Peripheral vascular interventions

[ZJz4]

Hey guys,
Just wondering what the state of doing peripheral vascular disease is in IR. I know there are turf wars with vascular surgery and interventional cardiology. Is it possible to do a 100 percent PAD? Are there jobs out there where some PAD work still occurs within an IR practice.

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[irwarrior]

Yes. There are many VIR physicians who are doing a great deal of PAD. Here are just a few .

An Interview With John H. Rundback, MD - Endovascular Today

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[irwarrior]

Meet Dr. Curtis Anderson

Board Certified and Fellowship Trained in Vascular and Interventional Radiology. A native of South Florida, Dr. Curtis Anderson attended the University of Miam

www.flinterventional.com

William H Julien, MD: Vascular Interventional Physician Coconut Creek, FL & Boynton Beach, FL

Trusted Vascular Interventional Physician serving Coconut Creek, FL & Boynton Beach, FL. Visit our website to book an appointment online: William H Julien, MD

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[ZJz4]

Thank you. This is a minority of physicians correct? From what I had seen it seems that interventional cardiology and vascular surgery were now doing most of PAD and control the referral base. So for a potential new IR, do you see this as viable or something that will be seeded over to those fields in the coming years?

 

[irwarrior]

There are a decent number VIR doing it in the private world, not so much in academic sites. But, more and more graduates are pursuing it. There is so much PAD out there and they need skilled operators to perform it. Vascular IR, IC and Vascular surgery included. There are several meetings that involve all of the disciplines including VIVA, AMP, ISET to name a few.

You need a clinic to see and follow these patients and an admitting service to admit these patients if they require urgent revascularization or iv antibiotics etc. You need to be comfortable with diabetes, statin use, diagnosing and managing wounds (Venous, neuropathic, ischemic, mixed) and need to go out and get referrals (podiatry, primary care, wound care nurses/centers, endocrinology, nephrology etc). If you garner this skill set including practice development techniques during residency training in my opinion no reason you can't build this rewarding aspect of interventional practice.

 

[ZJz4]

There are a decent number VIR doing it in the private world, not so much in academic sites. But, more and more graduates are pursuing it. There is so much PAD out there and they need skilled operators to perform it. Vascular IR, IC and Vascular surgery included. There are several meetings that involve all of the disciplines including VIVA, AMP, ISET to name a few.

You need a clinic to see and follow these patients and an admitting service to admit these patients if they require urgent revascularization or iv antibiotics etc. You need to be comfortable with diabetes, statin use, diagnosing and managing wounds (Venous, neuropathic, ischemic, mixed) and need to go out and get referrals (podiatry, primary care, wound care nurses/centers, endocrinology, nephrology etc). If you garner this skill set including practice development techniques during residency training in my opinion no reason you can't build this rewarding aspect of interventional practice.

Thank you for your input. Can I ask you about your thoughts on another "turf war" area? I was curious about what you think of interventional pain procedures and if they were staying with IR or being ceded to pain management?

 

[irwarrior]

There are a bunch of specialties involved in pain. Typically people do a pain fellowship from anesthesia and some from PmNR and less from VIR. They tend to see patients with pain syndromes. They diagnose and manage with pharmacologic (opiate and nonopiate medications/ gabinergic/ nsaids/tricyclics etc). They also provide injections (ESI,facet rhizotomy) and even pain pumps and spinal cord stimulators.

There are many who do spinal interventions (VIR, Neuro IR, MSK radiology, Neuroradiology, neurosurgery, Ortho, PmNR and anesthesia). These include vertebroplasty, kyphoplasty, spine jack etc.

There are VIR who also do ESI, facet rhizotomy, celiac blocks, hypogastric nerve blocs, pudendal blocks etc. The VIR also do Musculoskeletal interventions including ablation and cementoplasty with some venturing into Nails and screws. Also geniculate artery embolization is gaining popularity for osteoarthritis and even embolization of various joints. The key is to understand the clinical indications and non operative management of these conditions from an undifferentiated consult that arrives in your clinic.

Dr. Douglas Beall - Interventional Musculoskeletal Radiology, Pain Management & Sports Medicine Imaging

Dr. Douglas Beall specializes in interventional musculoskeletal radiology, pain management and sports medicine imaging.

www.drdouglasbeall.com

MSK embolization may be critical for managing pain in sports injuries

Yuji Okuno gave an update on the status of musculoskeletal embolization for pain management and sports related injuries at the GEST Symposium this year.

interventionalnews.com

 

[ZJz4]

There are a bunch of specialties involved in pain. Typically people do a pain fellowship from anesthesia and some from PmNR and less from VIR. They tend to see patients with pain syndromes. They diagnose and manage with pharmacologic (opiate and nonopiate medications/ gabinergic/ nsaids/tricyclics etc). They also provide injections (ESI,facet rhizotomy) and even pain pumps and spinal cord stimulators.

