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For patients who have exhausted conservative management but aren’t ready for the knife, shoulder embolization offers a minimally invasive intermediary option. In this episode of BackTable MSK, host Kavi Krishnasamy welcomes Dr. Yan Epelboym, an interventional radiologist trailblazing the MSK IR space. The doctors discuss the rapid development of musculoskeletal embolization applications with an emphasis on shoulder embolization. --- Get the BackTable apphttps://www.backtable.com/app --- Timestamps 00:00 - Introduction 01:42 - Dr. Yan Epelboym’s Origin Story in MSK03:02 - Building Referral Networks06:50 - Details on Clinic Workflow 10:08 - The Run Down on Shoulder Embolization Treatment Targets22:09 - Current Insights on Shoulder OA Embolization27:56 - Shoulder Embolization Setup and Access Choice34:28 - Shoulder Embolization Strategy and Endpoints36:38 - Post-Procedure Pain Control and Activity Limitations42:26 - Shoulder Surgery Status-Post Embolization44:17 - Discussing Existing Research Data on Shoulder Embolization01:00:32 - Key Shoulder Arterial Anatomy and Variants01:04:27 - Shoulder OA Case Discussion01:09:08 - Final Thoughts --- More about this episode The episode begins with Dr. Epelboym outlining how his interest in musculoskeletal embolization developed after exposure to Okuno’s early work, along with practical considerations for establishing referral pathways for these procedures. He also provides updates on the ongoing ELECTRC clinical trial at Brigham and Women’s Hospital evaluating shoulder embolization. The discussion then turns to outcome measurement, including pain scoring systems and approaches to standardized clinical follow-up. The conversation concludes with a review of the existing literature on adhesive capsulitis, including a meta-analysis demonstrating improvements in pain and range of motion with predominantly minor adverse events, while emphasizing the ongoing need for randomized trials and greater procedural standardization. --- Resources Dr. Yan Epelboym, MD, MPHhttps://www.linkedin.com/in/yan-epelboym-4a84991b/ Embolization Treatment of Chronic Refractory Shoulder Tendinopathy (ELECTRC)https://clinicaltrials.gov/study/NCT06095050 --- BackTable Vascular & Interventional (VI) is the go-to podcast for interventional radiologists, vascular surgeons, and interventional cardiologists. Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty. ► https://www.backtable.com/app

Your guide to better planning, access, and sampling. In this episode of the BackTable Podcast, we revisit every IR’s favorite procedure with Dr. Zoe Miller, Assistant Professor of Clinical Interventional Radiology and Associate Program Director at the University of Miami. Together with host Dr. Ally Baheti, Dr. Miller walks through a methodical approach to adrenal vein sampling to help you overcome common procedural challenges and reliably point your patients towards the proper therapies. --- Get the BackTable apphttps://www.backtable.com/app --- Timestamps 00:00 - Introduction02:26 - Preprocedural Workup Basics06:21 - Planning CT Utility and Protocol08:46 - Access Strategy10:36 - Procedure Day Preparation12:12 - Catheters and Side Holes15:44 - Adrenal Vein Selection Techniques18:50 - Troubleshooting Right Adrenal Vein Selection24:34 - Sample Acquisition Coordination27:38 - Aspiration Flow Optimization29:34 - Preventing Reintervention and Vessel Damage34:06 - Post-Procedure Follow-Up35:46 - AVS in Cushing Syndrome39:38 - Mentorship and Sourcing Knowledge39:25 - Closing Remarks --- More about this episode The physicians outline the key aspects of the pre-procedural workup, from setting expectations with patients to the utility of CT in operative planning. Dr. Miller provides a detailed exploration of strategies and tools for achieving safe access of the adrenal veins, particularly on the right side, and obtaining adequate samples. She emphasizes the importance of collaboration, both within the IR team and with other specialists, to ensure maximal procedural yield and to ultimately provide patients with valuable guidance in their treatment. The episode concludes with a discussion of the challenges presented by co-secreting tumors in hormone level assessment as well as the value of seeking out data and the experiences of mentors in developing your own best practices as an IR. --- BackTable Vascular & Interventional (VI) is the go-to podcast for interventional radiologists, vascular surgeons, and interventional cardiologists. Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty. ► https://www.backtable.com/app

