Episode 09

#StopTheChop in Peripheral Artery Disease

with Dr. Kumar Madassery and Dr. Sabeen Dhand

Dr. Sabeen Dhand and Dr. Kumar Madassery discuss interventional approaches, multidisciplinary relationships, and preferred technologies for managing and treating peripheral artery disease.

Cite this podcast: BackTable, LLC (Producer). (2017, August 16). Ep 9 - #StopTheChop [Audio podcast]. Retrieved from https://www.backtable.com/podcasts

Full Transcript Below

In this Episode

Podcast Participants

Dr. Sabeen Dhand is a practicing interventional radiologist at PIH Health in Whittier, CA.

Dr. Kumar Madassery is a practicing interventional radiologist with Rush University in Chicago.

Host Dr. Michael Barraza Jr is a practicing interventional radiologist at Radiology Alliance in Nashville.

Disclaimer: The Materials available on the BackTable Podcast are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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Full Transcript

#StopTheChop in Peripheral Artery Disease (PAD)

[Michael Barraza] 
Hello everyone, and welcome to the BackTable podcast. I'm your host today, Michael Barraza. Today I'm thrilled to welcome Sabeen Dhand and Kumar Madassery, to discuss their experiences and approach to treating peripheral arterial disease. For the listeners that missed our last episode on lung ablations, I'm fresh out of fellowship at the University of Pennsylvania and just started working with a private group in Nashville.

I really enjoyed PAD work as a fellow and hope to continue it, but nationwide exposure to these cases is pretty erratic and some places it's non existent. So a lot of new IRs are tasked with the challenge of picking it up on their own.

Sabeen and Kumar, you're both regarded as experts in the field managing PAD, and I'd just like to start by asking you both to share your story, where you are and how you got there. 

 

 

[Sabeen Dhand] 
Yeah. I'm Sabeen Dhand and I trained at Northwestern, and I did all my residency and fellowship over there, and I graduated about two years ago, and I moved back home to the West Coast in California, in Whittier, California, which is just close to Los Angeles at PIH. 

I'm glad to be regarded as an expert in PAD now, but I didn't have much PAD experience when I trained, and the group that I joined was really heavy PAD group that does about 400 legs a year.

 

When I started I had some great mentors that just taught me what to look for and how to treat, and I basically learned by fire and it's been a great experience. These days most of our patients are Rutherford five and six, just limb salvage and below-the-knee intervention, so it's quite fun, and I'm really happy to be talking on this podcast today.

 

 

[Michael Barraza] 
We're thrilled to have you. Kumar, what about you?

 

 

[Kumar Madassery] 
For me it's kind of an interesting story. I've been in Chicago my entire life. I actually was going the surgical route out of med school. I thought surgery was right for me. I did a proper internship but it just didn't click for me. 

 

In the middle of it, one of my surgical seniors who I got to know pretty well said, "Why don't you check out IR." I said, "Oh, that sounds cool. What's IR?" Then was able to go to the IR lab, met some fantastic people at that time, and luckily transitioned without missing time right into it and never looked back.

 

I've been at Rush Medical Center for surgery internship, for residency, for fellowship and as an attending now. For me it's a very different route but thank God it happened. I've been fortunate enough to see a transition or two at our institution with now a very steady and dynamic group that I think we're rapidly rising, in terms of complicated cases and success rates. To the leaders that I have there, Dr. Arslan and Dr. Turba, they helped teach me quite a bit of PAD and PLI and they're kind of innovators in the field. 

 

Very fortunate, and just love being part of the process and honored to be part of this podcast with Sabeen and you guys. So that's kind of the story.

 

 

[Sabeen Dhand] 
I was always impressed with being from Northwestern seeing what Kumar would do with these crazy cases he would present at angio club, so it was always nice to see that.

 

 

[Kumar Madassery] 
Yeah for us this is kind of nice too because Sabeen is now in La-La land over there on the west coast, but we knew each other since the AIRP days learning up in Silver Springs, Maryland, where Sabeen was the social chair for the event. From there we just kind of kept in touch and hung out. 

 

 

[Michael Barraza] 
So, Kumar, tell me about Stop the Chop.

 

 

[Kumar Madassery] 
That's funny, when you put all these social media type of tweets, especially on Twitter, I think Rob Ryu started great stuff with the filter stuff, and since we're doing so many PAD things I thought it would be interesting to come up with one. And just randomly, I always think about the guillotine when I think about amputation, because they still use it. So that's where it kind of came from, and I go, "We got to stop the guillotine" and I was talking to one of our friends and I go, "Did you know the catchphrase, it just came, the guillotine is a chop, so like, we need to stop it," and that rhymed. So that just started it, and I think-

 

 

[Michael Barraza] 
It's catchy.

 

 

[Kumar Madassery] 
It's like throwing it out there all the time.

 

 

[Michael Barraza] 
It's great, it's awesome, I love it.

 

 

[Kumar Madassery] 
It's universally applicable for every specialty that does PAD CLI's, so I think it works.

 

 

[Michael Barraza] 
It really is and just to take that a little farther, for me, coming out of training and trying to do this on my own. I've actually learned a ton of tips and techniques from the two of you and others, just through Twitter. It's been a great resource for that. It's part of how we decided to reach out to the two of you. 


But one of the things I noted, maybe about a month ago, was that you had posted something about your partnership with the podiatrists at Rush. Is that something that you guys use as part of your practice?

