BackTable / VI / Podcast / Transcript #312

Podcast Transcript: Which Dissections Matter, and How to Treat Them

with Dr. John Phillips

In this multidisciplinary episode, guest host and vascular surgeon Dr. Krishna Mannava interviews interventional cardiologist Dr. John Phillips about when and how he treats dissections after balloon angioplasty in peripheral vasculature. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Common Causes of Dissections

(2) What Are Tacks

(3) Tacks vs. Stents

(4) Preventing Dissections

(5) Deployment of the Tack System

(6) Using IVUS to Evaluate Dissections

(7) Using Tacks Distally in Lower Extremities

(8) Proper Use of Tacks

(9) Comparing Tacks with Other Treatment Methods`

(10) Other Indications For Tacks

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[Dr. Aaron Fritts]
We have a great episode today, multi-specialty, we've got an interventional radiologist, myself, interventional cardiologist, John Phillips, and Krishna Mannava, vascular surgeon, all with Columbus roots. John and Krishna are currently in Columbus. As the audience knows, I'm from Columbus and talk about the Buckeyes frequently. So I'm excited to have you guys on, and today we're going to talk about which dissections matter. We're going to talk a little bit about troubleshooting for dissections for peripheral arterial disease. But first, everybody's familiar with Krishna, he's been on the show before, but John, welcome to the show.

[Dr. John Phillips]
Thanks for having me, Aaron. I'm super excited. I always enjoy talking about things peripheral and endovascular means of treating things, so it should be fun.

[Dr. Aaron Fritts]
Great. And Krishna, welcome back.

[Dr. Krishna Mannava]
Thanks, Aaron. Always a pleasure. Happy to be on this multidisciplinary boxing match.

[Dr. Aaron Fritts]
We'll see. We'll see. Well, first, let's talk, John, tell us about your practice in Columbus, what it looks like.

[Dr. John Phillips]
Sure. I'm an interventional cardiologist. I work for Ohio Health, which is one of the large healthcare systems in central Ohio. I've been there, going on 11 years. I am the system director for our vascular institute, which is kind of nice. We get all subspecialists who treat vascular diseases kind of under one umbrella. We do quality metrics and educational seminars and things of that nature. And I do a lot of PAD, a lot of critical limb work. The topic of dissections is germane because I see them all the time and a lot of times we hem and haw about what to do about them. So I'm curious to have this conversation.

[Dr. Aaron Fritts]
As part of your practice, are you still doing cardiac work as well though, STEMIs and whatnot?

[Dr. John Phillips]
Yes, I take STEMI call for the group. My coronary work is probably maybe 20% of my entire cachet, so to speak. I wish I did more frankly, but there's a lot of CLI out there and my other partners are great, but I guess I'm the CLI guy, I'll just put it that way.

(1) Common Causes of Dissections

[Dr. Aaron Fritts]
Yeah. Well, let's jump into the meat of it today. We wanted to talk a little bit about which dissections matter with respect to peripheral arterial disease in the leg and whether it be above the knee, below the knee, or both. John, can you just tell us a little bit about when are you most commonly seeing dissections, when you're treating PAD?

[Dr. John Phillips]
Well I mean, honestly, anytime you inflate a balloon in a artery, you're creating some type of a dissection. Now, whether or not it's "flow limiting" remains to be seen. Oftentimes, at least for me, I try to think about the dissection in a couple of different ways.

The biggest one is, is flow being limited? Meaning, do I need to do something about this? It's always interesting when I would go out the conference out in Leipzig LINC, and you'd watch how the interventionalists and proceduralists, over in Europe, would just shred these arteries and they'd balloon it, but they'd leave a pretty nasty looking dissection.

As an interventional cardiologist, we don't leave dissections in the coronaries. We were doing a fair amount of stenting of these vessels and going out to LINC and seeing how other people are doing things and using a lot of just drug-coated balloons alone, we started leaving more and more dissections or at least thinking about them and maybe not necessarily having to put a scaffold in.

