Procedures in IR

[Mo991]

Hello
I'm a radiology resident doing my training outside the US and was hoping to know how you think the future of IR may evolve.
I love the field, the procedures.. but what troubles me is the fact that if you dont own the patients, other specialties may have an advantage to do the procedures.
(Like vasc surg and pad)
How does it work in the US? And how do you think it will evolve?
Thanks in advance.

---

Members don't see this ad.

 

[NDcienporciento100]

Hello
I'm a radiology resident doing my training outside the US and was hoping to know how you think the future of IR may evolve.
I love the field, the procedures.. but what troubles me is the fact that if you dont own the patients, other specialties may have an advantage to do the procedures.
(Like vasc surg and pad)
How does it work in the US? And how do you think it will evolve?
Thanks in advance.

Where I train vascular surgery sucks at Endovascular, anything remotely difficult the patient is getting a bypass or worse an amputation. Look PAD is only one piece of what IR does IO is a huge piece which frankly IR owns, TIPS (you will never see a vascular surgeon doing these), Pain management which includes such things as Kyphoplastys, treating venous disease, if you really want you can do stroke thrombectomies, uterine fibroids, prostate artery embos and list goes on. IR has always been at the forefront of pushing what is possible endovascular, certainly not vascular surgeons. You definitely can take ownership for your patients, have them follow-up with you and manage the whole disease process in conjunction with other specialty’s.

 

[irwarrior]

Vascular surgeons , cardiologists and VIR all participate in Endovascular and peripheral care. There are solid operators in all 3 of the branches. As a VIR physician you have to get your own referrals from primary care and direct patient referrals. If you can not manage them comprehensively, you probably won't be able to sustain that practice. Agree that if you don't gather the referrals and take ownership of the patient and their medical condition , IR will not have a sustainable role in high end procedural medicine.

Many VIR physicians have now branched out and comprehensively manage the PAD Patients. You have to be comfortable evaluating and managing wounds, infection, diabetes, putting patients on statins, smoking cessation etc. You have to have admitting privileges to admit the sick CLI patient to your service. You have to have a method to follow them in your outpatient center.

In the private sector and office based labs , peripheral vascular disease is a large component of successful VIR practices. Oncology is primarily limited to HCC treatment which occurs mostly where there is liver transplant and there is less oncology being performed in the smaller hospital settings or office based labs. I perform IO, but I learned more about our role when I attended a general oncology meeting where Medical oncologist, radiation oncologists , surgeons and a handful of IR were present.

As far as oncology and IR involvement go to the ASCO meeting to get a better understanding of where IO fits in the landscape of oncology therapies.

 

[NDcienporciento100]

Vascular surgeons , cardiologists and VIR all participate in Endovascular and peripheral care. There are solid operators in all 3 of the branches. As a VIR physician you have to get your own referrals from primary care and direct patient referrals. If you can not manage them comprehensively, you probably won't be able to sustain that practice. Agree that if you don't gather the referrals and take ownership of the patient and their medical condition , IR will not have a sustainable role in high end procedural medicine.

Many VIR physicians have now branched out and comprehensively manage the PAD Patients. You have to be comfortable evaluating and managing wounds, infection, diabetes, putting patients on statins, smoking cessation etc. You have to have admitting privileges to admit the sick CLI patient to your service. You have to have a method to follow them in your outpatient center.

In the private sector and office based labs , peripheral vascular disease is a large component of successful VIR practices. Oncology is primarily limited to HCC treatment which occurs mostly where there is liver transplant and there is less oncology being performed in the smaller hospital settings or office based labs. I perform IO, but I learned more about our role when I attended a general oncology meeting where Medical oncologist, radiation oncologists , surgeons and a handful of IR were present.

As far as oncology and IR involvement go to the ASCO meeting to get a better understanding of where IO fits in the landscape of oncology therapies.

IR plays a huge role in RCC and even AML’s.

 

[irwarrior]

There is no RCT data for T1a lesions comparing partial nephrectomy to ablative therapy to active surveillance. This makes it challenging to offer ablative therapy as first line therapy, though I personally believe if a trial done using renal nephrometry it may show equivalence of OS.

