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Podcast Transcript: Treating Above the Knee Calcium

with Dr. Bryan Fisher and Dr. Sabeen Dhand

CLI fighters Dr. Bryan Fisher and Dr. Sabeen Dhand discuss their approach to treating calcified arteries above the knee, including looking at newer technologies and choosing the appropriate device to effect real durable change to the calcified wall. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Risk Factors for Above Knee Calcification

(2) Differentiating Between Intima and Media on IVUS

(3) Approach to Intimal and Medial Calcifications

(4) Crossing Severely Stenotic Lesions

(5) Devices for Calcified Intimal Lesions

(6) Algorithm for Shockwave Lithotripsy Treatment

(7) Using Specialty Balloons for Balloon Escalation

(8) Indications for Intravascular Lithotripsy

(9) Open Bypass vs Endovascular Approach

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[Dr. Sabeen Dhand]:
I’m Sabeen Dhand, an IR in LA, and I'm so happy to welcome the infamous and famous vascular surgeon, Dr. Bryan Fisher, from the surgical clinic in Nashville. Bryan, welcome.

[Dr. Bryan Fisher]:
Thank you so much, it's always an honor to be here. This is round number two of I hope many visits to one of the best podcasts in its category. This is always a great time and I'm honored to be here.

[Dr. Sabeen Dhand]:
Great having you back on this show. I mean, last time we talked about intravascular ultrasound/pad. And we're definitely going to touch a lot back on that because today is going to be about treating calcific lesions, whether cyanotic or occlusive in the above the knee. Speaking about that, what factors of patients that you meet in your workup, what kind of tells you that you're going to be dealing with calcium?

(1) Risk Factors for Above Knee Calcification

[Dr. Bryan Fisher]:
Sure. So there are several risk factors, for the most part, that we can expect that there's going to be calcified disease. The first thing that comes to mind the most is our diabetic patients. They tend to have a pretty significant tibial disease, often calcified, oftentimes a medial calcium, which can be a little more difficult. Then the next category is end stage renal disease. And then my female smokers tend to have quite a bit of calcium, especially in the iliac vessels, which can be treacherous as you know.

[Dr. Sabeen Dhand]:
I mean, yeah. What is that about the smoking? I mean, it has a predisposition to kind of above the knee. It's kind of weird. And then you're saying females in iliacs too.

[Dr. Bryan Fisher]:
Yeah. So for women, not that I don't discourage all my patients to find, I always tell them to find another vice when they present to me for vascular disease. But, in our female patients, their vessels are already smaller. And so you combine then iliac calcified disease and they tend to go downhill a little bit quicker. So I’m a little more aggressive in talking to them about things like smoking cessation, because again, they start off with smaller luminal size anyway. So they there's less of a tolerance for disease, especially heavily calcified after atherosclerotic.

[Dr. Sabeen Dhand]:
It makes sense. And then what about noninvasive imaging? Is there anything you prefer that really gives you an accurate sense of your calcium or is it really just until you put them on the table?

[Dr. Bryan Fisher]:
No, no, that's a great question. CT scans do a great job in showing calcified disease. And when they're windowed correctly. Again, I've been blessed to have worked with some really talented radiologists interventional radiologists, and during my entire career. And so one of the things I remember during my training, one thing we always said was you need to window this thing like radiologists. And that was a sticking point. We weren't as good, but that was the model, because you guys of course do it the best.

[Dr. Sabeen Dhand]:
Click it and go to the right, the upper right. There you go, window it down right.

[Dr. Bryan Fisher]:
That's so true. But yeah, once you can window them up, it tends to overemphasize or overestimate the amount of calcium present. However, I like to use multiple imaging modalities, extravascular ultrasound works outstanding at identifying calcium. Now shadowing makes it difficult to really understand what's going on beneath those areas. However, you can get an idea of when it's there. And then finally, intravascular ultrasound does a really good job.

(2) Differentiating Between Intima and Media on IVUS

[Dr. Sabeen Dhand]:
Yeah, we're going to touch on that real soon. I mean you brought up a good point though, as far as overestimating the calcium and I think people should be aware about that and then the CT. Even if you window it down, like a radiologist, there's going to be these blooming artifacts. And so it's really hard to really know what you're seeing I feel until once you put the balloon on and actually get into the vessel. Like put your patients on the fluoroscopy table and you mentioned intravascular ultrasound. Right? And it can really tell you between the two great intimal and medial classifications.