What do the 2026 coding changes mean for the financial viability of IVL in the OBL? In this episode of the BackTable Podcast, host Dr. Ally Baheti sits down with Dr. Nicholas Petruzzi to break down how intravascular lithotripsy fits into OBL workflows, and how upcoming lower-extremity revascularization coding updates may impact outpatient economics. --- Get the BackTable apphttps://www.backtable.com/app --- This podcast is supported by Shockwave Medicalhttps://shockwavemedical.com/ --- Timestamps 00:00 - Introduction02:35 - 2026 Coding Changes Overview05:18 - Where IVL Codes Apply06:35 - Iliac Reimbursement Impact08:50 - IVL vs. Atherectomy11:54 - BTK Reality and Future14:44 - When IVL Is Not Ideal16:05 - Catheters and Setup Basics17:50 - Sizing and Technique Tips23:01 - Javelin Forward Emitter26:25 - Wrap Up --- More about this episode The episode starts with a walkthrough of the key 2026 coding updates, including territory-based coding, new IVL add-on codes for aorto-iliac and fem-pop segments, the introduction of below-the-ankle codes, and the shift toward ‘simple’ versus ‘complex’ designations. From there, the conversation focuses on where IVL makes sense clinically and operationally, particularly as an alternative or complement to atherectomy, with discussion of low embolization risk seen in the DISRUPT PAD trial and the potential to avoid distal protection in select cases. Dr. Petruzzi shares how he approaches IVL in the lab, including catheter selection, sizing, low-pressure technique, and repositioning strategies. They also touch on workflow considerations in the OBL and preview newer concepts like the forward-emitting Javelin device for heavily calcified lesions and situations where device exchange is limited. --- Resources DISRUPT PAD III RCThttps://shockwavemedical.com/en-eu/clinical-evidence/pad-iii-rct/ --- BackTable Vascular & Interventional (VI) is the go-to podcast for interventional radiologists, vascular surgeons, and interventional cardiologists. Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty. ► https://www.backtable.com/app

How do you differentiate between iliac vein compression, gonadal vein reflux, and Nutcracker syndrome in patients with chronic pelvic pain? Dr. Deepak Sudheendra, director and interventional radiologist at 360 Vascular Institute, joins host Dr. Ally Baheti to share his approach to evaluating and managing pelvic venous disease (PVD). --- Get the BackTable app https://www.backtable.com/app --- Timestamps 00:00 - Introduction01:43 - PVD Demand at Penn06:42 - Approach & Algorithm12:08 - Variation in Iliac Vein Compression15:58 - Treatment Approaches19:20 - Important Ultrasounds22:15 - Intra-Procedural Workflow31:14 - Iliac Vein Stenting and Avoiding Complications36:31 - Gonadal Vein Embolization and Working with Patients42:20 - Iliac Vein Embolization and Post-Op Care --- More about this episode Dr. Sudheendra's clinical algorithm for diagnosing PVD emphasizes the importance of patient history and specific symptoms over isolated cross-sectional imaging findings. He shares his approach to the pre-procedural workup, highlighting the necessity of a standing venous reflux ultrasound to rule out superficial venous insufficiency. Beyond the technical steps, Dr. Sudheendra emphasizes the "soft skills" of managing a venous practice: counseling patients on conservative treatments like pelvic floor therapy, explicitly setting expectations about postoperative back pain, and avoiding unnecessary bilateral stents in young women. Dr. Sudheendra details his intra-procedural workflow for diagnosing and treating PVD, providing a look into his unique preference for right internal jugular (IJ) vein access to perform venograms and place iliac vein stents. He explains how this approach allows him to consistently check inflow from the lower extremities, and shares his techniques for performing gonadal vein embolizations and accurately sizing iliac vein stents to prevent lifelong complications. --- BackTable Vascular & Interventional (VI) is the go-to podcast for interventional radiologists, vascular surgeons, and interventional cardiologists. Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty. ► https://www.backtable.com/app