And so for me, I try to assess the flow pattern above and below the dissection. If it's in a fem-pop region, I'll often put a catheter across it and try to measure a pressure gradient. If it's in the tibialis , I'll often put an IVUS catheter down and see what that dissection looks like. I know there are grades to dissection. I don't necessarily follow those, but in general, when I have a flap that's probably arcing greater than 180, I'm considering that this might be flow limiting and maybe we need to do something.

[Dr. Aaron Fritts] Got it. When you see a dissection, and let's say, it is flow-limiting, what's your algorithm? Where do you start after that?

[Dr. John Phillips] Well so I want to kind of get a makeup of what the plaque looks like. If it's heavily calcified and I've dissected it, and I feel it's flow-limiting and I'm going to need to put a scaffold in, it's probably going to be a stent of some sort and it's probably going to be a woven nitinol stent, like a Supera. If it's not and it is fem-pop region or iliacs or something, then I will be stenting it to some degree.

There's also Intact Vascular was purchased by Phillips and they have the little vascular Tacks. In full disclosure, I do speak for Phillips and so I'm pretty well versed in the Tacks, and I have been using more of those above and below the knee. I think that's a nice bailout. If there is a dissection below the knee and the tibial vessels depending on where it's located, I'll put a coronary stent in as well, but I try to limit the lengths of those and I try to keep it in the upper third of those tibial branches.

(2) What Are Tacks

[Dr. Aaron Fritts]
Yeah so let's talk a little bit about- I do have some questions from the audience about Tack, these are IRs that, again, the audience is familiar with. They're curious to know about the Tack system. Talk us through that decision, Tack versus stent. Is it all about the length of the dissection?

[Dr. John Phillips]
It is. I think the couple of things that you have to understand with the Tack system, it's not a stent. There's different sizes. They have an adaptive sizing platform, so to speak, so the larger ones are 4-millimeter, 8 millimeters, and they're eight millimeters in length. Those are great for fem-pop regions. I've been using Tack for a long time, so I've made mistakes with it and I know where to put it and where not to put it.

We use it off-label for some stuff as well. And so, depending on the length of the dissection and where it is, I consider, assuming it's flow-limiting-- So example, if we're talking fem-pop region, I've been using a fair amount of Tacks across the knee joint if there's a dissection, and basically you want to Tack up the proximal and distal edges of the dissection and then, in between, I usually put a couple of Tacks.

You get six in the device for the four to eights and then the three fives to six or something like that. We really don't use that one. Then the smaller ones, the tibial ones, are one five to four five millimeters, and you get four in those. I think you have to be smart with using them because they are a lot more expensive than stents and I try to avoid using them in heavily calcified areas unless if I've really modified the plaque and prepped that vessel aggressively.

In general, there's such little radial force in those, they're really meant to just quote, I mean literally Tack up the dissection. A lot of people ask me, "Do you use them in plaque?" I think, in their IFU, it's like if there's 30% residual stenosis or plaque, you're not really supposed to use them but I use them in plaque all the time. I avoid it in heavily calcified areas.

[Dr. Krishna Mannava]
I want to rewind a little, and it's been bugging me, but I've been meaning to ask you, you have an extra L in your name. Is it really just Phillips with one L and you really are somewhat involved with Phillips and we need to know about this as a disclosure?

[Dr. John Phillips]
It’s funny. No, it is funny. I am involved with the Phillips with one L, but I've got two Ls in my name, and if I had one L and had some affiliation on my own part of it, we'd having this conversation on a beach, I think.

(3) Tacks vs. Stents

[Dr. Aaron Fritts]
Traditionally, we've used bare metal stents, sometimes covered stents, sometimes coronary stents below the groin. What makes Tack so different, just at a high level, for those of us who haven't used it or used it very little, what makes it so different than just a typical stent in the leg?