There are many who do spinal interventions (VIR, Neuro IR, MSK radiology, Neuroradiology, neurosurgery, Ortho, PmNR and anesthesia). These include vertebroplasty, kyphoplasty, spine jack etc.

There are VIR who also do ESI, facet rhizotomy, celiac blocks, hypogastric nerve blocs, pudendal blocks etc. The VIR also do Musculoskeletal interventions including ablation and cementoplasty with some venturing into Nails and screws. Also geniculate artery embolization is gaining popularity for osteoarthritis and even embolization of various joints. The key is to understand the clinical indications and non operative management of these conditions from an undifferentiated consult that arrives in your clinic.

Dr. Douglas Beall - Interventional Musculoskeletal Radiology, Pain Management & Sports Medicine Imaging

Dr. Douglas Beall specializes in interventional musculoskeletal radiology, pain management and sports medicine imaging.

www.drdouglasbeall.com

MSK embolization may be critical for managing pain in sports injuries

Yuji Okuno gave an update on the status of musculoskeletal embolization for pain management and sports related injuries at the GEST Symposium this year.

interventionalnews.com

Thank you for the information! Are pain procedures done frequently by IR or in the minority of cases they do? Can you do a pain fellowship from DR or IR if you have interest? Would you be competitive for this fellowship if most are run by anesthesia departments?

 

[irwarrior]

Pain procedures are done more at the community sites as opposed to academic sites and each place varies on who does it. You can do a pain fellowship from DR/IR. The anesthesia division may be more likely to recruit anesthesia or PmNR but DR/IR have applied and gotten in.

 

[ZJz4]

Pain procedures are done more at the community sites as opposed to academic sites and each place varies on who does it. You can do a pain fellowship from DR/IR. The anesthesia division may be more likely to recruit anesthesia or PmNR but DR/IR have applied and gotten in.

Does it have to be DR/IR or can you be just DR? Maybe a silly question

 

[irwarrior]

Does it have to be DR/IR or can you be just DR? Maybe a silly question

No, I know DR who did pain fellowship or DR who do a great deal of MSK interventions . Just harder to get into a DR group as the VIR physicians want someone in their group to cover VIR call emergencies.

 

[IRattending2021]

Hey guys,
Just wondering what the state of doing peripheral vascular disease is in IR. I know there are turf wars with vascular surgery and interventional cardiology. Is it possible to do a 100 percent PAD? Are there jobs out there where some PAD work still occurs within an IR practice.

irwarrior paint an overly optimistic picture regarding PAD sometimes.

if your interest is PAD and only PAD you are better off doing vascular surgery. VS offers the whole spectrum of treatment for PAD including surgical treatments.

PAD is lucrative but is not particularly challenging or exciting to do compared to other advanced aspect of IR.

A minority of IR physiciand have PAD in their practice. In certain competitive locations it’s essentially all gone. In some less desirable location it’s still being practiced by IR because we fill a need.

Again, if you want to do PAD only or pain only, go into vascular surgery or anesthesia. If you want the option of doing both and man

 

[ZJz4]

irwarrior paint an overly optimistic picture regarding PAD sometimes.

if your interest is PAD and only PAD you are better off doing vascular surgery. VS offers the whole spectrum of treatment for PAD including surgical treatments.

PAD is lucrative but is not particularly challenging or exciting to do compared to other advanced aspect of IR.

A minority of IR physiciand have PAD in their practice. In certain competitive locations it’s essentially all gone. In some less desirable location it’s still being practiced by IR because we fill a need.

Again, if you want to do PAD only or pain only, go into vascular surgery or anesthesia. If you want the option of doing both and man

I guess that's what I'm looking for, is the option to do both and manage my own patients. What were the end of your thoughts IRattending2021 ?

 

[IRattending2021]

I guess that's what I'm looking for, is the option to do both and manage my own patients. What were the end of your thoughts IRattending2021 ?

ah I mean to say if you want to do both, go into IR.

let’s see, there are 76 IR jobs on SIR connect right now. When I click PAD in the procedure filter, there are 8 jobs that remain, and out of that 8 probably 4 will realistically give you PAD.

trust me, go with surgery or cardiology if you want to thrive in this space.