Clean lumen club! This week, BackTable meets you at the carotid bifurcation to discuss all things carotid angioplasty and stenting. Interventional neuroradiologist and cerebrovascular surgeon Dr. Adnan Siddiqui, Vice Chairman of the University of Buffalo’s Department of Neurosurgery, joins host Dr. Sameh Sayfo to discuss the evolution and current state of carotid disease treatment. --- Get the BackTable app https://www.backtable.com/app --- This podcast is supported by Terumohttps://www.terumois.com/ --- Timestamps 00:00 - Introduction02:48 - From Aspirin to Endarterectomy03:47 - Rise of Carotid Stenting06:46 - CREST-2 and CMS Coverage09:57 - Management of Severe Asymptomatic Carotid Stenosis 15:35 - New Stent Designs Explained17:56 - Five Tips for New Operators20:08 - Case Selection Algorithm22:04 - Learning Curve and Mentorship28:27 - What’s Next: IVL and Outpatient31:24 - Managing Complications Safely35:05 - Closing and Credits --- More about this episode Dr. Siddiqui details the history of carotid stenosis treatment, charting its path and progression from medical therapy to endarterectomy and modern stenting approaches. He includes how recent trial data and updated CMS reimbursements have influenced practice and generated recent developments such as second generation stent technology. Dr. Siddiqui shares perspectives on patient selection, operator learning curve, complication preparedness, and the importance of structured training and proctoring as technology and techniques continue to improve. The physicians close by overviewing future directions for the carotid space such as IVL and how to approach management of procedural complications. --- Resources Dr. Adnan Siddiqui provider profilehttps://www.ubns.com/physicians/dr-adnan-h-siddiqui/ Carotid Endarterectomy for Asymptomatic Carotid Stenosis: Asymptomatic Carotid Surgery Trial (ACAS)https://www.ahajournals.org/doi/10.1161/01.str.0000141706.50170.a7 Asymptomatic Carotid Surgery Trial (ACST-2)https://www.acc.org/latest-in-cardiology/clinical-trials/2021/08/25/23/24/acst2 Protected Carotid-Artery Stenting versus Endarterectomy in High-Risk Patients (SAPPHIRE trial)https://www.nejm.org/doi/full/10.1056/NEJMoa040127 Medical Management and Revascularization for Asymptomatic Carotid Stenosis (CREST-2 trial) https://www.nejm.org/doi/full/10.1056/NEJMoa2508800 The North American Symptomatic Carotid Endarterectomy Trial (NASCET trial)https://www.ahajournals.org/doi/10.1161/01.str.30.9.1751

As interventional radiology cements its position as a primary clinical responder for acute arterial hemorrhage, what if you could achieve rapid and durable arterial occlusion with a single, highly deliverable device? In this episode of the BackTable Podcast, Dr. Alex Villalobos (UNC), Dr. Nima Kokabi (UNC), and Dr. Brian Funaki (UChicago) join host Dr. Kavi Krishnasamy to explore the shifting paradigms of arterial embolization in a case-based discussion highlighting modern vascular plug technologies.--- Get the BackTable app https://www.backtable.com/app --- This podcast is supported by Okami Medicalhttps://okamimedical.com/ --- Timestamps 00:00 - Introduction01:24 - Trauma Activation Workflow06:42 - Empiric Arterial Embolization Indications10:40 - Embolic Agent Preferences and Value Analysis17:18 - Embolics on the Shelf19:32 - LOBO Plug Use Cases20:58 - Case 1: Abdominal Wall Hematoma23:54 - LOBO Advantages, Cost, and Microcatheter Compatibility26:33 - Alternative Access Approaches30:31 - LOBO Sizing and Trackability35:26 - Pusher Wire Features38:20 - Delivery Catheter Requirements43:41 - Case 2: Retroperitoneal Bleed45:15 - LOBO Deployment Technique49:41 - Case 3: Splenic Trauma53:51 - Occlusion Time and Adjunct Embolics57:07 - Closing Remarks --- More about this episode The panel begins by discussing the range of embolic options and combinations at their disposal, sharing their preferences and treatment algorithms in various clinical scenarios. In particular, they emphasize the need for tools that provide immediate, predictable occlusion without the technical burden and cost of needing to deploy multiple embolic agents. The physicians go on to focus on Okami Medical’s LOBO vascular plug as a primary solution for rapid vessel occlusion, highlighting the micro-pore architecture and unique deliverability through microcatheters that make it advantageous for precise positioning and reliable embolization. Exploring its use in cases including rectus sheath hematomas, retroperitoneal bleeding, and splenic trauma, the physicians detail the technical nuances of sizing and positioning the LOBO as well as the long-term advantages of its artifact-free design. This episode ultimately underscores a growing preference for streamlined arterial embolization workflows that prioritize rapid stasis and clinical predictability while leveraging the strengths of a multimodal embolic toolkit.