 

[NDcienporciento100]

There is no RCT data for T1a lesions comparing partial nephrectomy to ablative therapy to active surveillance. This makes it challenging to offer ablative therapy as first line therapy, though I personally believe if a trial done using renal nephrometry it may show equivalence of OS.

Yeah I read that line in Kandarpa as well..
If you look at the data in the study I’m posting you will see that local recurrence is 2.6% for partial nephrectomy and 4.6% for croablation, the morbidly of partial nephrectomy is high even in a good surgeons hands. I will take that 2% difference any day and that is why you are seeing cryo done more and more for these tumors. A head to head study as a gold standard I don’t think we will ever see because the urologist don’t want to take that risk.

 

[NDcienporciento100]

Excise, ablate or observe: the small renal mass dilemma--a meta-analysis and review - PubMed

Nephron sparing surgery, ablation and surveillance are viable strategies for small renal masses based on short-term and intermediate term oncological outcomes. However, a significant selection bias exists in the application of these techniques. While long-term data have demonstrated durable...

www.ncbi.nlm.nih.gov

 

[irwarrior]

I would look at the recently presented Ischemia trial . Again, need to have quality data or at least a solid prospectively collected registry to improve justification for wide utilization of a procedure. I do perform renal ablation, but make certain patients know the current gold standard. Again, if you look at pure volumes PAD is 8 to 10 million patients, HCC is around 20,000 and RCC is around 70,000 .

VIR was invented by Dotter performing an endovascular intervention in an 82 yo patient with PAD/CLI and so it is important for VIR training programs to provide that aspect of training. Bottom line in order to be a successful VIR outside of academic university based practices you have to learn how to compete and garner your own referrals.

 

[NDcienporciento100]

I would look at the recently presented Ischemia trial . Again, need to have quality data or at least a solid prospectively collected registry to improve justification for wide utilization of a procedure. I do perform renal ablation, but make certain patients know the current gold standard. Again, if you look at pure volumes PAD is 8 to 10 million patients, HCC is around 20,000 and RCC is around 70,000 .

VIR was invented by Dotter performing an endovascular intervention in an 82 yo patient with PAD/CLI and so it is important for VIR training programs to provide that aspect of training. Bottom line in order to be a successful VIR outside of academic university based practices you have to learn how to compete and garner your own referrals.

I hear you and I will look up that study. I agree 100% PAD training needs to be adequate and frankly it’s just not at a lot of big name institutions. I see old vascular surgeons that completely ignore TASK Criteria for PAD just because they don’t have the skill set to perform high end endovascular interventions. We should be trying to fill that need.

 

[NDcienporciento100]

I would look at the recently presented Ischemia trial . Again, need to have quality data or at least a solid prospectively collected registry to improve justification for wide utilization of a procedure. I do perform renal ablation, but make certain patients know the current gold standard. Again, if you look at pure volumes PAD is 8 to 10 million patients, HCC is around 20,000 and RCC is around 70,000 .

VIR was invented by Dotter performing an endovascular intervention in an 82 yo patient with PAD/CLI and so it is important for VIR training programs to provide that aspect of training. Bottom line in order to be a successful VIR outside of academic university based practices you have to learn how to compete and garner your own referrals.

Can you touch on how you build your referral base for PAD?

 

[irwarrior]

Give talks to primary care , nephrology, endocrinology, podiatrists and wound care teams. Look at every patient with diabetes that we are consulted on and look at their feet. Review vascular imaging. Do a lot of clinic with non operative management of PAD including exercise regimens, DM management, smoking counseling , anti hypertensives (ACE I) and high intensity statin therapy. Follow them longitudinally in clinic for life. Being very available to my patients and referring. There is a bit of controversy now about TASC II as it is felt to be outdated in the modern era. Look at BASIL and now the BEST CLI trial and BASIL III are ongoing.

Many very advanced endovascular operators out there including in interventional radiology (John Rundback, Bill Julien, Warren Swee, Robert Beasley, Bulent Arslan, Rob Lookstein, Miami Cardiac and Vascular Institute, Sabeen Dhand, Mike Watts etc). These operators get direct referrals and provide an Endovascular first approach. The problem is that most of them left the confines of academic medicine and are practicing in independent VIR groups.