 

[ZJz4]

ah I mean to say if you want to do both, go into IR.

let’s see, there are 76 IR jobs on SIR connect right now. When I click PAD in the procedure filter, there are 8 jobs that remain, and out of that 8 probably 4 will realistically give you PAD.

trust me, go with surgery or cardiology if you want to thrive in this space.

Thank you for your thoughts. Do you think it's possible having a practice with a good mix of both? My only concern is having done an IR rotation there seemed to be mostly lines/vascular access/biopsy with like a high end procedure like TIPs or Y90 once a week

 

[IRattending2021]

Thank you for your thoughts. Do you think it's possible having a practice with a good mix of both? My only concern is having done an IR rotation there seemed to be mostly lines/vascular access/biopsy with like a high end procedure like TIPs or Y90 once a week

if you graduate from VS, you will automatically do PAD, and can displace IRs who have 20 years of experience doing it wherever you go.

if you graduate from interventional pain, you’ll do all pain procedures and can displace IRs who have 20 years of experience doing it wherever you go.

if you do IR, you can possible do both, possible even do 2-3 cases a week of each, maybe more, but you still have to do regular IR stuff, maybe diagnostic radiology. Maybe some sort of unicorn job that irwarrior is alluded to that is available to perhaps 5-10% of practicing IRs and virtually none to a new grad.

 

[irwarrior]

Many of my VIR friends do PAD. Academics not so much as they do not compete for these referrals and are more focused on oncology , transplant interventions and trauma.

We work very similar to surgeons with busy clinics, market to our referring and have longitudinal clinic. The scope of my practice includes UFE, CLI work, PAE, some pain, DVT/PE , some oncology. Certainly, if I can do it many others certainly can as well. It takes effort to build the clinical infrastructure, clinical know how and aggressive marketing but trust me it is feasible. It is not easy but can be had.

 

[ZJz4]

Many of my VIR friends do PAD. Academics not so much as they do not compete for these referrals and are more focused on oncology , transplant interventions and trauma.

We work very similar to surgeons with busy clinics, market to our referring and have longitudinal clinic. The scope of my practice includes UFE, CLI work, PAE, some pain, DVT/PE , some oncology. Certainly, if I can do it many others certainly can as well. It takes effort to build the clinical infrastructure, clinical know how and aggressive marketing but trust me it is feasible. It is not easy but can be had.

How much of your practice is this higher end work versus the bread and butter IR procedures?

 

[IRattending2021]

How much of your practice is this higher end work versus the bread and butter IR procedures?

check out this paper published by JVIR, journal of vascular and interventional radiology.

DEFINE_ME

Vascular surgery and cardiology are the primary provider of PAD care in this country and overall the distribution remains stable. IR provide 13-15% of PAD care in the country.

Most IRs spend less than 50% of their IR time doing high end cases. If you do not enjoy doing bread and butter cases IR is not a good fit for you.

 

[ZJz4]

check out this paper published by JVIR, journal of vascular and interventional radiology.

DEFINE_ME

Vascular surgery and cardiology are the primary provider of PAD care in this country and overall the distribution remains stable. IR provide 13-15% of PAD care in the country.

Most IRs spend less than 50% of their IR time doing high end cases. If you do not enjoy doing bread and butter cases IR is not a good fit for you.

Thank you for your perspective!

 

[irwarrior]

Most weeks I am doing PAD, Cancer, UFE, ablations. Had a pedal loop reconstruction case today with antegrade stick and got a nice wound blush. My colleague did a tibial reconstruction in the other suites. Referrals were both from podiatry. So, again it is definitely feasible and VIR have the skill sets to offer this care. They just need to get trained. Encourage you to garner this training during your training and this may require you going to private practice that do it or working with vascular surgery or IC who do peripheral interventions. Very rewarding when you can provide a 2nd opinion and save a limb that otherwise would have been a BKA.

 

[irwarrior]

Most weeks I am doing PAD, dialysis work, Cancer, UFE, Prostate embolizations, Venous reconstructions, Filter retrievals, tumor ablations. Looking to increase our work in scopes and removing gallstones etc and perhaps move into thyroid ablations and Endovascular fistula creation.

Had a pedal loop reconstruction case today with antegrade stick and got a nice wound blush. My colleague did a tibial reconstruction in the other suites. Referrals were both from podiatry. So, again it is definitely feasible and VIR have the skill sets to offer this care. They just need to get trained. Encourage you to garner this training during your training and this may require you going to private practice that do it or working with vascular surgery or IC who do peripheral interventions. Very rewarding when you can provide a 2nd opinion and save a limb that otherwise would have been a BKA.