How do you differentiate between the two on IVUS. Tell us what the difference is.

[Dr. Bryan Fisher]:
Yeah. So again, just being able to identify from an anatomical standpoint, what you typically will see in the intima and then that medial stripe. It becomes pretty apparent when the medial stripe is calcified, it tends to have that white appearance. It tends to be a little thinner. And it appears diseased, but it's almost like a perfect ring around there. So in that area where the intima tends to be that whiter appearance, you get the darker media. When that media has that calcified portion, it typically stands out quite a bit.

[Dr. Sabeen Dhand]:
I see. And then does that change the way how you approach a lesion? We know that you are a big fan of intravascular ultrasound when you're doing these cases. So are you actually looking at the location of the calcium, and then treating based on that?

[Dr. Bryan Fisher]:
You have to in my opinion. When it comes to doing definitive treatment of these patients and what you see, it's important to understand what's there and what the pathology is that you're treating. And understanding that if you have medial calcium, the ability to one: deliver drug through into the media is going to be a little more difficult. It makes it more challenging. Atherectomy may or may not have the same effects because you're dealing with that deeper layer. And the truth is though there are some companies that tout some interesting things about being able to treat medial calcium. We know that based on post damaging, it's an extremely difficult area to treat. And so that's why some emerging technology has really been nice and being able to address this.

(3) Approach to Intimal and Medial Calcifications

[Dr. Sabeen Dhand]:
Awesome. Well, let's talk about it. So, you have a case, you have a patient and we'll start off with something like a severely stenotic lesion, in the distal SFA pop that area. That, that adductor canal, you just see both intimal and medial calcifications, they are on IVUS. What is your approach to treating that?

[Dr. Bryan Fisher]:
That's a great question. So my approach is one: that the first thing I'm looking at is that we've established there's intimal and medial calcium. We've got a chance to both treat at the superficial and the inner layer. And then we have to be able to address that, that middle layer as well in order to change the compliance of the vessel. Some way or another, you have to be able to modify that plaque, if you will.

So there are several options that are available. There are some really good atherectomy devices that can address the intimal calcium quite well. But the question is once you get to that medial layer and once you've done some sort of debulking, how can you change the compliance of the vessel by addressing that medial layer? And that can be through balloon angioplasty. And I think we're going to touch on a little bit later, but balloon lithotripsy works outstanding and is clinically proven on multiple levels to be able to address that medial layer and change that compliance in the vessel.

So that's kind of my approach is that I address where the calcium is. I want to know vessel diameter, and then also the lesion length. Where am I going to land? If I ended up having to do scaffolding, or if I'm doing whatever my definitive treatment is with this drug coated balloon angioplasty or scaffolding or stinting, being able to go from pseudo normal vessel to normal vessel.

[Dr. Sabeen Dhand]:
Got it. Yeah, that's very important. You want to go from basically normal to normal as best as to healthy as you can.

[Dr. Bryan Fisher]:
Absolutely

(4) Crossing Severely Stenotic Lesions

[Dr. Sabeen Dhand]:
Okay. Let's check back just a little bit. What is your technique to cross a severely stenotic lesion? Do you use 035 system and cross it again? We're talking about above the knee, so I know everything's different. With someone who has a really nice tibial runoff and really bad distal fem-pop disease, what is your approach and technique to cross? And then all the steps before an IVUS?

[Dr. Bryan Fisher]:
Okay. So, typically I'll start with an up and over sheet. I like to have a good backbone to be able to get up and over and to help guide any kind of treatment whether it's wires or catheters. So having a sheet present in having close to the lesion is obviously very important. Then I've learned very well from my cardiology colleagues about wire escalation. So typically once I get to the lesion, we'll start off with something 035 and see what I’m exactly dealing with. That proximal cap, if it's a ton of chronic total occlusion, the challenges of getting through that are obviously apparent. So we want to classify that cap and see whether or not we'll be able to get through it in an integrated fashion, or if there's a retrograde option to be able to get through the disease process.

My colleagues, Jihad and Fati, have really pioneered understanding what caps look like and how we can address those. And so I've really tried to model that and has been extremely successful in doing so and being able to cross these types of lesions. Depending on the level of calcium you have to make a decision. Are you going to try and stay true lumen? Or are you going to go into the subintimal space? I often say that the mode of success and the guys up in Michigan is that they were able to really establish being true lumen based on extravascular ultrasound and then able to apply their treatment. I would add that if you're dealing with very heavily calcified disease, sometimes being in that subintimal space is easier to navigate and you can get the same amount or similar luminal gain by being able to approach it that way.