From consult to catheter, success in prostate artery embolization is shaped by a series of decisions that directly impact patient outcomes. In the third installment of our 2026 PAE University series, Dr. Chris Beck is joined again by Dr. Art Rastinehad and Dr. Don Garbett to discuss patient selection, procedural strategies, and practical case-based learnings in prostate artery embolization. --- Get the BackTable apphttps://www.backtable.com/app --- This podcast is supported by an educational grant from Guerbet. --- Timestamps 00:00 - Introduction03:33 - Typical Referrals and Patient Workup06:08 - Prostate Sizes and Bladder Necks12:33 - Radial Versus Femoral Access16:38 - Ipsilateral Crossing Techniques17:02 - Preferred Microcatheters20:32 - Troubleshooting Techniques with Microwires22:35 - Intra-arterial Medications and Checkpoints26:01 - Protecting Penile Collaterals29:47 - Evolution of PAE Technique32:20 - Liquid Embolics and Dilution Strategies37:48 - Bead Sizing Considerations39:59 - Managing Symptoms Post-PAE48:33 - Repeat PAE Procedures52:49 - Managing No-Flow After Injection57:06 - Case Studies --- More about this episode The discussion begins with consultation frameworks, focusing on imaging modalities and symptom scoring systems used to determine candidacy for PAE. Scenarios in which PAE may be less suitable, such as patients with high bladder neck anatomy, are also addressed alongside alternative management considerations. The conversation then transitions to procedural planning, including arterial access (radial versus femoral), workflow efficiencies to reduce operator fatigue, and preferred device selection such as microcatheters, microwires, and adjunctive vasodilators.Technical challenges encountered during PAE are explored in detail, including management of collateral vessels and avoidance of non-target embolization through techniques such as coil protection and flow modulation. The role of liquid embolics is also discussed, with emphasis on dilution strategies that vary based on operator technique. Post-procedural care is then reviewed, including assessment of symptom response, expectations for clinical outcomes, and criteria for repeat embolization in select patients. The episode concludes with three case studies highlighting procedural decision-making in complex scenarios, emphasizing recognition of anatomic variants and strategies to address intra-procedural challenges. --- BackTable Vascular & Interventional (VI) is the go-to podcast for interventional radiologists, vascular surgeons, and interventional cardiologists. Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty. ► https://www.backtable.com/app

Patients and IRs alike dread the persistent cycles of malfunction and repeated procedures that often accompany biliary drains. What can you do to keep patients off the doorstep of reintervention? In this episode of the BackTable Podcast, Dr. Ahsun Riaz of Northwestern Medicine joins host Dr. Michael Barraza to walk through strategies for preventing and managing complications of percutaneous biliary drain placement. --- Get the BackTable app https://www.backtable.com/app --- Timestamps 00:00 - Introduction01:51 - Complication Rates and Associated Factors06:09 - PTC in Non-Dilated Biliary Systems11:00 - Techniques for Access and Drain Placement15:10 - Drain Flushing, Capping, and Ideal Positioning17:48 - External versus Internal-External Biliary Drains20:42 - Managing Pericatheter Leakage23:01 - Life Expectancy and Stenting Malignant Strictures26:32 - Tract Maturation and Minimizing Access Sites28:56 - Addressing Unresolving Hyperbilirubinemia34:52 - Managing Bloody Drain Output38:12 - Approach to Dislodged Drains39:40 - Drain-Associated Pain and Exchange Timing42:49 - Strategy for Benign Biliary Strictures45:18 - Final Thoughts and Closing Remarks --- More about this episode The discussion begins with a look at the data on biliary drain-related adverse events, emphasizing the need to bring down the high rates of complications that may take a toll on patients' quality of life. Dr. Riaz stresses the importance of employing techniques at initial drain placement, such as placing left-sided drains where appropriate and minimizing biliary pressure buildup, to reduce the starting risk of malfunction. The physicians go on to share their algorithms for approaching various scenarios, from pericatheter leakage and drain dislodgement to unresolving hyperbilirubinemia, pointing out the factors and observations that should influence treatment approaches during planning and intraprocedurally. Finally, the physicians address the evolving landscape of long-term biliary management, assessing potential drainage strategies as survival rates improve in hepatobiliary malignancies, and underscore the critical importance of collaboration with gastroenterologists and surgeons to ensure cohesive, goals-of-care-centered management. --- Resources Adverse Events After Percutaneous Transhepatic Biliary Drainage: A 10-Year Retrospective Analysishttps://doi.org/10.1016/j.jvir.2024.12.022