Your goal is to get as many primary care and podiatry referrals as feasible (that builds sustainability) . Specialty referrals are not a good long term strategy.

 

[NDcienporciento100]

Give talks to primary care , nephrology, endocrinology, podiatrists and wound care teams. Look at every patient with diabetes that we are consulted on and look at their feet. Review vascular imaging. Do a lot of clinic with non operative management of PAD including exercise regimens, DM management, smoking counseling , anti hypertensives (ACE I) and high intensity statin therapy. Follow them longitudinally in clinic for life. Being very available to my patients and referring. There is a bit of controversy now about TASC II as it is felt to be outdated in the modern era. Look at BASIL and now the BEST CLI trial and BASIL III are ongoing.

Many very advanced endovascular operators out there including in interventional radiology (John Rundback, Bill Julien, Warren Swee, Robert Beasley, Bulent Arslan, Rob Lookstein, Miami Cardiac and Vascular Institute, Sabeen Dhand, Mike Watts etc). These operators get direct referrals and provide an Endovascular first approach. The problem is that most of them left the confines of academic medicine and are practicing in independent VIR groups.

Your goal is to get as many primary care and podiatry referrals as feasible (that builds sustainability) . Specialty referrals are not a good long term strategy.

That’s a group Titans, having personally done a rotation with one of them I can attest that everything you just said is true. Also interesting fact when I did that rotation with that person I never saw a lesion that he could not cross via endovascular approach and that is certainly not true or even close to true across all operators.

 

[irwarrior]

I think that many VIR do have the technical skill set to provide such a service, but some may need to expand on their clinical skill set and infrastructure to provide these services in a comprehensive fashion.

 

[NDcienporciento100]

I think that many VIR do have the technical skill set to provide such a service, but some may need to expand on their clinical skill set and infrastructure to provide these services in a comprehensive fashion.

I’m just curious are you using CTO crossing devices frequently in the tx of chronic total occlusions, if so what devices do you feel work the best and why? What circumstances are you using them?

 

[irwarrior]

If in SFA/pop will use outback/pioneer to reenter if I am in subintimal space and can not get back into true lumen easily. Pioneer is IVUS guided . Both are 6 French systems. In the tibial, I will tend to use SAFARI, CART, reverse CART etc.

 

[NDcienporciento100]

If in SFA/pop will use outback/pioneer to reenter if I am in subintimal space and can not get back into true lumen easily. Pioneer is IVUS guided . Both are 6 French systems. In the tibial, I will tend to use SAFARI, CART, reverse CART etc.

Do you ever use them in the femoral or Iliac’s? Why/why not?

 

[irwarrior]

By, SFA I meant superficial femoral artery. Can use in iliac when subintimal and want to get back. Though in Iliacs I try to stay in true lumen as much as feasible in the proximal common iliac artery and the common femoral artery . If going subintimal in aorta-iliac space I tend to use covered stents (balloon expandable in common iliac artery and self expanding in external iliac artery).

 

[NDcienporciento100]

By, SFA I meant superficial femoral artery. Can use in iliac when subintimal and want to get back. Though in Iliacs I try to stay in true lumen as much as feasible in the proximal common iliac artery and the common femoral artery . If going subintimal in aorta-iliac space I tend to use covered stents (balloon expandable in common iliac artery and self expanding in external iliac artery).

By femoral I meant common femoral. Thanks for your insight.

 

[Mo991]

Thank you guys for all your replies. It comfirmed what i had in mind. I guess we have to be more agressive and more available to patients to defend our territory.
I think all will be fine.
Thanks again!

 

[NDcienporciento100]

By, SFA I meant superficial femoral artery. Can use in iliac when subintimal and want to get back. Though in Iliacs I try to stay in true lumen as much as feasible in the proximal common iliac artery and the common femoral artery . If going subintimal in aorta-iliac space I tend to use covered stents (balloon expandable in common iliac artery and self expanding in external iliac artery).

Do you do EVAR’s? If so do you do them with vascular surgery supporting?

 

[Kuratz]

@irwarrior
Also curious about EVAR. Scrubbed a handful on a vascular surgery rotation recently and would love to do these in practice, if feasible. Also saw a couple of physician-modified supra-renal and even supra-celiac grafts... those are gnarly.