 

[ZJz4]

I strongly disagree

Not every IR job has the opportunity to do PAD, but if you want to do it there are plenty of jobs out there that offer it. I do 7-10 pad/aorta and 5-10 vein cases per week. There is a lot of vascular disease out there. I still do some oncology work, but outside of academic institutions / transplant centers it is much harder to build this practice. The 'hard' part of oncology cases is the clinical decision making, not the actual procedure. CLI cases are technically way harder to do. Pedal loop, SAFARI, DVA cases require a really strong skill-set and patience. The only other cases that provide me the same level of difficulty / excitement are PAE and the 'acute' cases (GI bleeds, TIPS, stroke, etc).

I still do a little pain work too (kypho, epidurals, celiac plexus block). There is a lot of this work out there too. If you want to take care of these patients it is fairly easy to build this practice no matter who you are.

The great part of IR is that you can do a wide variety of cases in different parts of the body. Just don't expect to be given anything. You got to work for it.

How many years have you been in practice? Are you primarily doing procedures in the hospital or are clinic model?

 

[applicant2017]

Academics not so much

But, out of curiosity, wouldn't all IR-residency programs need to have some IR PAD so they can adequately train their residents in PAD (the # of cases required per ACGME requirements), or does Vascular Surgery train the IR residents to meet that quota?

 

[IRattending2021]

But, out of curiosity, wouldn't all IR-residency programs need to have some IR PAD so they can adequately train their residents in PAD (the # of cases required per ACGME requirements), or does Vascular Surgery train the IR residents to meet that quota?

most IR programs are utilizing vascular and cardiology to provide this part for their trainee.

The ugly truth is that when you go to top institutions where IRs push the envelope, other specialist push envelop as well and in this situation it tends to mean that the other specialist claim their turf such as PAD.

You can try to go to programs where IRs own a lot of PAD but outside of historical, contractual situations, most of those programs own PAD because they have weak vascular surgery/cardiology and they tend not to be at centers where the very forefront of medicine is being pushed (think MGH or Stanford). There are exceptions of course.

Personally I think it’s silly to pursue peripheral vascular training to the detriment of one’s DR and other IR training for a very simple reason: for most IRs, you either have pad or you don’t. If you don’t (as in cards or VS have it), it can be difficult or impossible to use your pad skills. If you have it, then either your senior partner will train you or you will go to courses but nearly all IR fellowship will provide enough foundation for you to pick up PAD skills (at least above the calf). Below the calf takes more getting used to and initiative if you didn’t train with it but I don’t find it harder to acquire than say...complex hepatobiliary interventions.

 

[qxrt]

Figuring out whether an IR training program includes PAD or not is irrelevant. Your first job out of practice is far more relevant. If you do a fellowship that does PAD and end up in a practice that doesn't do PAD, then all your training in that line will be useless. Conversely, if you do absolutely no PAD work in fellowship but end up in a job that does PAD work routinely, you will eventually become more proficient at it than the person in the vice versa case.

The primary purpose of IR fellowship is to teach you the baseline skills and clinical management needed to branch out into other areas. No single fellowship will teach you everything (hence the reason that I also think that this move to a 2 year IR fellowship is detrimental to trainees, because the 2nd year of fellowship at the same institution gives much lower yield compared to practicing at a different group or as an attending).

Techniques can be learned from your colleagues once you are in practice. You will learn far more from your years as an attending than you can in 1-2 years of IR fellowship.

 

[IRattending2021]

Figuring out whether an IR training program includes PAD or not is irrelevant. Your first job out of practice is far more relevant. If you do a fellowship that does PAD and end up in a practice that doesn't do PAD, then all your training in that line will be useless. Conversely, if you do absolutely no PAD work in fellowship but end up in a job that does PAD work routinely, you will eventually become more proficient at it than the person in the vice versa case.

The primary purpose of IR fellowship is to teach you the baseline skills and clinical management needed to branch out into other areas. No single fellowship will teach you everything (hence the reason that I also think that this move to a 2 year IR fellowship is detrimental to trainees, because the 2nd year of fellowship at the same institution gives much lower yield compared to practicing at a different group or as an attending).

Techniques can be learned from your colleagues once you are in practice. You will learn far more from your years as an attending than you can in 1-2 years of IR fellowship.

100% agree. One’s IR fellowship should be chosen in order to get that perfect first IR job.