Radial roots, peripheral reach! Radial to peripheral (R2P) access is the focus of this week’s episode with interventional cardiologist Dr. Shailendra Singh (Pennsylvania’s Lehigh Valley Heart and Vascular Institute) and dual hosts Hady Lichaa and Sameh Sayfo. The conversation focuses on key techniques, pre-procedure planning and imaging, and ideal case selection for those new to the R2P approach. --- Get the BackTable apphttps://www.backtable.com/app --- This podcast is supported by Terumo https://www.terumois.com/ --- Timestamps 00:00 - Introduction04:42 - Radial-to-Peripheral: Right vs Left Radial10:18 - Ultrasound and Pedal Access Applications17:10 - Ideal Cases When Starting Radial to Peripheral25:59 - Impactful Radial Success Stories29:38 - Managing Radial Spasm 35:22 - Left Radial Workflow42:00 - Shelf Setup Essentials48:43 - Renal Mesenteric Access55:37 - Safe Sheath Removal01:01:10 - Training and Courses01:04:48 - Closing Thoughts --- More about this episode Dr. Singh shares how he began incorporating radial-to-peripheral procedures into his practice after fellowship and how his experience with radial coronary access translated naturally to peripheral interventions. The group reviews access strategy, including right versus left radial selection, along with techniques for preventing and managing radial spasm. They also touch on staff workflow and training when introducing R2P into the lab. The episode closes with practical insights on case selection for operators new to the approach, the role of pedal access in selected CTO cases, and strategies for safe sheath removal and hemostasis. --- Resources Dr. Shailendra Singh’s Provider Profile https://www.lvhn.org/doctors/shailendra-singh Dr. Sameh Sayfo’s Provider Profilehttps://www.bswhealth.com/physician/sameh-sayf Dr. Hady Lichaa’s Provider Profilehttps://healthcare.ascension.org/find-care/provider/1336267533/hady-lichaa

With the single-stick technique proving to be an effective addition to the venous line placement toolkit, what is stopping IRs from venturing beyond the traditional dual-incision approach? In this episode of the BackTable Podcast, pediatric interventional radiologist Dr. Kevin Wong of USA Health joins host Dr. Ally Baheti to review the single-stick technique for central venous access, a method widely utilized in pediatric practice. --- Get the BackTable app https://www.backtable.com/app --- Timestamps 00:00 - Introduction01:35 - Origins of Single-Stick Access03:10 - Setup and Bending the Needle07:17 - Tunneling to the IJ10:06 - Line Positioning and Measurement14:45 - Wire Handling Considerations18:55 - Clinical Advantages of Single-Stick Access21:27 - Femoral Single-Stick Tips23:41 - Common Mistakes and Pitfalls27:39 - Needle-Free Lidocaine Administration30:48 - Closing Remarks --- More about this episode Delving into the origins, technical nuances, and clinical advantages, the physicians explore how the single-stick technique can reduce the risk of infection and minimize interference with other lines and tubing to improve patient care. The discussion provides a detailed technical breakdown of the procedure, offering a masterclass on navigating the curves up the neck as well as the equipment selection and sizing necessary to facilitate the process. With the aid of visual slides and demonstrations, Dr. Wong steps us through the specifics of bending the access needle, maneuvering tools to adapt to anatomical configurations, and handling ultrasound movement to confirm and maintain a safe trajectory throughout the procedure. The conversation emphasizes the tactile “feel” and attention to forces acting on the wire that are required to appropriately position the catheter.Recognizing the logistical constraints that make it challenging for attendings to regularly adopt alternative procedural techniques, this episode serves as an accessible primer for clinicians looking to broaden their options for venous access with this effective, patient-centric technique.