 

 

[Kumar Madassery] 
Yeah, I think the collaboration with podiatry is something that over the last few years has been growing leaps and bounds. Dr Arslan, our director, he's a big aortic and PAD guy, he actually brought the president of the APMA, the American Podiatry Association, to SIR a couple of years ago as a first ever joint session where we kind of talked about how important it is for IR and podiatry to work together, because we both have ultimately the same exact goal which is saving that limb. 

 

I mean, podiatrists are daily battling the non healing wounds, and we are the ones who can help them with kind of the best expertise and capabilities to get them the best help possible, so it's kind of a natural relationship that gives the patient the best options. So, we do a lot of work with podiatrists, a couple of us cover the wound care clinic with them, and then help them on all patients and kind of co-manage them. 

 

It's a beautiful relationship, and I think we try to educate and tell others to work on as well. Actually I give a talk with one of our podiatrist at our medical school because they also have one of the best podiatry schools in the country. So giving those students an understanding early on, the importance of this relationship, I think it's something we need to all extrapolate. 

 

 

[Michael Barraza] 
Yeah. Sabeen, what about you? 

 

 

[Sabeen Dhand] 
Yeah. I mean the relationship with podiatry I think is very important. It was something that was already established when I came to my group. There's a wound care center that's run by five or six podiatrists and the relationship with interventional radiology was established in endovascular care. They just get so many patients with terrible wounds and they're automatically, in addition to all their medical therapy, they automatically refer to us.

 

It's been a great resource. Most of our legs come from them. They're great people and we have a great relationship. And I think if anyone's starting to start a PAD practice, just reaching out to the community of podiatrists and showing that you're available would help you a ton. There's so much out there and so many podiatrists that don't have an endovascular specialists that can help them. It's just an unused resource. 

 

 

[Michael Barraza] 
Did the  two of you have many issues with turf battles, with either cardiology or vascular surgery, either involving the podiatrist of otherwise? 

 

 

[Kumar Madassery] 
In our platform, in our district, we have what's called interventional platform, where we have 14 rooms. The majority of it's for IR, but there's one or two for cardiac interventional, and then neurointerventional. 

 

And vascular surgery is a very great surgical specialty that we have as well. Once Arslan and Turba came a few years ago, it just demonstrated the capabilities. We started working together with vascular surgery and co-managing all the patients, and deciding together which one would be best for surgical options, which one is not. We can try it first. We're not burning any bridges, because we demonstrated that we had that capability. 

 

It's kind of a unique relationship because they trust us and we always discuss cases together. We have a weekly vascular surgery conference. In between there are some transitions that may come and go, but so far we've demonstrated our capabilities and our outcomes are very good. Working with podiatry is an added benefit. So in terms of turf war, it's not really there. Some of the other specialties are doing some work, but in the grand scheme of things, especially at CLI, we do primarily all of it. I think we keep up our outcomes and everybody's happy. 

 

 

[Michael Barraza] 
And for me, here in Nashville, it's primarily vascular surgery and so it's been a bit more of a challenge to go out and get these. And what it appears to me is that the best place for me to start, is to start below the knee, which in my experience tends to be more of the challenging cases. 

 

 

[Sabeen Dhand] 
Yeah, definitely. I see it a lot when I talk to other people about turf wars with vascular surgery, and even cardiology. And I think below the knee is definitely a place where interventional radiology can shine because I've also seen vascular surgeons just not really go below the knee. Our cardiologists just are not comfortable with it. 

 

My situation at PIH is kind of unique where we have two vascular surgeons who are a bit older and they're not interested in endovascular interventional stuff. And our cardiologists don't touch legs either. All the care goes to us. Which is unique and I hope it stays like that forever. I know that can change. But it's a good situation for me. 

 

Below the knee is where I think most interventionalists can really shine. And they are the tougher cases. If you have a good mentorship or something, someone just to teach you how to do it, you can do a lot of good care. 

 

 

[Kumar Madassery] 
Sabeen and I were actually talking with some other colleagues around the country on Twitter. When you have those battles and you feel like it's difficult to get those patients, you just have to learn how to be the collaborative one, and take on the hard cases but also try to mend a fence. Try to reach out, try to say, "Hey, we can probably work on this patient together," or send the referral when you think it's a better surgical candidate. 

 

Once you open up those doors, which is not always easy, at least you're demonstrating a better multi-disciplinary approach than just trying to do cases that feel like you're being observed. 

 

 

[Michael Barraza] 
Right. 

 

 

[Kumar Madassery] 
Whether you're cardio interventional or interventional radiology or vascular surgery, you want to develop a system in your institution that gives the patient the best outcome, not just the service line. 

 

 

[Michael Barraza] 
Absolutely. 

 

 

[Sabeen Dhand] 
Exactly. Even sometimes I'll call the vascular surgeon in the middle of the case, and have them review the films, and ask them, "Do you think this would be better for a bypass?" And more so, I kind of already know the answer, but I'm just keeping them in the loop. And I think just working collaboratively is important just to keep relationships up top, too. 

 

 

[Michael Barraza] 
Okay. I'd like to take this opportunity to switch gears for a second and focus on some technical points. For something that's complex the best way I can think to tackle this is just to ask you guys to walk me through your approach to a hypothetical patient with CLI on your table. What are some specific things to address including antegrade versus retrograde access, your go to wires and catheters, and also your algorithm crossing CTOs. 