So then again, wire escalation. So I usually start with a good workhorse wire. I'll try and cross with an 014 and a crossing catheter. My catheter of choice Is a NaviCross catheter. I have no conflicts, don't work with Terumo in a consulting fashion at all. However, I've said this before, that the catheter itself has no rivals from the taper standpoint, from his trackability. And it's your ability to push through these lesions in the least traumatic fashion. There's really no other catheter on the market that I've found that's being able to do so with quite as much ease. In addition, you can make it into a triaxial system with the…

[Dr. Sabeen Dhand]:
Just going to ask you that. Do you do it normally, or do you just go straight with 014 or you do co-ax? What do you do most of the time?

[Dr. Bryan Fisher]:
First of all, I'm very price conscious. So I have a dual practice, both being in the hospital and the OBL setting. And I try to be conscious in both settings on what I'm spending and what can I do from the most cost-efficient standpoint while still being able to achieve success. That triaxial system can be really important. However, I'll often just switch, I'll go either 014 workhorse or 018 workhorse wire. And most of the time I'm able to get through those lesions without too much difficulty. If I run into problems, then I typically will go to a more weighted wire with a heavy gram tip and try and work my way through in that manner with the idea that for the most part I want to try and stay true lumen during my course.

There's some other things you can do. I think that the advanced operators can describe when you start turning wires backwards and doing those kinds of things, which again, I would not recommend for the novice interventionalist. However, for those that are experts that I've had the privilege of working with and observing, those are real options and being able to get through these types of lesions. So then in progressing along once I've done my wire escalation strategy, and once I'm able to get through the lesion, which, by the time you add retrograde access, I can get through about 95% of those lesions. Then it's time to switch to an 014 or 018 system, and really start to understand what's going on with that vessel architecture with intravascular ultrasound.

[Dr. Sabeen Dhand]:
Are you normally using an 014 IVUS? Or are you using 018 or it just depends on what your wire is? I've heard different things about what's better and not. We personally use 014 IVUS in our practice.

[Dr. Bryan Fisher]:
Yeah. No, that's a great point. The 014 imaging is much better than the 018 system. Now I understand that there is an 018 system that's come out that's since been introduced to the market that offers some better resolution. I tend to lean towards the 014 system especially in the case where I've gone retrograde from the tibials, I can have a 4-French sheath. Then if I've got single wire control, I can do what I like to refer as the Edward technique, where I have an IVUS catheter coming from below, and I can do my definitive treatment and do diagnostic work from above. Therefore I'm saving a little bit of time in doing the case.

(5) Devices for Calcified Intimal Lesions

[Dr. Sabeen Dhand]:
Very cool. I like it. Okay. So now you cross and I use IVUS and we've kind of talked about atherectomy for intimal calcifications. Is there any kind of specific device or type of device that you like for a calcified intimal lesion?

[Dr. Bryan Fisher]:
That's a great question. For a really heavily calcified disease where I can't get devices to track through, so we often run into the problem with getting a balloon or some sort of definitive treatment through the lesion because of that heavily calcified disease. There are a couple of devices that I like to use. Orbital atherectomy works well in this case in that you can kind of create that bird hole through the area and allow other devices to track through. I found that laser surprisingly works. It works in a decent manner in getting through those lesions and being able to provide a definitive care. I don't have much experience with directional atherectomy in my practice, and I'm learning some newer technologies that may offer some help. But heavily calcified disease is really kind of the last frontier and really the thing that we're working so hard to be able to conquer because it makes these cases so much more difficult.

[Dr. Sabeen Dhand]:
Absolutely. So I agree. In our practice too, we don't have too much directional. It's kind of like the devices you've already mentioned. It can be a big challenge to get devices across these big coral reefs that you can find in the SFA and pop. But after that and you’re now media, let's down to media. After you do your atherectomy do you typically repeat an IVUS or do you then already know what you're doing? So then you're going to go to the next step?

[Dr. Bryan Fisher]:
Nope. That's actually an outstanding question. And for those folks that have been in lab with me, I'm known for breaking the IVUS catheters. They're delicate little specimens. And if you use them to their greatest ability, sometimes they'll kind of peter out as you get towards the end of the case. I like to see what kind of luminal gain I'm getting with a particular device. And now I've moved around with working with some of the atherectomy devices because I really want to see, am I able to make a difference? Am I doing something to the vessel, based on that treatment algorithm. And what I found is that there are varying degrees of what we describe as plaque modification that I'm able to see after I perform atherectomy. So out of curiosity, I do like to see what I've actually done with using this device. There's quite a bit of controversy about the use of atherectomy in the first place. And I can understand that. I know that there's some misuse out there.