[Dr. John Phillips]
Well, a couple of things. It is very short so you're getting, let's say you're going to use the bigger ones, the 4-millimeter to 8-millimeter, those are 8-millimeter in length. Basically, the way I describe it, there's two little crowns soldered together basically. It's very short. Very, very little radial strength, but enough to, I think, seal a dissection where there is some residual plaque, but not enough to, say, treat somebody that has coral reef calcification in a fem-pop region because you can get into trouble with them because after you deploy them you have to post-dilate them with a fresh balloon. You don't want anything winged because they can catch and tumble on you.

The ones in the tibialis , the smaller ones, the one five to four fives, those work well also, but again, the tibialis , I think there's a fair amount of calcification in those, whether we see it or not. That medial calcification is always a problem. You have to be careful when you use them down there. I think the sweet spot for them, in my opinion, is some of these no-stent zones as well as the tibialis, below that upper one-third because I've put in a fair share of coronary stents in the tibialis and they come back crushed. I've got one guy that he needed an amp and they put a tourniquet on his leg and he lost the toe and then we lost his stents as well because it was crushed.

I used to Tacks a fair amount, and I've learned, over the years, that I don't need to put in as many as I used to for some of these dissections. I've also learned, over the years, where not to put them to avoid a mangled mess that really irks and it creates complications, in the long run.

(4) Preventing Dissections

[Dr. Krishna Mannava]
Before you reach for whether it's a stent or a Tack, are there certain things you do to limit or avoid dissections altogether that you've found, over experience?

[Dr. John Phillips]
Yes. Well, number one, I think, in general, let's talk about the tibialis here. I think we undersize our balloons in the tibialis. We know, on average, I think a tibialis is probably about 2.6 or so, taking all comers, 2.6 millimeters, but people typically are grabbing for a half size lower than that because they are worried about dissections, which rightfully so. And I'm not saying that we should IVUS every vessel and go really aggressive and try to create dissections and use devices to treat the dissections.

The one thing that I have learned is that the longer inflation times and the serial-- So for example, I'll take a-- If I've got a long tibial dissection, I'll cross it and then I'll take like a 2-0 balloon and have it up for a couple of minutes just to let the vessel adapt. Then I'll take maybe I'll IVUS it, maybe I don't, but I grab the balloon that I think I'm going to do definitive treatment with, and then I leave those balloons up for a long time, like five, six minutes. It drives my staff crazy. That's just what I've learned and that whether-- I feel like I get better results that way.

Also, I think it helps treat some of that recoil. Then, after it, I try to assess the blood flow in that vessel. I make some assumptions when I'm treating a tibial vessel that I don't have any significant lesions or problems with flow from inflow. My iliacs are clean, my SFA, my pops clean. And so in my mind, I feel like after I've opened up whatever vessel it is, I should get a good signal in that foot or maybe even feel the pulse. I have my staff, they have the Doppler out, we're kind of checking to see what the pulses are as the procedure moves forward.

Hopefully, we'll get the FlowMet from Medtronic and maybe use that to help guide whether or not we're done treating things. But for me, a lot of times, I've put a stent in or a Tack in where I think there might be something going on and then I'll reassess flow, "Oh, okay, I've got a better signal now." Then I'll search around. Maybe I missed something, maybe I haven't, but I don't typically stop until I've got a good signal because you spend all this time doing it, you're on third base you might as well go home. It's like, "Let's get the job done." But I know other people, everybody's a little bit different.

I actually just got back from the national sales training meeting for Phillips, and they had me do a lot of Tack stuff, and just hearing from their reps, they're having a hard time getting traction with the device for a number of reasons. Cost is one of them, but physicians are just a little unclear about where to use it. It's a pin-and-pull method, so it's not a triaxial thumb wheels. It takes a little bit of finesse, and there's just a lot more questions I think out there. I do these things called Tack chats. I started them with Philip. Well, it was within Tack Vascular and just before the pandemic because, frankly, what's new in peripheral arterial disease, really not much. Obviously, we've got drug-coded stuff and whatnot and maybe we'll get some new Limus devices in the future, but the Tacks are something new. Again, not every dissection needs to be treated, but I think this has started a conversation about dissections and how to assess them, and how to figure out, is it flow-limiting or not.