 

 

[Sabeen Dhand] 
Okay, I'll start this one off. I had this discussion actually again, we had this little group chat going on, on Twitter with some guys who are interested in CLI. I feel like when I go to the conferences people talk about having CTAs and MRAs on all their patients, but practically speaking, most of these patients have pretty bad renal failure. And whenever we get a consult for someone with CLI, I'm thinking a couple of things. One, before I even see the patient, I'm looking at what imaging we have. And typically it tends to be either nothing, or maybe an xray of the foot and maybe a Doppler, a duplex study. I've become a huge fan of the duplex studies to learn the anatomy, what might be occluded, where the disease is, and even just looking at access. 

 

Before I see the patient I hope to have a duplex study. And already in my head I'm thinking, "Where would I access this patient?" If they're large and their body habitus doesn't allow it, I typically go retrograde up and over. But if they have a good femoral pulse when I see them, and they're not huge, or they have a flat groin, I'll prefer antegrade any day. And as long as they don't have aortoiliac disease. 

 

 

[Michael Barraza] 
And is that because of the mechanical advantage, or is it just avoiding the trouble of getting up and over? 

 

 

[Sabeen Dhand] 
No, it's a mechanical advantage for sure. It's just a straight line shot to the tibials. You really do lose a little bit with fighting the vector of the bifurcation. And especially if there's tortuosity of the iliacs, it just hurts your torque ability and everything like that. Antegrade just makes things easier. I still use exchange length wires and everything, so I'm not using shorter systems when I'm antegrade. But I think the mechanical advantage is huge. 

 

And then, the first thing I'm thinking about is access, but then I'm also, when I see the patient, I'm looking where the wound is. I think the angiosome concept … it's been evaluated in a lot of detail, and the angiosomes are the three vessels, the trifurcations of where they're supplying the foot, and there's data showing direct intervention versus indirect intervention for the angiosome concept. Both are effective, but direct is better. 

 

Practically speaking, I'm just thinking, "I want to improve any flow to the foot," whether it's indirect or direct. Before I go into my system, I guess I'll let Kumar talk about his approach before actually putting the patient on the table. 

 

 

[Kumar Madassery] 
I agree with pretty much everything you said. I think we're not a very cross-sectional imaging heavy institution when it comes to PAD CLI, unless our physical exam when we see him in clinic or in the hospital suggest that there's going to be an inflow disease at the access area. Primarily, we'll get a CTA, or maybe an MR, if there's question of weak pulses in the femoral, et cetera. Or there's been extensive aorta bifem, to get a lay of the land. I think cross-sectional comes in handy then, but we primarily rely on our non invasives, to get an idea what we're going to do. 

 

The majority of patients we’ll go up and over technique from the contralateral groin. If there's an issue, or if tortuosity we can easily go antegrade on the same side. Sometimes the antegrade I just don't like just because of the way the positioning with the sheath and the wires. Sometimes in the room it can become difficult. As long as you plan ahead it can be much easier. 

 

So, antegrade is our first approach, coming down the leg, in terms of after up and over, or same side, get our, pretty much always a six-french sheath,  and we'll go from there. But in terms of the workup, I agree with Sabeen. Earlier on we used to say, "We need to get a single inline flow," that was kind of our thing. And for us it was always trying to get the single inline to the area of the wound. But now, I think we're getting more aggressive and saying, "We need as many vessels as possible, and we want to complete that pedal arch." 

 

 

[Michael Barraza] 
Yeah, I'm glad you said actually. For me it's been a challenge identifying an appropriate endpoint for below the knee particularly. 

 

 

[Kumar Madassery] 
The need for us is about at least two vessels. If you can get one of the AT/PTs and a peroneal, great, but you want to also try and get that arch completed when you're dealing with toe wounds. We try to go for at least two nowadays, maybe three if possible. Primarily if we’re having trouble, we want to get that arch, because when you get that arch completed, you kind of increase the outflow of the other vessels. 

For us, that’s our goal. Whether or not that always happens, it might be a step by step process. You can open one or two, and see how they do in a few weeks, and then come back for the other if you can. 

 

 

[Sabeen Dhand] 
I think it's a really good question, Mike, that you bring up is what is the endpoint? And a lot of times, before the initial angiogram that we perform, I really don't know what those tibials are going to look like. It could be a complete disaster, where all of them are occluded, which happens a lot. Or sometimes there's one vessel that has a lot of disease and then, the other two are occluded, but maybe one will reconstitute distally. 

 

I think that two vessel is a great endpoint. And you have to consider time and everything, too. My techs and staff start getting pretty antsy after three and a half hours in a leg, and they're like, "what are you doing?" I'm like, "Okay, I got to stop and maybe bring the patient back for other stuff." 

 

I think the whole direct angiosome intervention is great, but I think it's hard. Sometimes there's no anterior tibial  or DP available, but if you can just establish one big inline flow, it's going to help. And maybe they won't be able to get away with a toe amputation, but they'll be able to get away with a TMA, rather than a BKA. You got to be in reason, but if you could establish a three vessel in the pedal arch, that would be awesome. You have to be reasonable on timing and everything, too. And staging is always reasonable. 

 

[As for] antegrade, I prefer ipsilateral antegrade. I'll first do my run and I'll do a whole run-off study and then determine what my intervention's going to be based on that. And I typically work with an .018 system. And that would be and .018 wire and support catheter, sometimes .014. And I'll spend a good amount of time but not too much trying to cross any occlusion that I see from the antegrade approach. 

 

But I'm pretty quick to go pedal. We can talk about pedal later, but I'll have the foot prepped and everything. And even after 5 minutes of trying antegrade, I'll go pedal. 