[Dr. Sabeen Dhand]:
You probably see a lot more because most people don't see what's going on in between these steps, other than maybe a little light angiogram. But there's so much more like you're saying And the dreaded medial calcification. Okay. So, you've plaque-modified the intimal area. Now, we've had problems of treating this medial calcification, like you've mentioned. Now, you mentioned intravascular lithotripsy, right? So what is that?

(6) Algorithm for Shockwave Lithotripsy Treatment

[Dr. Bryan Fisher]:
It's a really exciting technology that has been modified from what's been done in the urologic world. The ability to use pulses of energy and almost like a shock wave, if you will, to modify those calcified areas. With intravascular lithotripsy, you're delivering these very focal areas of energy that are all the way up to 50 atmospheres, which is an interesting concept. And you thought about trying to take a balloon up to that point, we'd ruptured those vessels all day. That would be probably a bad plan. But this newer technology allows the delivery of energy in an intermittent fashion, but very focal and allows you to modify those areas. And that's been a really exciting newer frontier when it comes to treatment of calcium because we really haven't had anything like it so far in the treatment of lower extremity disease. I've been interested in vascular surgery now for 15 years. And so this is one of the first technologies to really truly come out and address this in a systematic fashion, but then you've kind of got the proof and the imaging afterwards.

[Dr. Sabeen Dhand]:
Yeah. Talk like that's what I wanted to ask you. So what have you seen on IVUS post-shockwave? Do you see any differences? I mean, I know it's a low resolution of the media. When I see a cartoon drawing, I see a bunch of cracks in the media after a shockwave. Do you see anything equivalent to that?

[Dr. Bryan Fisher]:
You do see something in it and it can be quite subtle. But if you can think of a Cheerio where you crack it in a couple of different areas. If you really go through those IVUS images slowly, you can clearly see that there's evidence of true cracks in the calcium. And again, there are lots of claims everyone's made about calcium. And this is really the first company that I've seen that can show the proof and even better. I don't use this technology yet, and I'm looking and trying to incorporate into my practice because of the imaging that you get. But OCT shows those cracks in the calcium brilliantly. And that's been really one of the more exciting aspects of kind of that advanced imaging is seeing the proof in the pudding.

[Dr. Sabeen Dhand]:
Yeah, that's right. I mean, OCT. I agree too. I haven't used that in my practices. I see those cool orange colors that look like astronomy pictures or sometimes a black hole or something. Cardiologists use it very frequently and it is a nice new frontier that we can use. Now, when you see your angioplasty gear, you’re seeing basically that the stenosis or something resolved pretty easily after a few pulses?

[Dr. Bryan Fisher]:
Right. So right now I’m in the process of development of shockwave. The price is something that is a realistic concern, both in the outpatient OBL setting…

[Dr. Sabeen Dhand]:
Sure, and you mentioned price conscious, right?

[Dr. Bryan Fisher]:
Absolutely. So in the hospital setting as well. I set up treatment with atherectomy or balloon angioplasty. Now the question is whenever that balloon, we do an insufflation and we take that up to 4 to 6 atmospheres. We have to really understand that this is an important device to address a very specific problem. Our algorithm to avoid this kind of overuse is we'll do our definitive treatment for this atherectomy. What are we getting as far as a balloon dilatation? Oftentimes with a 270 and 360 rings of calcium, you'll kind of get that napkin ring appearance. You won't get expansion. And even with higher atmospheric pressures or increased millimeters of mercury, you don't see that balloon expand in that particular area. My next step in the algorithm, I actually will go with a shorter balloon I'll land the shoulder of the balloon and put it in that area. I think the amount of energy that's delivered at the shoulders of the balloon is different than whats…

[Dr. Sabeen Dhand]:
Shoulder, not the mid. Interesting. Okay.

[Dr. Bryan Fisher]:
Sometimes I can actually get that calcified area to crack as well. It's when I get failure in those two things that I then go to shockwave. And I've seen almost invariably that with very low pressures, 2 to 4, you can actually start to see, with the increased level of pulses, you see the balloons start to give way, you see the vessels start to give way, and you can see the real time luminal gain. And I'll tell you the first couple of times you see it, it's a sight to behold because that's an area that otherwise you wouldn't be able to dilate. But again, with this new technology, you can certainly see a difference.