(5) Deployment of the Tack System

[Dr. Aaron Fritts]
Is the deployment mechanism for Tack-- You kind of mentioned this, but is it complicated or is it pretty simple? I mean can you walk us through it, for listeners?

[Dr. John Phillips]
Yes, sure. Basically, you get-- Let's use the big boy. So the 4 to 8-millimeter sizing lumens, you get six Tacks on the catheter, and it's a pin-and-pull system. And so basically, you have the device and what you need to do is, under fluro or having talked to the rep ahead of time, you have to understand there's a lot of markers and the catheter itself is kind of busy. The Tacks themselves, the radiopaque portion of the Tack is actually in the middle of the two crowns. That, in and of itself, is a little bit of a hurdle because when we're putting stents in, our eyes look for the radiopaque marker.

But in most stents or all stents, the radiopaque marker is distal and proximal. This is a little bit different. There are little radiopaque bands between each Tack. So ultimately, what you have to do is loosen the tuohy and then you-- I describe it like popping a bottle of champagne and trying to pull that cork out. You don't just necessarily crank the—You kind of have to massage it sometimes. You are pinning and pulling, but sometimes you're pushing as well on the deployment device, and so, there's nuances. You shimmy it out.

And the Tacks too, they can pop out on you a little bit, and that irks physicians. When I am asked to speak to reps about how to train and coach physicians through this, it's not uncommon to deploy a Tack and have it go in the wrong spot. When we were involved in their clinical trials, I had some, they popped out. It takes about five or six, I think, deployments to kind of really get an understanding of the mechanism and what you're looking at. I find that, after a while, you can be quite accurate with them and place them very specific spots and feel comfortable doing so.

[Dr. Aaron Fritts]
A question from the audience. Ali Bahati was asking, for new users, one of the challenges that she has is that it's a bailout device and so she never has a rep nearby and so she usually ends up just stenting if she has a flowing dissection. Are there any solutions if an operator who may not have a high enough case volume to justify having the rep there just because they want to try the product? Because she's in Tacoma, Washington, so it's a different kind of territory.

[Dr. John Phillips]
A couple of things. I think the company is looking at maybe ways to use Immertec. They have those Oculus glasses for training. I think doing some remote proctoring would make sense. We do these Tack chats remotely and those are nice intimate conversations between a couple of physicians and myself or other users, and we go over the deployment there also.

I haven't recorded any of my cases yet, but they were asking potentially if we do that. B honestly, those reps, at least the ones I've talked to at the sales meeting last week, they just want to try to help docs understand this. So most of them are pretty willing to be there and sit through it. A lot of times too, I get asked, is it really a bailout? I don't know that it's a bailout, it's just another option for treatment and I think when we were talking, Christian was asking me about like, "Hey, do I do anything different to prevent dissections?"

Yes. Obviously, we do atherectomy and whatnot and I try not to get too silly with ballooning, but I think IVUS really helps us gauge what the true size of that vessel is. For me, it allowed these devices, and I guess I didn't mean for the whole conversation to be about Tacks, but it allows us to get more aggressive, at least in the tibial vessels with treating these long CTOs.

(6) Using IVUS to Evaluate Dissections

[Dr. Krishna Mannava]
You mentioned something interesting with IVUSing below the knee and I've had some struggles when I go mid-calf or distally with IVUS, just getting the quality measurements and images I want. Down to proximal calf, I'm good, but then below the knee, I struggle with using IVUS to guide my therapy. I don't know if you have any pearls or wisdom on that.

[Dr. John Phillips]
We have the Phillips IVUS, and my understanding is that Boston's might be a little bit more easier to see, but a couple of things that I've noticed too is that when you- to your point, when you do get into the smaller areas of the vessel, the device can almost fill up the whole lumen. It's hard to see dissections. I don't really use IVUS for dissection assessment, to be honest with you. I'll use it just to try to help size and just kind of take a look. When you IVUS these things and you just see it's just chuck full of plaque, yeah I mean my balloon was probably okay, but I know in my heart that this probably isn't going to stay open too long, so I've got to maybe do something different, whether it is maybe some atherectomy or even just stent it. Not necessarily for dissection, but just stent it because there's so much plaque there.