 

 

[Michael Barraza] 
Yeah. Now, does your approach change if we're talking above the knee versus below the knee, approaching a chronic total occlusion? Are you going to spend time trying to go subintimal or go straight to the foot? 

 

 

[Sabeen Dhand] 
It's funny. Even when I go pedal I feel like I ended up going subintimal but just in a retrograde fashion. 

[Michael Barraza] 
Okay. 

 

 

[Sabeen Dhand] 
Yeah, I'm much quicker to go pedal if it's below the knee. Above the knee, I'll try a lot more to get back in. If I end up going subintimal, into the lumen, wherever it reconstitutes. But I don't use too many re-entry devices and things like that. I'll do a SAFARI or something like that if I need to. But yeah, I definitely work more in an antegrade fashion, or do the flow of the artery, if it's above the knee disease, like SFA and pop.

 

 

[Kumar Madassery] 
Yeah, I agree. I think above the knee, if you have a CTO of the SFA, it pops open, you have a target. We'll go antegrade and re-entry wise we do use quite a bit of the Outback, which helps us re-enter quite a bit back into, normally from a subintimal plane, that's kind of been a go-to for us in the above and below, even. Just kind of proximally below the knees, to go antegrade in direction. 

 

Because coming, just like Sabeen said, from retrograde from the pedal, it is typically a lot easier to get back up because of the way the caps. We can talk about the different kind of caps you have of the CTO. But antegrade when you're in the above knee, we can majority of the time do it just in the antegrade direction. With the re-entry or whatever else you need to use. 

 

 

[Michael Barraza] 
Yeah, okay. This may be a good point to ask another question. We've got a lot of relatively new technologies in the field. Just to be up a few examples, what role if any does atherectomy, or drug-coated balloons, or protection devices play in your PAD practice? 

 

 

[Kumar Madassery] 
Yeah sure. Technology wise, we're blessed to have tons, or a lot of new technologies and equipment. However, I think the way to know what to use when is very anecdotal, it's very experienced based. 

 

 

[Sabeen Dhand] 
I agree. 

 

 

[Kumar Madassery] 
It's easy for everyone to say, "Oh, this is what I use," but then that might not be the same success someone else gets with it. And I don't think that's a fault of any, it's just what you're comfortable with. What you've learned the nuances of. 
 
For us, atherectomy wise, primarily we'll use directional or orbital. We have access to get the other types. For directional, the TurboHawk to shave plaque, we'll use that mostly in the above the knee category area. But the caveat is that we typically use the distal protection filter for that, just to be on the safe side. Fortunately, because of all these safety guides, we've had very little evidence of embolization for us, but we don't use it all the time. But we also use orbital CSI Diamondback which is kind of sanding the plaque away, which helps us to get luminal gain. 

 

There's always talk about should you plaque modify before ballooning, because ultimately most of us will decide, based on the lesion and the characteristics, are we going to just balloon this with some DCB, or are we going to stent it, depending on the patient and their ambulatory status, and all that. Atherectomy is a great tool. It's not something that we use heavily, but it is something in the arsenal that I think helps you especially for above the knee. 
 
Below the knee, drug-coated trials have been tough and haven’t done so well. But there's newer ones coming out, and there's newer devices for tacking the dissections in the tibials and all that. So there's a lot of new technologies coming out. What's going to be the best for everything, I think it's going to be operator dependent and based on experience. 

 

 

[Sabeen Dhand] 
Yeah, I think Kumar hit it on the point. Coming from a standpoint of a community hospital, and as you know if you follow me on Twitter, I always want more toys and gadgets, but unfortunately we don't have everything on the shelf. And sometimes it's a blessing in disguise because we don't have to make a decision of which one to use over the other. For atherectomy, I like it, I use the Diamondback and it's really only atherectomy we have on our shelf. We may get the laser soon. Typically I believe in remodeling the plaque. I think it gives you less dissection after you do angioplasty. And I will prefer drug eluting angioplasty if I can get away with it. 

 

Stenting tends to be something I use as a last resort. Unless the patient's older and especially if I have these kind of flow limiting dissections. But my goal is to get away, just trying to put kind of drug up there. Of course with the tibial, we don't have that yet. But once we do I will end up probably using those too, if the data supports it. 

 

 

[Michael Barraza] 
And when you stent, do you use IVUS at all? 

 

 

[Sabeen Dhand] 
Rarely. I've been using it a little bit now, because I do know I definitely think angios undersize our vessels. Even if you measure it perfectly. And sometimes I just account for that by oversizing it in my head. Sometimes it's hard, it's another step. We have to bring out the IVUS. But it is pretty useful, because there's so much stuff you see in IVUS that you don't see on angio.

 

 

[Kumar Madassery] 
I think there's a cost associate thing that many people may say, "What's the purpose?" But if you do notice, if you feel like you're getting results and follow-ups that are undersize, then I think it's something very reasonable.

 

But as a routine practice, we don't, based on angio and contralateral side, if we have images or … you kind of get an idea. But I do agree with Sabeen, you do get a ton of information but then again, you get a ton of information … 

 

 

[Sabeen Dhand] 
Is it important? You don't know. Maybe it's not even clinically relevant that there's some stenosis or residual stenosis there. The dissection you see maybe doesn't really matter, if the patient's on aspirin or Plavix. Too much information can be bad.

In addition, the other thing I believe in for below the knee is I do think drug eluting stents, the coronary stents are really useful. I've seen great results with them. In those instances when you have this nasty disease that's not resolving with angioplasty. 

