much experience?..leave it to the experts... Physicians/surgeons should just stick to what they're good at that's what makes them experts of their field

If vascular is not very comfortable with performing open surgery then this is a major threat to IR.
Wouldn't they "practically/hypothetically" be an IR if they stay away from open procedures? (i know IR does things that they cannot)

Thanks for your reply, much appreciated!

 

[deleted950463]

"I would not be surprised if in our life time endovascular peripheral bypasses become a reality. "
This would be a dream, hope IRs are experimenting if not already...it would change alot.

I know that people are generally greedy for money and excited that another procedure could be theirs, but at what quality? And how much experience?..leave it to the experts... Physicians/surgeons should just stick to what they're good at that's what makes them experts of their field

If vascular is not very comfortable with performing open surgery then this is a major threat to IR.
Wouldn't they "practically/hypothetically" be an IR if they stay away from open procedures? (i know IR does things that they cannot)

Thanks for your reply, much appreciated!

VS are already doing most endovascular PAD now in most places. They are practicing interventional radiology.

 

[Tman507]

VS are already doing most endovascular PAD now in most places. They are practicing interventional radiology.

Then i guess the IR vs Vascular will always remain a thing.
Thanks for the reply!

 

[NDcienporciento100]

VS are already doing most endovascular PAD now in most places. They are practicing interventional radiology.

Then why don’t they call them for TIPS, Y90, UfE, PAE, stroke thrombectomies, GI bleeds, BRTO, kyphoplasty and the list goes on??? If they are already practicing IR... hell where I train vascular can’t even eject thrombin into there own pseudo aneurism. Look I keep saying this but I’m going to say it again complex endovascular cases are almost never done by vascular it’s one thing to slip a glide by an SFA occlusion, I did it as a Med student but it’s another thing sticking a needle through the liver hopeing to come out the right side of the portal vein. Vascular surgery can cut and IR can’t it’s as simple as that. The whole we fix all of IRs screwups is laughable, say that to the surgeon that calls you to take care of a GI bleed, do you think he would call you if he could do it himself??

 

[NDcienporciento100]

If you are dead set on the treatment of PAD and that’s what your passion is and don’t really care about the tons of other cool stuff IR does you are probably better off doing Vascular Surgery. And I think most of the IRs on this forum would agree. To me PAD is just one slice of what makes IR great it’s not the whole pizza, that’s just me.

 

[deleted950463]

Then why don’t they call them for TIPS, Y90, UfE, PAE, stroke thrombectomies, GI bleeds, BRTO, kyphoplasty and the list goes on??? If they are already practicing IR... hell where I train vascular can’t even eject thrombin into there own pseudo aneurism. Look I keep saying this but I’m going to say it again complex endovascular cases are almost never done by vascular it’s one thing to slip a glide by an SFA occlusion, I did it as a Med student but it’s another thing sticking a needle through the liver hopeing to come out the right side of the portal vein. Vascular surgery can cut and IR can’t it’s as simple as that. The whole we fix all of IRs screwups is laughable, say that to the surgeon that calls you to take care of a GI bleed, do you think he would call you if he could do it himself??

So here’s the real talk. VS took over a lot of work because IT PAYS WELL.

TIPS doesn’t pay well. Thrombin injection doesn’t pay well. Thrombin injection is scut. Just because they don’t want to do it doesn’t mean they can’t do it or that specific thing is safe.

The issue is to develop a clinical specialty with our own brand so that other physicians refer to us directly when they think of certain procedures.

How hard or how easy a procedure is has no bearing in whether people will fight for it or not. The only thing that matters mostly is RVU.

One of my buddy said famously: if paracentesis starts to pay the same as a stent graft, no IR will ever touch a fluid filled belly and paracentesis fellowship for IM will be competitive.

And by the way, IRs can cut. IRs are out there doing fistula ligations which is a surgical cut down. Port is a surgical procedure. It’s all about what you managed to do.

So in conclusion, the safest thing is to develop IR into the fullfledged “third option” besides surgery and medicine. IR needs to be that big.

 

[NDcienporciento100]

So here’s the real talk. VS took over a lot of work because IT PAYS WELL.

TIPS doesn’t pay well. Thrombin injection doesn’t pay well. Thrombin injection is scut. Just because they don’t want to do it doesn’t mean they can’t do it or that specific thing is safe.