If trained on EVAR in residency could one reasonably build a practice that does some?

 

[irwarrior]

There are several VIR physicians as well as interventional cardiologists who perform EVAR/TEVAR/FEVAR. Most do it jointly with cardiac surgery/vascular surgery. But, others do it independently as well. This can be done purely percutaneous. With the advancements in endograft technology, ie lower profile systems (reconstrainable systems). Fenestrated/branch/pmeg take a much more advanced technical skillset and is typically done at higher volume centers. In these more difficult cases there is an opportunity to independently perform or collaborate with the other endovascular teams (VS, IC etc).

Endografting has become more and more available and reproducible even in the smaller community hospitals. The key is to identify the aneurysms at a smaller size 3.5 to 4 cm and then set them up in a follow up clinic with follow up US/CT etc. Having knowledge of the natural history of this disease (growth rates, rupture rates, when to get follow up ). Putting them on statins and BP control and DM controls are keys to managing these patients. Good luck.

 

[deleted950463]

Honestly if you are super into EVARs and PAD you are better off going into vascular surgery.

Now if you like imaging and are content doing both high end and low end nonvascular cases IR is good for you.

 

[NDcienporciento100]

Honestly if you are super into EVARs and PAD you are better off going into vascular surgery.

Now if you like imaging and are content doing both high end and low end nonvascular cases IR is good for you.

Nahh, VS does not do Y90, TIPS, kyphoplastys, stroke thrombectome’s, tumor ablations. Do you know what VS does in between there EVAR’s???? Toe amps and wound debridements, sound like fun to you it sure does not to me! Flip side IR’s do ct guided drains/biopsy’s, central access catheters, u/s guided biopsy in between our high end procedures. I’ll take that over some gangrenous toe.

 

[irwarrior]

Some VIR are providing wound care and some basic debridements on their patient's wounds and is an important part of theirnpractice . Some are getting wound care certified and are even medical directors of wound care centers and is an important source of referrals for developing a PAD practice.

I mainly chose VIR because I enjoyed minimally invasive procedure and did not enjoy open surgery as much mostly due to its more morbid nature and longer recovery time . I also love the scope of our practice (fibroids, BPH, oncology, hepatobiliary, portal hypertension, PE/DVT, IVC filters).

There are 3 groups now providing endovascular care and that includes vascular surgery, cardiology and VIR and there is tremendous overlap. The weakness of VIR has historically been there lack of clinical training and clinical infrastructure, but luckily this is steadily changing in training programs and in the practices.

 

[NDcienporciento100]

Some VIR are providing wound care and some basic debridements on their patient's wounds and is an important part of theirnpractice . Some are getting wound care certified and are even medical directors of wound care centers and is an important source of referrals for developing a PAD practice.

I mainly chose VIR because I enjoyed minimally invasive procedure and did not enjoy open surgery as much mostly due to its more morbid nature and longer recovery time . I also love the scope of our practice (fibroids, BPH, oncology, hepatobiliary, portal hypertension, PE/DVT, IVC filters).

There are 3 groups now providing endovascular care and that includes vascular surgery, cardiology and VIR and there is tremendous overlap. The weakness of VIR has historically been there lack of clinical training and clinical infrastructure, but luckily this is steadily changing in training programs and in the practices.

I hear you and agree with your mentality. My point was simply that VS is not all that.

Back to the discussion, do you feel that a vascular surgeon should be present for every EVAR/TEVAR? What is the General consensus on this?

 

[deleted950463]

Some VIR are providing wound care and some basic debridements on their patient's wounds and is an important part of theirnpractice . Some are getting wound care certified and are even medical directors of wound care centers and is an important source of referrals for developing a PAD practice.

I mainly chose VIR because I enjoyed minimally invasive procedure and did not enjoy open surgery as much mostly due to its more morbid nature and longer recovery time . I also love the scope of our practice (fibroids, BPH, oncology, hepatobiliary, portal hypertension, PE/DVT, IVC filters).