 

 

[Kumar Madassery] 
Yeah, I agree. We rely on the tibial drug eluting stents quite a bit. In a lot of our CLI patients we've had great outcomes with it. I know people are questioning whether or not to use it, but sometimes you get remarkably improved flow. Sometimes we'll kiss the tibial stents too, if you have two vessels that you're preserving. It's something that if you're dealing with a lot CLI, I think it's good to have in your armamentarium.

 

 

[Sabeen Dhand] 
Exactly. Exactly. To talk about it, I'm quick to go pedal and we actually had discussion this morning about pedal access. I try to keep the access as small as possible by going bareback with my support catheter, or using the inner dilator, the micropuncture sheath. 

There is talk about doing a lot of interventions from the foot. It's coined "TAMI". But I still prefer obtaining the floss access from the pedal [approach]. And then using that, once I don't need floss anymore, I'll reverse the wire and get hemostasis at that site. That's kind of my algorithm for that. 

 

 

[Kumar Madassery] 
I agree. Sabeen and I were talking about this earlier. I think we have a similar approach. We pretty much puncture. For puncturing, ultrasound is a great tool that we can use and since we use it every day we're pretty comfortable with it. But if it’s a very calcified artery, one of my partners, Dr. Arslan, he's more of a rambo style. He likes to puncture everything under fluoro.

 

 

[Sabeen Dhand] 
Yeah. He does.

 

 

[Kumar Madassery] 
When you have a nice calcified vessel, you don't need to play with the hockey stick probe and all that. A lot of times you can stick it directly under fluoro [and] you can watch the vessel move. And for us, typically what most of us do is through the micropuncture we'll put a V-18, or Nitrex wire first, make sure it goes up, and then put the inner 3 french of the microcatheter in there, and inject a little contrast just want to prove that you're actually in the artery. Sometimes you might get fooled with the vein. 
 
And then through the inner 3, we'll put a V-18 as our primary wire to go all the way retrograde. But like Sabeen said, the majority of the time, we just keep that inner 3 french in there. That's about as big of a profile system we put in there. Once we're doing our flossing and stuff, we'll keep the inner 3 with a little flow switch. Then when we're ready to switch our direction, we put the wire across and then hemostasis takes just like a finger touch hold because it's such a small hole. 

 

In our entire experience of pedal access we've almost never used a particular sheath. Even though they do have a couple of companies, Cook and there's a slender sheath. They're small profile sheaths, but we just prefer not to make big holes down there because those are lifelines for what we're trying to keep open. 

 

Just to go back to earlier, we primarily use an 0.014” system, even in the antegrade direction, going in the tibials. Most of us use like a Quick-Cross or a SEEKER after we have our main sheath in the SFA/pop we've treated, or evaluated what the disease is up there. Now we're in the tibials. 

 

We use a SEEKER or a Quick-Cross, an 0.014” wire. Normally we start with a soft wire, something like a Hydro ST or a Command or something, and try to navigate our way. And then in the attempts, which are sometimes pedal, to go antegrade we'll switch to a heavier set wire, or a weighted tip wire, Asato, something like that, to give it a shot going antegrade. And once you're in the tibials, if that's not going, that's when we kind of get the foot going. And then everybody uses different platforms. I think if you're in the 0.018”, 0.014” platform, that's pretty much standard for everybody with the tibials. 

 

 

[Sabeen Dhand] 
Actually it's funny. A lot of people I talk to start off with an 0.014” system. I guess the way I started I like the 0.018” just because there's just more torque-ability and push-ability. I don't think it's worth going into all the different wires, because that used to really … it was overwhelming for me when I started. Because I didn't really know. Everyone that says, "This wire's good, this wire's..." - whatever you pick, you stick with it, you learn that wire, and you get really good. Mine is the V-18, but I think everyone else can use anything just as long as you remain consistent. 

 

 

[Kumar Madassery] 
Agreed. 

 

 

[Sabeen Dhand] 
I think starting off with an 0.014” is kind of nice. What I noticed, is just because then you can use the 0.014” and 0.018” balloon if you need to go to a lower profile, really in those distal tibials, if you have a lot of disease. 

 

 

[Kumar Madassery] 
I think down in the infra-ankle, I think the 0.014” helps, like you were saying. I agree. Luckily, we're fortunate now to have much smaller balloons too. And tapered balloons, and yeah, we use … sometimes you have to go down to a 1.5 when you're going around the pedal arch or down by the dorsal, and work your way up. Everybody may have a slightly different approach but for us, below the ankle, we try to get at least up to a 2 mm balloon. And then go up to about 2.5 along the tibials, and sometimes up to 3 by the TP trunk proximally.  That's kind of our expected end points on the balloon side. If we can get that caliber, that's what we want. 

 

 

[Sabeen Dhand] 
Yeah, I agree. It's exactly the numbers we use. I’m slowly trying to push it these days now, and I'm trying to go half a milliliter larger. I'm like, "Okay, maybe this whole vessel can take a 3, and maybe a 3.5 on top." And the angio looks great after. 

 

But it's still a question. What's the top number to use for me, and I'm still kind of experimenting. I think staying with 3 at the tibials, I don't see that many dissections or occlusions right after. So I think whether we're under treating a little bit on the sides, you're saving the vessel versus over treating and oversizing and then damaging the vessel. It's a balance. 

 

 

[Kumar Madassery] 
I think if you take into consideration what the vessels look like, like you're saying, I think everybody develops their own guidelines, but everybody's kind of in that range within a few millimeters. You work with the premise of the enemy of good is your motto, and you go from there. 