The advent of newer thrombectomy devices has turned what were once hours-long surgical cutdowns into endovascular cases that last under an hour. In this episode of BackTable, host Dr. Sabeen Dhand is joined by Dr. Shang Loh from the University of Pennsylvania and Dr. Khanjan Nagarsheth from the University of Maryland to discuss the evolution of arterial thrombectomy devices and modern techniques for acute arterial occlusions. --- This podcast is supported by: Inari Medicalhttps://www.inarimedical.com/artix-system --- SYNPOSIS The episode highlights major technological advancements over the past decade, including the development of mechanical and computer-assisted thrombectomy systems. The physicians review key features of newer devices, such as the ability to combine aspiration with stent retrievers, the use of PTFE baskets to reduce distal embolization, and the advantage of maintaining wire access throughout the case. They share strategies for managing specific cases, including acute femoral-popliteal occlusions with distal reconstitution, intraoperative ischemic pain due to flow arrest, trauma-related thrombosis, and cases complicated by extensive calcification and chronic vascular disease. As vascular surgeons, they also discuss the ongoing role of open approaches, outlining when surgical cutdown is indicated and where they prefer endovascular first. The conversation further explores challenges such as acute limb ischemia, stent thrombosis, and visceral artery thrombosis, emphasizing the importance of staying current with rapidly evolving technologies to improve procedural efficiency and patient outcomes. --- TIMESTAMPS 00:00 - Introduction02:04 - Evolution of Arterial Thrombosis Treatment04:11 - New Devices and Techniques10:42 - Case Studies and Practical Applications24:26 - Techniques and Devices for Thrombectomy25:33 - Managing Flow and Patient Safety27:25 - Surgical vs. Endovascular Approaches29:25 - Dealing with Complications and Failures37:50 - Visceral Thrombosis and Advanced Techniques41:09 - Future of Thrombectomy Devices44:27 - Closing Remarks

Chronic limb-threatening ischemia (CLTI) represents the most advanced stage of peripheral artery disease. While many patients can be treated with endovascular or surgical revascularization, a subset of individuals remain ‘no-option’ candidates when conventional therapies fail or distal targets are absent. In this episode of BackTable, host Dr. Ally Baheti speaks with Dr. Mary Costantino, interventional radiologist at Advanced Vascular Centers, and Jill Sommerset, vascular technologist and Director of Clinical Education and Training at Aveera Medical, about the emerging role of spinal cord stimulation (SCS) as a potential therapy for patients with no-option CLTI. --- SYNPOSIS This episode explores where spinal cord stimulation may fit within the treatment landscape for advanced CLTI, particularly for patients who are not candidates for revascularization or deep venous arterialization (DVA). Dr. Costantino describes how interest in the therapy developed through multidisciplinary collaboration and early physiologic observations using pedal acceleration time (PAT) measured with duplex ultrasound alongside angiography. A representative case highlights immediate, setting-dependent improvements in PAT following stimulation, and the group reviews early trends from a small patient cohort suggesting improved distal perfusion in individuals with severe infrapopliteal disease. The conversation also addresses practical barriers to adoption, including site-of-service and reimbursement challenges and the difficulty of implanting permanent stimulators in patients with active wounds. Jill Sommerset adds perspective from the vascular lab, discussing ultrasound-based methods to quantify physiologic changes after DVA and how similar perfusion metrics may help evaluate spinal cord stimulation. The episode concludes with a discussion of the potential role of neuromodulation in this population and the need for larger datasets to better define its clinical impact. --- TIMESTAMPS00:00 - Introduction02:02 - Why CLTI Needs Options06:25 - First No Option Case11:06 - Trial Turns Flow On14:38 - Timing and Reimbursement19:59 - Early Results and Adoption22:45 - How Spinal Cord Stimulation Might Improve Flow26:46 - Patient Selection and Access30:24 - Treatment Algorithm and Timing32:37 - Quality of Life and Mobility37:57 - Implant Delays and Coordination39:41 - Data --- RESOURCES Paper on Maturation after DVAhttps://www.sciencedirect.com/science/article/pii/S1078588426000523