I think IVUS does help guide you a little bit with sizing. That's obviously the best thing for it. For me, if you said, "Hey, do I use it for measuring dissections and then trying to look for flow patterns?" I really don't below the knee because I find it hard to do.

(7) Using Tacks Distally in Lower Extremities

[Dr. Krishna Mannava]
How far distally have you ever deployed a Tack?

[Dr. John Phillips]
A couple of weeks ago, I put three—well I wanted three, but I ended up putting four in the foot, and it was just one of these situations. The way I approach somebody who has critical limb ischemia-- I don't go into people's tibialis unless they have CLI or rest pain or whatever. For me, it's like, "All right, you got one or two shots at this. Let's do whatever we can," and I just could not get this vessel to stay open. It just kept recoiling. It was the dorsalis pedis. I thought, "Well let's just see where-- let's see, number 1, can I get the Tack down there?" Because I sure as heck am not going to put a coronary stent, but can I get the Tacks down there, and was able to do it.

You have to mag up pretty good, and you can't see, really, because the Tack is obscuring blood flow, and so you're blind a little bit, but you mark it on the screen. That's another thing, too, I think, when people ask about pearls of deploying these, making sure you're marking on the screen, or you've got a ruler and you're off the bone and mag’ed up and all that good stuff.

To answer your question, it's pretty rare, that's only the second time I did it. The first time I did it, I made the mistake. I thought I could prop open this plantar vessel that had a lot of calcium, and I couldn't even get the device to it. It's a pretty forgiving device, but I couldn't get it to where I wanted it to be. So hopefully, they stayed open for the past couple of weeks. I don't know how long it’s going to stay open, but we'll see.

(8) Proper Use of Tacks

[Dr. Krishna Mannava]
Sabine had a really good question about sizing. For me, sizing has always been a little confusing, and I think there's three different sizes. I personally keep two on the shelf, mainly, to limit my own confusion in device selection, but do you have any guidance on some of these sizes that overlap in numbers and trying to pick the right size for the right vessel?

[Dr. John Phillips]
Yes. To your point, you really only need two skews. The original device was, I think three, five to six, five or something like this. That has been eclipsed with the 4-millimeter to 8-millimeter adaptive sizing. And then the little guy, the one, five to three, five-- I'm sorry, one, five to four, five. For me, most tibialis are getting the one, five to four, five, and then probably maybe the TP trunk. But any popliteal, SFA, whatever, is four to eight. We've got probably five or six patients that we deployed these in the common femoral artery for an iatrogenic perclose dissection, which I thought was a curious way to do it.

The nice thing about it, too, is because of that adaptive sizing, you're able to land that first crown, the more distal one, like in the SFA, and then you can take that second one across into the common femoral and not necessarily jail the profunda. So this was an acute event, but we knew, going into it, that what the size of the vessel was. It was clean. There was a dissection there, so we were able to do it. But again, I think if you have the two sizes on your shelf and anything below the distal pop or TP trunk, you use the small ones and anything above, you use the big ones. You should be okay.

[Dr. Krishna Mannava]
When you have multilevel disease for CLI and let's say you've got dissections above the knee, below the knee, do you open two devices? Do you try and finagle one?

[Dr. John Phillips]
Yeah, I think I try not to open more than two devices in any case, because again, the cost is an issue. I had one doctor tell me that he felt like he needed to deploy all of them-- all the Tacks that were in the catheter. I don't subscribe to that notion, but I do recognize that you have to be smart. If you're going to put 12 Tacks in, you might as well put a stent in right.

I think they are considering. Having six, I think, is a good number. Four is a little bit limiting. On average, for me, in the tibialis, I'm probably opening two of the small ones and then anything above that SFA pop, I'm only opening one.