The issue is to develop a clinical specialty with our own brand so that other physicians refer to us directly when they think of certain procedures.

How hard or how easy a procedure is has no bearing in whether people will fight for it or not. The only thing that matters mostly is RVU.

One of my buddy said famously: if paracentesis starts to pay the same as a stent graft, no IR will ever touch a fluid filled belly and paracentesis fellowship for IM will be competitive.

And by the way, IRs can cut. IRs are out there doing fistula ligations which is a surgical cut down. Port is a surgical procedure. It’s all about what you managed to do.

So in conclusion, the safest thing is to develop IR into the fullfledged “third option” besides surgery and medicine. IR needs to be that big.

I like and respect the things you say and agree with almost everything you just wrote. SIR made a documentary series for all those that are curious it comes with an amazon prime membership. And you know what the name of the documentary is???? “Without a Scalpel!!!!” No IR is not a surgical field and I don’t see that as a negative to me it’s a positive, everyone that matched into an IR residency could have matched into surgery seriously every single one of them. IR may do a few little things like small cutdowns etc that are sorta surgical but not really. Yes it’s a surgical lifestyle, I completely agree on what you said about RVUs and TIPs not paying well what have you, but that said I don’t think 99% of vascular surgeons could do tips tomorrow if there life depended on it just like 99% of IR could not do an open AAA repair.

 

[deleted950463]

I like and respect the things you say and agree with almost everything you just wrote. SIR made a documentary series for all those that are curious it comes with an amazon prime membership. And you know what the name of the documentary is???? “Without a Scalpel!!!!” No IR is not a surgical field and I don’t see that as a negative to me it’s a positive, everyone that matched into an IR residency could have matched into surgery seriously every single one of them. IR may do a few little things like small cutdowns etc that are sorta surgical but not really. Yes it’s a surgical lifestyle, I completely agree on what you said about RVUs and TIPs not paying well what have you, but that said I don’t think 99% of vascular surgeons could do tips tomorrow if there life depended on it just like 99% of IR could not do an open AAA repair.

People have different opinion about who they are. IRs I am most familiar with self identify as surgeons. The practice of IR is endovascular and minimally invasive surgery.

 

[NDcienporciento100]

People have different opinion about who they are. IRs I am most familiar with self identify as surgeons. The practice of IR is endovascular and minimally invasive surgery.

Fair enough.

 

[irwarrior]

I disagree that PAD endovascular interventions are easy. I think some of the tibiopedal revascularizations or heavily calcified femoropopliteal occlusive disease are some of the tougher cases we do. Many graduating VIR fellows are currently not as well trained in this as they should be. If you are a student, I would encourage you to look at a place that gives comprehensive training including PAD, stroke/neurointerventions, Oncology, Venous interventions, dialysis work. Again, without a good working knowledge (clinically and technically ) of PAD and dialysis work, it is difficult to sustain a robust VIR practice in the community. Academic places thrive on transplant (liver directed therapy/hepatobiliary) and trauma interventions and so any medical student should look to make sure they get all facets of VIR training . I have seen numerous VIR physicians, who because of their strong clinical and technical skill set develop a booming PAD practice after training. But, ultimately to be successful you have to manage all aspects of the disease similar to our cardiology and vascular surgery colleagues.

 

[NDcienporciento100]

I disagree that PAD endovascular interventions are easy. I think some of the tibiopedal revascularizations or heavily calcified femoropopliteal occlusive disease are some of the tougher cases we do. Many graduating VIR fellows are currently not as well trained in this as they should be. If you are a student, I would encourage you to look at a place that gives comprehensive training including PAD, stroke/neurointerventions, Oncology, Venous interventions, dialysis work. Again, without a good working knowledge (clinically and technically ) of PAD and dialysis work, it is difficult to sustain a robust VIR practice in the community. Academic places thrive on transplant (liver directed therapy/hepatobiliary) and trauma interventions and so any medical student should look to make sure they get all facets of VIR training . I have seen numerous VIR physicians, who because of their strong clinical and technical skill set develop a booming PAD practice after training. But, ultimately to be successful you have to manage all aspects of the disease similar to our cardiology and vascular surgery colleagues.