There are 3 groups now providing endovascular care and that includes vascular surgery, cardiology and VIR and there is tremendous overlap. The weakness of VIR has historically been there lack of clinical training and clinical infrastructure, but luckily this is steadily changing in training programs and in the practices.

it’s exceedingly rarefor IRs in a big city to practice PAD or EVAR.Nearly unheard of outside of select centers like Rush, baptist or maybe Oregon. All the academic IRs I am familiar with are doing oncology, vascular access, biopsy,drains, the occasional stenting and aneurysm coiling, trauma, etc.

Honestly, if a med student really enjoy vascular procedures like PAD and aortic work, it’s unimaginably easier for them to do it through vascular surgery. Although that route will preclude them from oncology, trauma and women’s health procedures.

 

[Kuratz]

?? A huge chunk of PAD is done in my prelim community program by IR (who are not aggressive at all). At my med school program IR does quite a bit of PAD; and at my future residency program they do the majority of the PAD and split aortic work. All three in large metros. Maybe my N is too small but I’ve yet to come across an IR set-up where they didn’t do PAD but actively want to. I believe the aortic part but PAD is so incredibly common that I have a hard time believing it’s hard to get cases for those who are out looking to build it up

 

[nimbus]

All EVAR/TEVAR are done by VIR at my hospital with groin access by CT surg or vascular...large metro/coastal/west coast/L1 trauma

 

[irwarrior]

There are many VIR in the private arena doing EVAR/TEVAR. The majority are co-scrubbing with Vascular or Cardiac surgery, but there are some VIR and IC who are performing these procedures independently. This is similar to what is currently happening with structural heart procedures including TAVR. The majority are being performed in a percutaneous fashion without surgical cutdown. The key technical components are getting your large vessel access down with percutaneous closure devices. For a straight forward EVAR procedure, it has become so streamlined it is nearly becoming an outpatient procedure.

 

[NDcienporciento100]

it’s exceedingly rarefor IRs in a big city to practice PAD or EVAR.Nearly unheard of outside of select centers like Rush, baptist or maybe Oregon. All the academic IRs I am familiar with are doing oncology, vascular access, biopsy,drains, the occasional stenting and aneurysm coiling, trauma, etc.

Honestly, if a med student really enjoy vascular procedures like PAD and aortic work, it’s unimaginably easier for them to do it through vascular surgery. Although that route will preclude them from oncology, trauma and women’s health procedures.

PAD is done commonly by IR, yes in mega academic centers where IRs do 2-3 y90 mappings a day or even more high end exotic procedures the IRs don’t Seek out PAD in the centers because they are busy doing other thing (sucks for there trainees). Aorta cases are becoming more rare to be done by IRs but my question is should vascular or cardiac surgery be present for complications and to answer this question one most know how common it is to have a complication that results in the need for surgery?

The IR program that does more Aorta’s than probably anywhere else in the country is University of Illinois Peoria- from what I understand IR owns all the Aorta’s. Will someone from this program comment on how this dynamic works between IR and vascular surgery for theses cases?

 

[Smoking Jay Cutler]

In Peoria, a vascular surgeon is available in the control room and rarely utilized.

Curious if anyone has heard of or seen VIR doing back table PMEG FEVAR without vascular surgery involved?

In "community" setting all 3 specialties provide vascular care cardiology>VIR>VS. This is largely based on number of total# of providers.

In academics VS>>VIR and Cards.

Some exceptions are historically strong VIR programs that have held on to some of the work, but now cooperate with VS for the time being (UVA, MCW, Mich), and the anomalous programs with good VIR but a relative vacuum of endovascular trained vascular surgeons(Peoria, Rush). In time, every good hospital will continue to be staffed with vascular surgeons and all new VS are trained extensively in endovascular technique, so those ones that have the turf now will have a tougher time going forward.

As for the academic centers where there is "co-scrubbing" there's no guarantee that the vascular surgeon will continue to request the services of VIR for those types of cases, and while not all vascular cases require open surgery or at least an open access, some do, and so VIR cannot be a 100% one stop vascular shop, but the VS can, and that along with the long standing clinical practice they have is a distinct advantage.

The work is available out in private practice/community hospital setting so getting as much exposure as you can in residency is a good idea.

If you want to do it in academics you probably can but you have to recruit for the work constantly and do all the things IRWarrior says.