 

 

[Sabeen Dhand] 
Oh, I have a question, Kumar, and everyone else. Do you typically use moderate conscious sedation for your patients, or a lot of them under GA?

 

 

[Kumar Madassery] 
Majority of our antegrade procedures, if we're doing antegrade approach, are going to be moderate conscious. There's a few of them we do SAFARI with moderate conscious, if they're pretty stable. But I know that when you're dealing with a lot of the pedal ones, we're spending three, four hours, it's hard for anybody to stay still, even when they're conscious, so we'll go anesthesia, deep sedation, or sometimes general … but we don't like to do that. I know that someone talked about it, in Germany, they pretty much use local lidocaine for all their procedures, so I don't know if we just-

 

 

[Michael Barraza] 
Whoa … 

 

 

[Kumar Madassery] 
… No. Yeah. They do every single one of their procedures with local anesthetic and that's it. 

 

 

[Michael Barraza] 
Oh wow. 

 

 

[Kumar Madassery] 
No, I swear. It was amazing. I was at a PAD summit, and my jaw's dropping. I'm like, "That's incredible," … sometimes PICC line should be conscious sedation but …  

 

 

[Sabeen Dhand] 
Mike, what about you with your [practice]?

 

 

[Michael Barraza] 
We did everyone at Penn with moderate conscious sedation. I'm sure that they've done a few with general anesthesia, but not in my experience. And certainly no local anesthesia only. 

 

 

[Sabeen Dhand] 
I agree. We do most of ours with moderate conscious, but a lot of this will come up in my workup now. Because I do notice I get a little bit of better outcomes when they are under GA, just because I'm not fighting their movement and what not. I'll assess the patient when I see them. If they're an old frail lady, who sometimes surprisingly is better under conscious sedation than old frail men, but I just get an assessment.

 

If I think there's something that's just giving me one ounce, I'm a little bit quicker to GA. So I would say right now I'm performing maybe about 15% to 20% of my outpatient procedures under GA now. Which I don't know is the right thing, increasing that, am I putting him at another risk? 

 

 

[Michael Barraza] 
I think that sounds like a very reasonable number. Especially looking back to certain cases. I could very easily see myself starting to book the patients with really bad stage 4 CKD, because if anything, GA would save me a lot of contrast for the people wiggling around. 

 

 

[Sabeen Dhand] 
Yeah, yeah. Exactly, exactly. 

 

 

[Kumar Madassery] 
I think also the issue, if you try conscious sedation, which may work, it's great if it's working, then you find out the ones who can't tolerate on the table, then you got to reschedule them with anesthesia. You kind of spend extra time and another procedure, which if you think your patient population can tolerate it that’s great. I just know our patient population typically … it must be a regional thing. They just can't sit still. I don't know why.

 

 

[Sabeen Dhand] 
Us too. I don't know. It must be those calcified arteries or something, I don't know. They cannot sit still. 

 

 

[Michael Barraza] 
Classic Chicago and California. Not surprised. 

 

 

[Kumar Madassery] 
I actually have a question for Sabeen. What is your intraprocedural anticoagulation and do you have issues with Heparin versus Angiomax? Let me know what you think. 

 

 

[Sabeen Dhand] 
Surprisingly we don't really use Angiomax or anything. I was thinking about it, but we use Heparin. Typically once I get access, say I'm going up and over, I'll first access with a six french short sheath and I'll use an Omni Flush catheter and then get up and over. I'll do my whole diagnostic run and then once I switch over to my up and over sheath, that's when I end up anticoagulating the patient. And typically I used to start off a standard 5,000 unit of bolus. And now I've been just doing 100 units per kilogram. Which is now, on average, it's about 7,000 or 8,000 units to start the case. 

 

And really as the case is going, if I'm doing a lot of intervention, then I'll typically, every 45 minutes of so, bolus about 2 to 3 K. You know I want to do ACT more, and I feel like our machines are not calibrated right, because they sometimes don't respond appropriately, or maybe they're real. But I haven't done, I don't know, I kind of just do it, and I've been luckily okay. When I have done ACTs I typically try to keep it between 200 to 250. And my typical below the knee, say a pretty long case, like a three hour case, I'll probably end up doing anywhere between 12 to 16 thousand units of heparin, which is more than when I started. Last year I would say I would average about 5 thousand to max 10 thousand. So I've been more aggressive lately, and I’d be interested to know what you guys do. 

 

 

[Kumar Madassery] 
I think it's interesting. We use heparin primarily. I feel like in the community when we all talk about these things, we're seeing more and more patients that may be heparin resistant or something. When we see all these cases that they're saying they're doing a normal case, and suddenly there's thrombus that just won't kind of stop. So I don't know what's going on, but we primarily use heparin. 

 

I agree with you we typically start at 5,000. If we're letting the fellow kind of get the access and start, and we know it's a disease vessel, we'll get 5,000 after they get access, just because you know they're going to be playing around in the artery, in the aorta. 

 

 

[Michael Barraza]             
Yeah. Blame it on the fellow.

 

 

[Sabeen Dhand]
Blame it on the fellow. Totally … 

 

 

[Kumar Madassery]         
It's actually really one of the things my partners taught me, if the fellow's in there starting the angio, and you know there’s a lot of disease, just give 5,000 at the start. If we're in there from the start, then we give it after we do our sequential run, like Sabeen does. So it's very operator dependent.