I agree Pedal access, or any below the knee endovascular pad intervention can be extremely difficult, especially in the setting of CLI, the problem is the great majority of vascular surgeons don’t/can’t do it, seriously it’s a very small number that actually do it. To me this is where IR has its biggest advantage in the PAD world is below the knee and particular retrograde access in the setting of CLI. I’m many places vascular surgeons push these patients for amputations before they have exhausted these options. There is Microstent’s that are in trials for below the knee PAD which depending on how the data works our could make below the knee interventions more popular.

 

[NDcienporciento100]

I disagree that PAD endovascular interventions are easy. I think some of the tibiopedal revascularizations or heavily calcified femoropopliteal occlusive disease are some of the tougher cases we do. Many graduating VIR fellows are currently not as well trained in this as they should be. If you are a student, I would encourage you to look at a place that gives comprehensive training including PAD, stroke/neurointerventions, Oncology, Venous interventions, dialysis work. Again, without a good working knowledge (clinically and technically ) of PAD and dialysis work, it is difficult to sustain a robust VIR practice in the community. Academic places thrive on transplant (liver directed therapy/hepatobiliary) and trauma interventions and so any medical student should look to make sure they get all facets of VIR training . I have seen numerous VIR physicians, who because of their strong clinical and technical skill set develop a booming PAD practice after training. But, ultimately to be successful you have to manage all aspects of the disease similar to our cardiology and vascular surgery colleagues.

Again I agree long femoralpopliteal occlusion can be extremely difficult and challenging and time consuming, But again this is when a vascular surgeon is going to do a bypass or endarterectomy more often than not just because it’s easier for him to do then attempt a long endovascular revascularization of and occlusion/CTO. There are some doing it but most don’t.

 

[irwarrior]

VIR trainees need to participate in wound care clinics and help manage diabetic foot ulcers. They need to learn to work with our podiatry colleagues and evaluate and manage diabetic foot ulcers. appropriate offloading, antibiotics, footcare, wound debridement (sharp/enzymatic etc) as well as revascularization. Also statins, ace, arb, antiplt, should be initiated. Long term follow up is critical to limb salvage and amputation prevention.

 

[badasshairday]

Bypass is a great durable option for patients who are good surgical candidates (often those younger than 80). Just because we have a means of treating doesnt mean it is the best. Long segment SFA CTO with 3 vessel run off on a 59 year old goes to bypass.

Btw. Thrombin Injections are actually lucrative for the time it takes to do the procedure for a radiologist. So are cholecystostomy tubes which can be done quickly with a 18 or 19 g needle with Salinger technique, or better yet with Trocar technique directly to drain at bedside.

 

[irwarrior]

Zilverpass suggests that DES for long segment SFA is not a bad alternative to bypass.

 

[Tiger100]

-I think in future IR group start ups should employ like 2 vascular surgeons(depend on group size) to be part of their group for standby....That way it'll be easy for IR and vascular to flourish at what they do best

-also DRs part of their group could recommend IR treatment(if applicable) on their reports to increase work as well

IRs just need to be more aggressive like Cardio and NPs at getting their way

What you guys think?

Edit:
- increase in pcp awareness of IR and what it can do

Any collaboration is two-sided.


1- The question is:
Why a vascular surgeon wants to work with IR? A few groups have done that and have been successful but most vascular surgeons work independently.

Most vascular surgeons are not interested in embolizations (very few of them do but not a common practice for them) or non-vascular work.

2- In most practices that IR is part of DR and the line between them is not strict (IR does DR and some DRs do IR), many referrals come from DR. For example, ii is common for ICU doctors and hospitalists to call radiology to see whether there is a PE or not and if yes, ask for IVC filter.
But if IR is a separate group, then you can not expect DR to facilitate the process. In that case, DR doesn't care wjether the case goes to IR or vascular surgery or even cardiology.

 

[irwarrior]

There has already been great strides in a purely endovascular bypass. http://pqbypass.com This was initially designed by James Joye. Pretty interesting technology and techniques.

 

[NDcienporciento100]

There has already been great strides in a purely endovascular bypass. http://pqbypass.com This was initially designed by James Joye. Pretty interesting technology and techniques.

Cool technology,
They are using a stent and not that there is anything wrong with that, it’s revolutionary.
You don’t need the GS, I wonder how far the technology is from marking the fistula and plugging proximal and distal to the anastomoses and not even using a stent, the patency would likely be higher then useing a stent and it would not limit you from using a stent down the road. I don’t know how far we are from this idea but it would be a game changer.