Because if I feel I need more than six, then I'm going to put a stent in or I'm going to use a stent someplace and maybe put the Tacks in a no-stent zone or something like that.

[Dr. Krishna Mannava]
When we deploy stents in the leg, we're often taught don't leave little gaps or gap areas between some of the stents. What about with Tacks? Do you tend to overlap them? Do you ever leave gaps? Is there any amount of overlap that's the right amount?

[Dr. John Phillips]
I think the company will tell you that you shouldn't overlap them because, again, very little radial strength. You have to be careful and you want to deploy, Captain Obvious here, but you want to deploy distal the proximal because you don't necessarily want to be running the catheter through fresh Tacks. We do it all the time if you have to, but for me, if I've got, let's say, an 8-centimeter dissection, I'm Tacking inflow outflow the top of it, and then I'm probably putting a couple in between. Over the years, I'm putting less in between. That's where I do use IVUS to take a look and see, "All right, what are those Tacks doing? Is there something I might be missing?"

It's not meant to-- because I don't kiss them, really, and so I try to separate them. You can kiss them if you need to because when you start using them, you're going to miss, and physicians don't like missing. We don't like geographical miss, but you're going to have it. You just have to understand that. I was telling the salesforce, too, I'm like, "You guys need to tell docs that, 'Hey, these aren't as accurate as you might think early on, so you're going to get some misses.'"

So if you have a miss, yes, you can kiss them or overlap. But I usually try to leave 3, 4 millimeters of gap between. Because, again, if you're going to pile them on top of each other, you might as well just put a stent in because it's a heck of a lot quicker.

[Dr. Aaron Fritts]

Krishna, you want to talk about like surveilling Tacks versus stents?

[Dr. Krishna Mannava]
Yes, I thought that was an interesting topic-- as I've deployed a few of these, some of my ultrasound techs are now asking me, "Did you deploy a Tack or a stent or what do I need to look for?" Is there any differences you've seen or heard of on surveillance duplex imaging with these?

[Dr. John Phillips]
No. I mean it was interesting, too, that you hear, across the country, that docs were reporting lack of use because there was acute or subacute closures and a lot of restenosis or occlusion where I've seen them restenose, and it's in the tibialis. It's between the two Tacks. I think the closures are probably related to just, in my opinion, failing to see or treat another dissection or some plaque disease that the thing was going to fail either way.

I think if you size a vessel appropriately, prep the vessel and treat it appropriately ahead of time, and if you do have a dissection, putting them in specific spots along the way without having to, again, stack a bunch of them, it leads to pretty good results.

When we scan the folks at the one-month, six-month, year, whatever, no difference. I have not, in my knock-on wood, seen any issues with it or at least any reports from our ultrasound staff.

[Dr. Krishna Mannava]
To jump even further past surveillance, is billing. It's something that I've been thinking about during the conversation. When you do your dictation or your report and you dictate that it's a Tack was used, do you ever find that you have to elaborate a little further in order to make sure that, on the receiving end, the payers know that it was a stent versus a Tack or they're avoiding any confusion?

[Dr. John Phillips]
I have not run into that issue because I always try to convey to people that this is not a stent, but it's a scaffold, but it gets billed as a stent. I've talked to our coding folks, and they have not run into any issues. Interestingly enough, we're running into some issues with lithotripsy, but in the peripheral, but we're not running into any issues with Tack yet.

(9) Comparing Tacks with Other Treatment Methods`

[Dr. Krishna Mannava]
John, if you use a lot of DCB and drug-coated technology, do you think that there's a difference POBA versus DCB, whether you have to put in metal or use Tacks?

[Dr. John Phillips]
Yeah, I think, for me, best practice is drug. Our lab, we were the first lab to deploy the Zilver PTX back in the day. So we were pretty hot and heavy with silver for a while, and we still use them, but I've gotten smarter about not full metal jacketing these folks. At least, again, in the fem-pop region, all of our patients get a DCB as a definitive treatment. We're not seeing these folks come back like we used to.