 

Why did we give the Heparin first? But we typically start with 5,000. And I do agree with you, I think the weight based may be a better way to go. And we do check ACTs. It was painful the last few years because the machine would take a minute to read, but now I think we got some newer machines where they can do it on the spot. So it's kind of sped up how fast the results come.

 

 

[Sabeen Dhand]
I have the old machines then, yeah. It takes a little bit.

 

 

[Kumar Madassery]         
There's a point of care style one or something now that's available and that’s what we use. Where they can instantly, in every room, just check it for us quickly.

 

 

[Michael Barraza]             
Yeah, at Penn it would take one or two minutes, and it's just like time would stop. It's just like how it is when you're holding pressure. It's like time slows down to a halt.

 

 

[Kumar Madassery]        
Yeah. Yeah, the newer machines are pretty fast.

 

 

[Sabeen Dhand]
Maybe it's more a fact of being inpatient or a little bit of laziness that I don't do it, and I should. Because I think it would gear and titrate my heparin better. Luckily, knock on wood, I haven't seen too many thrombi forming after intervention. I've been lucky in that. It's happened once or twice, but when you go to these meetings and they talk about Angiomax, I feel like they're saying it happened 10% or 15% of the time, which I don't see that in my patient population.

 

 

[Kumar Madassery]         
Yeah, we see it every now and then rarely, but I know some people who are just showing it out there on Twitter, but again, I agree with you. I don't see it that often. But what about use of Nitro, or calcium channel blockers for atherectomy? Since you spin a lot, are you using nitro during the spins, or anything like that, or just the viper solution?

 

 

[Sabeen Dhand]
The viper slide already has about 800 micrograms. I think our standard solution is 800 micrograms of nitro in there, or 8 milligrams. So it's a big dose in the bag. After every spin, which is usually lower, or medium, I'll push the button [and] it injects more of the solution over the wire.

 

 

[Kumar Madassery]         
Correct.

[Sabeen Dhand]
And yeah, it runs it through. And I'll do that a lot but I also inject. I do inject nitro if the tibials are small. And this is not atherectomy, just past the … I do inject some nitro through my access sheath, SFA or something, and let it kind of bathe the vessel. I don't have any data or even anecdotal evidence to say that it's better than if I didn't, but it makes me feel better.

 

 

[Kumar Madassery]
Peace of mind, I agree.

 

 

[Sabeen Dhand]
So yeah, and my bolus' are usually typically 200 micrograms of nitro, something like that. And when I get pedal access I use a radial artery cocktail, I just treat it like a radial artery.

 

 

[Michael Barraza]  
Okay.

 

 

[Sabeen Dhand]
Yeah. I'll put 2.5 verapamil, 200 of nitro, and I'll even put two or three thousand units of heparin. But I’m little bit scarred. One of my first cases when I started going pedal, the vessel occluded. And ever since then I've just been really aggressive of putting whatever I can in there.

 

 

[Michael Barraza]             
Yeah, and I mean that was probably the fellows fault anyway.

 

 

[Sabeen Dhand]
What's that?

 

 

[Michael Barraza]             
That was probably the fellow's fault anyway.

 

 

[Sabeen Dhand]
Yeah, exactly, exactly. It was the tech's fault. For me, I just blame the tech.

 

 

[Kumar Madassery]         
Be careful if you blame the tech. They'll get you back. Fellows won't.

 

 

[Sabeen Dhand]
Oh, I know. They do.

 

 

[Kumar Madassery]         
Yeah, that's interesting. That's a good approach. We've never really used the cocktail from the leg, and we haven't had any complications, but that's not a bad safety guard.

 

 

[Michael Barraza]             
Yeah, and quite frankly I don't see a reason not to.

 

 

[Sabeen Dhand]
Yeah, really I just treat it like the radial artery. It's really just to keep that flow going across the inner dilator, the Quick-Cross, and yeah, I haven't had issues with hemostasis at the pedal site or anything like that. Yeah, I recommend that cocktail, but again, there's no evidence, I don't have evidence or something to back me up except that I haven't had an occlusion since using it.

 

 

[Michael Barraza]             
Great. That's enough for me. Well, I mean this is an extraordinarily large and complex topic, and so I know we're not going to cover everything. I think we've done some really great stuff here to help really anybody, particularly myself go and do this in practice. Just before we go, and one last question. I just wanted to get your input on how you recommend early career IRs like myself can approach this, all of the technological advancements and educational resources, like how do you stay on top of all this?

 

 

[Sabeen Dhand]
What you mentioned in the beginning, Mike, Twitter has been an awesome resource. You see people posting really good cases. They're not going to post bad outcomes, but you learn a lot on it. I've learned so many things, either in PAD or other spots too, that I've use in my practice now. So that's one aspect. I don't think it's everything. But it's something especially for early career IRs who are into social media or into computers, it's a fun thing too, and a networking aspect as well.

 

I think the other way I've kept up on a lot of things is just looking at cases. Whether it's my partner's cases, or if you're in a practice that isn't doing it [and] you're starting it, then just looking at other people's cases. Endovascular Today always has some really good ones. And just reading online, just seeing what people go through, then you actually really learn all these alternatives or things that you can do.

And it's always nice to have someone who knows. For me, my partners that are older than me that have been doing this, and if I have a question I go to them. But if you don't have that, if you have a friend or someone you know that does it or anyone else who's available to talk on the phone, if you have questions, that's really helpful too. I think just having a point of guidance is something. Because these vessels are, in the end, and in interventional radiology, we're used to anatomy, arteries of all different types. It's not hard, it's just something to get familiar with, and to battle the politics of it too.