 

[Neurointerventionalist]

Also a lot of those turf issues come from the way Americans practice medicine. In many countries, clinicians stick with clinical medicine. Surgeons stick with surgery and IRs do IR work. Here it’s more like people divide up their turf by organs and people who own the organ try to do everything in their organ system. It’s a money thing.

One of the reason why NeuroIR in Europe is practised (almost exclusively) by neurorad and nsgs/neurologists don't rush to take stroke EVT calls.

 

[ZJz4]

Just a follow up to this. Do you feel IR has lost the turf war or is there enough PAD work to go around

 

[irwarrior]

Growing population of PAD with aging population, rising obesity and diabetes. There are several who are able to provide care for this population of diabetic foot ulcers (vascular surgery, podiatry, interventional cardiology and vascular IR). The key is to have firm knowledge on disease management, have a clinic, have admitting privileges, understand wounds and market yourself to primary care, podiatry, wound care, endocrinologists, and nephrologists. You have to get the referrals in order to provide this care. There are so many untreated or under treated patients out there who could benefit from people passionate about limb salvage. Encourage you to find a VIR training program that provides this care so you can garner this valuable skill set and enable you to provide rewarding care for this vulnerable population.

 

[ZJz4]

Growing population of PAD with aging population, rising obesity and diabetes. There are several who are able to provide care for this population of diabetic foot ulcers (vascular surgery, podiatry, interventional cardiology and vascular IR). The key is to have firm knowledge on disease management, have a clinic, have admitting privileges, understand wounds and market yourself to primary care, podiatry, wound care, endocrinologists, and nephrologists. You have to get the referrals in order to provide this care. There are so many untreated or under treated patients out there who could benefit from people passionate about limb salvage. Encourage you to find a VIR training program that provides this care so you can garner this valuable skill set and enable you to provide rewarding care for this vulnerable population.

Thanks. I guess my question is, could you realistically compete with those specialties since most have the referral base while you don't necessarily?

 

[irwarrior]

Unless you are a PCP, you don't necessarily have your own patients. You have to market to the referring teams (primary care, urgent care, ED, podiatry, wound care nurses, nephrologists, endocrinologists). You manage the circulation, place on high intensity statins, ace, anti platelets and then follow them frequently in clinic until wound has healed. Then you follow patient to prevent wound recurrence? Also important to educate patients about diabetes, adequate protein intake to heal the wound, offloading, appropriate orthotics etc. So , no reason you can't manage these patients. You should try to get training in this as it is such a common disease and there are so many patients who we can help (preventing amputations) with our clinical knowledge and endovascular skill sets. Very satisfying to provide limb salvage treatments.

 

[Tiger100]

Just a follow up to this. Do you feel IR has lost the turf war or is there enough PAD work to go around

It is not completely gone but definitely cherrypicked.

 

[ZJz4]

It is not completely gone but definitely cherrypicked.

So you basically only have a few places you can actually still do it? Assuming you don't want to start a practice from scratch

 

[irwarrior]

So you basically only have a few places you can actually still do it? Assuming you don't want to start a practice from scratch

Plenty of people that I interact with who do PAD. Many of the VIR that do PAD go to VIVA or ISET and less likely to go to SIR meeting given the paucity of PAD content. CIRSE actually has pretty good PAD content as well. Many VIR are doing it. But, in most sites you will have to go out and market and build service lines (spine interventions, prostates, fibroids, oncology, DVT/PE, varicose veins, PAD etc).

 

[IRattending2021]

So you basically only have a few places you can actually still do it? Assuming you don't want to start a practice from scratch

not a few places, many practices do it, but I estimate probably less than 33% of IR do PAD, even less do it with regularity.

let’s look at practice settings.

academia: if your group lost PAD already, it’s over. It’s essentially impossible for a new hire to really grab those pad pie back. Maybe you can try to get a case here and there from podiatry etc, but it’s not gonna be a regular thing

health system: same as above.

this leaves private practice and IR only practice as places where you can grow PAD. Most private practices are not receptive.

 

[irwarrior]

More and more VIR are doing it and it is an invaluable skill set. More and more tibial and pedal intervention options now available for CLI patients. There are too many patients getting amputations without angiography. VS, IC and VIR can provide this invaluable service. You have to be motivated and passionate about limb salvage to make a dent in this challenging disease process. Some pretty good pearls at this site from a VIR.

https://www.youtube.com/c/drtummalasvascularchannel