Below-the-knee (BTK) arterial disease remains one of the more challenging areas in vascular care, particularly in patients with chronic limb-threatening ischemia (CLTI), where heavy calcification complicates endovascular treatment. As new calcium-modifying technologies emerge, an important question remains: what evidence supports their use in BTK interventions? In this episode of BackTable Vascular & Interventional, host Dr. Sabeen Dhand speaks with vascular surgeon Dr. Paul Foley of Doylestown Health about the Disrupt BTK II clinical trial from Shockwave Medical, which evaluates the performance of peripheral intravascular lithotripsy (IVL) in heavily calcified BTK disease. --- This podcast is supported by: Shockwave Medicalhttps://shockwavemedical.com/ --- SYNPOSIS Dr. Foley begins by outlining his training and the evolution of his vascular surgery practice, setting the stage for a broader discussion on how BTK interventions have changed over the past decade. The conversation explores shifts in access strategies, procedural approaches, and the unique characteristics of calcification encountered in CLTI. Because BTK calcium differs from calcification seen elsewhere in the peripheral vasculature, imaging and device selection play a particularly important role when planning IVL-based therapies. Dr. Foley reviews the design and outcomes of the Disrupt BTK II trial, where devices such as the Shockwave M5+ and S4 catheters were used to modify calcified plaque, demonstrating encouraging safety and performance signals. The discussion then turns to emerging technologies, including Shockwave’s Javelin catheter, designed to deliver focused pressure waves to fracture dense calcium within peripheral arteries. Dr. Foley describes how the device fits into BTK workflows, including technique considerations and its use alongside adjunctive therapies such as balloon angioplasty. The episode also addresses the ongoing skepticism surrounding IVL in BTK disease, emphasizing the need for careful patient selection, procedural precision, and continued multidisciplinary collaboration as the field works to refine treatment strategies and improve outcomes for patients with peripheral artery disease (PAD). --- TIMESTAMPS 00:00 - Introduction08:20 - Evolution of Below-the-Knee Treatments11:10 - Differences in BTK Calcification13:13 - Imaging and Technology in BTK Interventions15:18 - Disrupt BTK II Trial Data and Results23:17 - Introduction to the Javelin Device26:39 - Technique Considerations with Javelin28:36 - Comparing Javelin and E831:17 - Future Directions for Lithotripsy Technology35:30 - Skepticism Around IVL in BTK Disease38:47 - Final Thoughts --- RESOURCES Disrupt BTK II Trialhttps://www.jvascsurg.org/article/S0741-5214(24)02063-9/fulltext

When standard-of-care checkpoint blockade fails in metastatic melanoma, how can oncologists and interventional radiologists join forces to turn around patient outcomes? In this episode of the BackTable Podcast, medical oncologist Dr. Jennifer McQuade and interventional radiologist Dr. Rahul Sheth join host Dr. Tyler Sandow to discuss the growing evidence for intratumoral oncolytics as a therapeutic strategy for frontline immunotherapy-refractory melanoma and the interdisciplinary work that is required for successful implementation in practice. --- SYNPOSIS The physicians review how engineered viral vectors, particularly RP1, complement checkpoint blockade through direct tumor lysis and immune activation, and summarize the IGNYTE trial data supporting their use in patients with metastatic melanoma