 

I think with those two things, CLI is something that we can one hundred percent treat and get awesome outcomes. I know we can.

 

 

[Kumar Madassery]         
Mike, that's a great question you said, because I think I get this from a lot of guys around too. Especially with social media [being] a good platform to reach out. When you're out there and you don't have the fortunate guidance that Sabeen has or I even have with my partners who are phenomenal at this, I think a couple of things are because we're in such a virtual social community, you have access to everybody that you could reach out to, including us, which we're all still learning too as we go. Everybody's learning in this game.

 

But now you have a platform where, in the old days you had to know somebody who knew somebody, or run into them and get their number, but now you have ways to reach out. I get a lot of messages, not for any particular reason, but just questions and dialogue and it starts from, "Hey, what would you do here?", send a picture, that's what I would do, or we ask somebody else. So now you have a huge audience of experts that you can ask, far greater than us. And have direct contact to, and you can reach out to them, ask for their number. We've done that a lot. I've met a lot of people through social media.

 

But I think one other things that's very important is pick and choose certain educational conferences to go to. I go to VIVA every year. And AMP, which is in Chicago, they just finished. Those are phenomenal, phenomenal places, and you see the same people. And they're showing you live cases and new cases. And you get to interact, and you get to know people, and you see new things, you can ask them, "Hey, how do you do this, or how would I do this, or how would I do that, do you mind if contact you" - I think all of us, whether it be interventional cardiology, vascular surgery, IR, who are in the social media or in the conferences, are all people whose primarily goal is to educate and to help each other advance, for the patient. So I think you're in a great era to start out. You have a great access to people now.

 

 

[Michael Barraza]             
Absolutely and I'm really impressed and appreciative of really how quickly and enthusiastically people have gotten back to me for procedural questions like that. And that is really what we're hoping to make with BackTable is just to make it an appropriate resource, for the IRs and really for anybody in our sphere to just help answer these questions, talk about techniques, ideas, basically make it like a virtual angio club.

 

 

[Sabeen Dhand]
Yeah I like that.

 

 

[Kumar Madassery]         
You guys are doing a great job with this.

 

 

[Sabeen Dhand]
Yeah, I think it's great  what you guys are doing at BackTable because I feel like the SIR open discussion forum is also a really great resource to ask questions, but I feel it's pretty much run by the older generation. And there's a couple of egos on there, and things like that.

 

 

[Michael Barraza]             
I agree. I would like it to be something where a fellow could get on there, and ask a question he's embarrassed to ask on there. What wire do I use here? Something like that.

 

 

[Sabeen Dhand]
I feel the stuff on open discussion is like more complex or just end stage, but something that has, like Kumar said, reach out on social media and also on your platform, I think it would be great. And there's really no stupid question, especially in the early career.

 

 

[Michael Barraza]             
That makes me feel better.

 

 

[Sabeen Dhand]
For sure, I mean even for me, I think you should reach out to everybody.

 

 

[Kumar Madassery]         
Yeah.

 

 

[Michael Barraza]             
And I have. But this is the point of it. The podcast like this, the idea is education and collaboration, and we're so appreciative of the two of you, and everyone else who's been involved in these. Is there anything else that you guys think we should cover that I didn't hit today?

 

 

[Kumar Madassery]         
No…I think we're lucky to have Sabeen. I think you've got two different perspectives on here. Especially Sabeen kind of going and just self-dominating with a little bit of guidance. I mean it's incredible to watch because it's just different from where you train and what you do, and then you go out and just like you, you have to kind of develop your own game and how you do it and how you develop relationships and politics. But I think we kind of hit a lot of the bases. Talking more about how to collaborate and develop multi-disciplinary systems in your own practice with others, especially to make it less of a turf battle and more of a patient success system, is what we need to work on. And I think that's everybody's approach. How to do it is something we can all learn from and Stop the Chop has to continue.

 

 

[Sabeen Dhand]
Yeah, Stop the Chop. I didn't realize Stop the Chop rhymed and I thought it was Stop the Chomp for a little bit. He quickly corrected me on social media … the chomp is for a complex filter removal, the chop is for the white coat.

 

 

[Michael Barraza]             
That's right Feed the Chomp. Feed the Chomp.

 

 

[Sabeen Dhand]
… so funny.

 

 

[Michael Barraza]             
Well, this has been fantastic for me, as I'm sure it has for all of our listeners. I just want to thank you both for the time, for the effort, and for helping keep all of us informed.

 

 

[Kumar Madassery]         
Oh, I say thanks a lot for having a phenomenal platform, that we even have this capability to kind of just have a chat and reach out to everybody. It develops a lot of dialogue afterwards too, for everybody. Appreciate that.

 

 

[Sabeen Dhand]  
Thank you for inviting me to talk. I'm happy to talk about anything else, too.

 

 

[Kumar Madassery]         
Yeah, agreed.

 

 

[Sabeen Dhand]
I like to share my enthusiasm with the rest of the IR community and anyone else, and happy to help in anything because that's what helped me, so I want to return the favor.

 

 

[Michael Barraza]            
Thanks again, and just for all of our listeners, I'll direct you to the Apple Store for our BackTable app, and you can find us on Twitter at @_backtable. Let us know what you want to hear, and we can keep these discussions going. Thanks again everyone.

 

 

[Kumar Madassery]         
Thank you.

 

 

[Sabeen Dhand]
Thanks.

 

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