(7) Using Specialty Balloons for Balloon Escalation

[Dr. Sabeen Dhand]:
It's almost like you're describing instead of a wire escalation technique, you're describing a balloon escalation or angioplasty escalation technique because we have these new devices. Do you ever utilize scoring balloons or like any of those as well in this segment?

[Dr. Bryan Fisher]:
Now that's a great question. The scoring balloons, those specialty balloons do quite. You may or may not know, but I was one of the biggest users of a particular balloon that had, I believe it was pillows and crevices that, and it worked quite well in these situations when we didn't have this…

[Dr. Sabeen Dhand]:
That was the, get the chocolate balloon

[Dr. Bryan Fisher]:
Chocolate balloon. Yes. And, I like to joke because I'm kind of chocolate. I was Dr. Chocolate.

[Dr. Sabeen Dhand]:
That's good.

[Dr. Bryan Fisher]:
So those balloons worked well. The one thing that may have been a little bit disappointing to me was just in spending that much for a balloon. You didn't get the primary patency. I'm always looking for primary patency. It's not a definitive treatment. You have to do something else. Whether again it's drug alluding balloon or a drug-coated balloon or scaffolding. You had to do something extra to be able to get that luminal gain. And in truly heavily calcified lesions where it was a napkin ring, fairly thick, 270 to 360 calcified disease, I didn't see that I was making much of a difference, until I started using shockwave a year or two ago.

[Dr. Sabeen Dhand]:
That’s great. It's always nice to have these new technologies to aid us in these problems that we deal with all the time. Now do you need to use an embolic filter device for any of these escalated strategies you're saying? Whether it's a scoring balloon atherectomy and / or shockwave.

[Dr. Bryan Fisher]:
That's another outstanding question and no. So in my practice, I tend to steer away from devices that are going to shower disease. And I've been fortunate in whether it's atherectomy devices, but especially with intravascular lithotripsy, the need for embolic protection is low. And I've not, I can't say that I've ever used a filter wire to perform an intervention. Now, maybe I've been lucky. Maybe I need to knock on wood, but I think having a slow and deliberate process to do these cases and then choosing the appropriate device. I just showed a case that I did not long ago and in this particular lesion, it looked like it was calcified in certain areas but as it turns out on IVUS, there was this large swath of very soft disease, and maybe even some thrombus. So you can imagine if you choose the wrong device to go through that, you've turned a two-hour case into a five hour case. And so, understanding what the vessel architecture looks like, I think all the guys that do a lot of this stuff have had this happen before. So hopefully we learn from it.

(8) Indications for Intravascular Lithotripsy

[Dr. Sabeen Dhand]:
Yeah. So that's great. So you found these devices that are causing less distal emboli. Do you feel that IVL might be causing less dissection? And I know it's really hard to know, but that's one of the claims is that there's less dissection because of low atmospheres. Do you feel that you're seeing that, or you might still see the dissections but you've at least got the luminal gain?

[Dr. Bryan Fisher]:
I would say this. One of the most important things that we all have to keep in mind whenever we’re treating blood vessels. If you take a balloon to that blood vessel and you stretch it, by the very nature and physics of doing so you're going to cause injury to the intima.

[Dr. Sabeen Dhand]:
Yeah.

[Dr. Bryan Fisher]:
Now I would agree that if you take in a 6mm vessel, if you take a 7mm balloon and inflate it to 20 atmospheres, you may rupture the vessel. But in all likelihood, you're going to cause a pretty significant and probably flow-limiting dissection in that area. So as we get more gentle with our insufflations and we lower the amount of atmospheric pressures that we're delivering to the vessel wall, we minimize the amount of dissections that occur. However, the idea of eliminating those dissections is, I have not seen it. And again, with maybe with arteriography, if you don't look really closely, you don't necessarily appreciate that. But anytime you're touching that vessel wall and you're stretching that vessel wall, you're going to cause breaks in the intima. I'll say that with delivering low pressure in addition to those focal energies delivered to the vessel, it does minimize the amount of dissections. However, in all truthfulness you still are causing, you may minimize them, but you're still causing dissection in those areas.