 

[NDcienporciento100]

In Peoria, a vascular surgeon is available in the control room and rarely utilized.

Curious if anyone has heard of or seen VIR doing back table PMEG FEVAR without vascular surgery involved?

In "community" setting all 3 specialties provide vascular care cardiology>VIR>VS. This is largely based on number of total# of providers.

In academics VS>>VIR and Cards.

Some exceptions are historically strong VIR programs that have held on to some of the work, but now cooperate with VS for the time being (UVA, MCW, Mich), and the anomalous programs with good VIR but a relative vacuum of endovascular trained vascular surgeons(Peoria, Rush). In time, every good hospital will continue to be staffed with vascular surgeons and all new VS are trained extensively in endovascular technique, so those ones that have the turf now will have a tougher time going forward.

As for the academic centers where there is "co-scrubbing" there's no guarantee that the vascular surgeon will continue to request the services of VIR for those types of cases, and while not all vascular cases require open surgery or at least an open access, some do, and so VIR cannot be a 100% one stop vascular shop, but the VS can, and that along with the long standing clinical practice they have is a distinct advantage.

The work is available out in private practice/community hospital setting so getting as much exposure as you can in residency is a good idea.

If you want to do it in academics you probably can but you have to recruit for the work constantly and do all the things IRWarrior says.

Great post!

 

[deleted745951]

Nahh, VS does not do Y90, TIPS, kyphoplastys, stroke thrombectome’s, tumor ablations. Do you know what VS does in between there EVAR’s???? Toe amps and wound debridements, sound like fun to you it sure does not to me! Flip side IR’s do ct guided drains/biopsy’s, central access catheters, u/s guided biopsy in between our high end procedures. I’ll take that over some gangrenous toe.

Lol, does sound fun to me. We also deal with aortic ruptures/transections/dissections/aneurysms with open, endo and hybrid solutions, operate all over the body and serve as the firemen in the OR putting out various bleeds. It's hard to have a boring day when you especially want one. Current Vascular training encompasses tons of endo throughout all 5 years. There is plenty of patients to go around and collaboration is key, we can learn so much from each other.

There is room for those who are dedicated to providing good care to vascular patients in my humble opinion.

 

[NDcienporciento100]

Lol, does sound fun to me. We also deal with aortic ruptures/transections/dissections/aneurysms with open, endo and hybrid solutions, operate all over the body and serve as the firemen in the OR putting out various bleeds. It's hard to have a boring day when you especially want one. Current Vascular training encompasses tons of endo throughout all 5 years. There is plenty of patients to go around and collaboration is key, we can learn so much from each other.

There is room for those who are dedicated to providing good care to vascular patients in my humble opinion.

People like different things. Open procedures never really appealed to me. I agree collaboration is key.

 

[Tiger100]

At the level of community, the practice of IR is very different than academics.
For example, still in a lot of community hospitals IR does PAD. But in academics due to local politics and referral pattern, IR may not do PAD.

Different people like different things. I know IRs who are happy doing diagnostics and some needle work on the side and I Know IRs who want to do 100% IR and they do.

In the current environment of US healthcare where more and more PAs and NPs are practicing as PCPs and the healthcare becomes more and more referral-based from PCPs, it is not hard for IR to get referral from them. But it has its own hassles.

Everything is a trade-off. You want to practice high end IR, you can but you have to give up something. On the other hand, you want to practice DR or do bread and butter procedures, you can nut you have to give up something else.

 

[NDcienporciento100]

At the level of community, the practice of IR is very different than academics.
For example, still in a lot of community hospitals IR does PAD. But in academics due to local politics and referral pattern, IR may not do PAD.

Different people like different things. I know IRs who are happy doing diagnostics and some needle work on the side and I Know IRs who want to do 100% IR and they do.

In the current environment of US healthcare where more and more PAs and NPs are practicing as PCPs and the healthcare becomes more and more referral-based from PCPs, it is not hard for IR to get referral from them. But it has its own hassles.

Everything is a trade-off. You want to practice high end IR, you can but you have to give up something. On the other hand, you want to practice DR or do bread and butter procedures, you can nut you have to give up something else.

All true.