refractory to anti-PD-1 and anti-CTLA-4 agents. The discussion then shifts to practical administration, highlighting the central role of interventional radiology in delivering these therapies to visceral and deep-seated lesions under image guidance. The doctors go on to address the nuances of patient and lesion selection, injection technique, and response assessment, including the importance of recognizing pseudo-progression. They place particular emphasis on the need for multidisciplinary collaboration and stakeholder buy-in efforts on the part of IRs seeking to integrate intratumoral oncolytic injections into their scope of practice. The episode concludes with a forward-looking discussion on the potential for expansion of oncolytic platforms into other solid tumors, underscoring this field as a growing, IR-forward frontier in cancer treatment. --- TIMESTAMPS 00:00 - Introduction02:28 - Immunotherapy Basics06:51 - How Oncolytic Viruses Work11:01 - IGNYTE Trials and Why IR Matters18:14 - T-VEC vs RP1 Indications and Logistics21:57 - Physician Communication and Multidisciplinary Treatment23:06 - RP1 Protocol and Administration Techniques30:28 - RP1 Safety Profile32:46 - Follow-Up Imaging and Response Assessment35:44 - Future Applications Beyond Melanoma41:42 - Final Thoughts and Closing Remarks --- RESOURCESWong MK, et al. RP1 Combined With Nivolumab in Advance Anti-PD-1-Failed Melanoma (IGNYTE). J Clin Oncol. 2025;43(33):3589-3599.https://doi.org/10.1200/jco-25-01346 IGNYTE-3 Trialhttps://clinicaltrials.gov/study/NCT06264180

With data increasingly positioning thermal ablation as a viable alternative to surgery for select liver metastases, the demands on the interventional oncologist have never been higher. Mastering the nuances of patient selection and precise margin assessment is now essential for ensuring effective disease control locally. In this episode of the BackTable Podcast, interventional radiologist Dr. Jonas Redmond of UC San Diego Health joins host Dr. Sabeen Dhand to discuss the current state of microwave ablation (MWA) in the management of oligometastatic liver disease, focusing on tumor assessment, preprocedural planning, and the integration of local and systemic therapies. --- This podcast is supported by: Varian IntelliBlatehttps://www.varian.com/products/interventional-solutions/microwave-ablation-solutions --- SYNPOSIS The conversation delves into the complexities of timing systemic versus local ablative therapies and explores questions surrounding adequate treatment margins. Dr. Redmond goes on to emphasize the need for operators to approach procedures with a high level of adaptability, advocating for interdisciplinary preprocedural planning and thoughtful modality selection. Exploring the complications that could arise from injury to adjacent viscera, the physicians speak to the critical importance of rigorous intraprocedural reassessment and discuss how modern software and robotics are transforming procedural precision and safety. Framing these MWA pearls within the context of recent clinical trials like COLLISION and ACCLAIM, the episode underscores the transition of interventional oncology from providing palliative services to increasingly curative solutions that may offer better prospects for patients with metastatic disease. --- TIMESTAMPS 00:00 - Introduction04:30 - Role of Local Therapy in Systemic Disease09:49 - Patient Selection and Treatment Modalities13:15 - Challenging Lesion Characteristics and Locations19:56 - Y-90 Radioembolization versus Microwave Ablation23:04 - Intraoperative Ablation and Combining Locoregional Modalities29:36 - Complications of Microwave Ablation in the Liver36:43 - Future of Ablation and Liver Metastases Treatment39:25 - Final Thoughts and Closing Remarks --- RESOURCES UC San Diego Health. Cryoablation and Arterial Infusion of SD-101 in Combination with Durvalumab and Tremelimumab.https://clinicaltrials.ucsd.edu/trial/NCT06710223 COLLISION trialhttps://clinicaltrials.gov/study/NCT03088150 ACCLAIM trialhttps://clinicaltrials.gov/study/NCT05265169