[Dr. Sabeen Dhand]:
Got it. When do you decide, and this is an important question for you because you have both sides of this. I mean, years of calcific lesion, you're doing all this, is it taking the need for a surgical open bypass? Is there less of a need? Or is there still as much of a need? This is a loaded question, but what I'm trying to get to is we're having all these endovascular techniques that are helping us be successful, for otherwise cases that would have not been. What do you think about that as far as the open and now this new endovascular space?

(9) Open Bypass vs Endovascular Approach

[Dr. Bryan Fisher]:
That's an outstanding question and something that I've debated. And it's one of the reasons, there's a particular vascular surgeon and I talk about all the time I look up to a lot and one of the things that I've always been able to take away from him is this idea that open bypass is a tried-and-true method. And when you have vein, when it comes to the lower extremity, if you've got a target, there is not much else that is going to do a better job from a patency standpoint. However, the reality is our patients are getting older, the disease processes are becoming more complex, and we're starting to address those in a more regular fashion. Many of these patients that we're doing tibial bypasses on, when they have lead pipes, or when you go on down to the pedal vessels and they don't have a really great target to be able to sow into, that makes that, that operation, there are failures there. I spent three or four hours and you can't get a needle to go through the tissue. You have to crunch the tissue with a hemostat to be able to get a needle to get through.

So the reality is that there are some scenarios where open operation is not ideal. And the pioneer work that's been done to address lower extremity disease and to address the pedal arch, all these things are extremely important in continuing to offer patients more options when it comes to treatment.

So as a vascular surgeon, sure it’s my bias to be able to perform bypass. Is that an important aspect of patient care and something that we should be able to offer to our patients? 100%. In that same vein if you will, I think it's important to continue to push the envelope and look for opportunities where we can treat patients in less invasive fashion and being able to still get a decent and durable result. As you know, durability is one of our biggest problems. And it's one thing that from vascular surgery standpoint, we love to talk about that. When you do a fem-pop bypass or a fem-below the knee-popliteal bypass with a good reversed vein, you're looking at 10 - 12 years. And sometimes I've got some older partners that have done bypasses on folks. And I don't know what kind of magic these dudes do when they're operating, but those are 15, 20, 25 years old and they're still wide open. It's an interesting concept. But I'm also forward-thinking, I’d like to think.

Back in the day, we only did open cholecystectomies. Now remember, never forget, one of the minimally basis surgeons, Scott Melvin, who I thought was the most technically gifted person, amazing person I ever worked with. I’ll never forget when he was telling me the story about he's doing open cholecystectomy, and then someone talks about take it out minimally basically. And he goes, yeah, that'll never work. And then what is it? Three years later, he's one of the leading minimally invasive specialists in doing these types of interventions. And he just kind of laughs at himself. He's like, I was completely wrong about it. But he wasn't too dogmatic to say this is my opinion. I'm wrong about it. I'm going to switch gears and make some adjustments. And so he was able to actually get on that train soon enough and help to actually pioneer some of those different procedures.

[Dr. Sabeen Dhand]:
Yeah, no, it's true. I mean, you have to keep an open mind and you are definitely pioneering a ton of stuff in the PAD and all spaces. So thank you so much. This was awesome just having you and, and I learned a ton right now just talking to you. So I know our listeners will totally appreciate this episode. So thank you, Bryan. Thanks

[Dr. Bryan Fisher]:
Oh man, listen, brother. It is always an honor. You guys are just doing, speaking in pioneering, this is one of the most forward thinking podcasts that’s on the market. And I just appreciate the multidisciplinary efforts. You guys are doing this stuff is cutting edge. And I've listened to him most of the BackTable episodes. And I plan on getting through all of them and I always rock my swag. I know this isn't a video, but I always enjoy the quality content you're putting out there. And again, look forward to the next time of being on the show.

[Dr. Sabeen Dhand]:
Oh, it will be soon for sure. Thank you so much. And look forward to hanging out in person soon to, Bryan.

[Dr. Bryan Fisher]:
Hi brother. Listen, you take care. Enjoy that California weather.

Podcast Contributors

Dr. Bryan Fisher

Doctor Bryan T. Fisher Sr. is a practicing Vascular Surgeon and the Chief of Vascular Surgery at Tristar Centennial Medical Center in Nashville, TN.

Dr. Sabeen Dhand

Dr. Sabeen Dhand is a practicing interventional radiologist with PIH Health in Los Angeles.

Cite This Podcast

BackTable, LLC (Producer). (2021, December 13). Ep. 172 – Treating Above the Knee Calcium [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com 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.