Those that have some residual plaque or a dissection, we'll put a drug-coded stent in if need be, or I like using the Tacks in that situation because it can limit some of the metal. Again, thus far we've had pretty good success with it. I understand the cost of DCB and whatnot, but I do think it should be standard of care, in my opinion.

[Dr. Krishna Mannava]
What about medical adjunctive therapy with Tacks? Is that different for you than denting?

[Dr. John Phillips]
Meaning like atherectomy, or–

[Dr. Krishna Mannava]
Medical therapy. Dual antiplatelet therapy or anticoagulation. Do you handle that differently with Tacks?

[Dr. John Phillips]
No. So for us, it's DAPT for probably three months, and then reconsidering monotherapy thereafter. We treat it as an implant in a stent. We're trying to use more Xarelto and low-dose aspirin or I know it's off-label, but Xarelto and Plavix or Clopidogrel at the 2.5 twice daily of Xarelto. The hurdle there is cost for these folks. But those that can afford it, we're really pivoting to that, too, based on COMPASS and VOYAGER and whatnot.

(10) Other Indications For Tacks

[Dr. Krishna Mannava]
You mentioned you went a couple cases below ankle, off-label, have you ever put in any other sort of weird, unusual places, upper extremity or some other weird location?

[Dr. John Phillips]
I have thought about it a couple times in the arm and have punted. We have used it in folks that have come in with acute limb ischemia that we have liaised and done thrombectomy to, and we still can't get rid of some of the clot and nothing is working.

I will use it to Tack up the thrombus. We've had a couple of cases that was successful and that's usually distal tibialis. Let me think where else again. I mentioned, as the common femoral inappropriate size for those dissections. I have not put any in iliacs or any other places like that. A couple in the profunda. I think we've done, but again, we try to use it on-label as best we can. But the nice thing about it is that the more you, at least in my opinion, the more you use it, the more comfortable you are deploying it.

And then you can think about maybe, yes, this is an interesting dilemma here. I'm not getting good blood flow, what should I do? And does it play a role there? Maybe. The other thing, too, I like about it is I always tell people it allows you to be a little bit of an artist. A stent is pretty brain-numbingly easy, I mean my kids could deploy them. The Tacks are a little bit trickier and so you're trying to-- you got to get good at it. Once you get good at it, then you nuance it and figure out, all right, maybe I'll put it this way or maybe I'll put it here or something.

[Dr. Aaron Fritts]
We did end up talking a lot about Tacks in the context of dissections, which is great. It's one of those things where, when we talked about doing this episode when I pulled some of my IR colleagues, I think it was the same concerns that you mentioned before, John, from the sales meeting is there's concern about the price and the concern about the deployment mechanism and not being as straightforward as a stent, like you just said.

Are there any resources out there? Training courses, I know Phillips is really good about putting together training courses, but anything that you can think of to help people get more comfortable with this technology?

[Dr. John Phillips]
Again, what I would do is, if you are thinking about using them or want to learn more, reach out to your Phillips rep. You can give folks my contact information. I help folks out all the time with these Tack chats that we do. Basically, what they'll do is they take out a couple of docs from their region to a restaurant and then I zoom in or somebody zooms in and I show cases and we go over the deployment, we talk about it.

You have two types of physicians, in my opinion; those that are very comfortable doing what they've done. They've treated X disease pathology the same way and they just don't want to try anything new. Those are one subset. And then there are other physicians that are interested in trying to do something or learn a different technique. And those are the people that gravitate towards using these devices.

I think it was launched in COVID, so I think it never really got a good launch, frankly. I think they're considering re-launching and are doing some more marketing towards it. I think that'll help but, at the end of the day, they do have resources, reach out to your rep and they'll get you in touch with somebody and you can give out my contact information. I'm happy to field questions or whatnot.

[Dr. Aaron Fritts]
Thank you so much for that. One last question. Have we seen the cost change at all since it's been launched?

[Dr. John Phillips]
I don't think so. You can get a drug-eluting stent for about $800 or something. These might be three times that, so you have to be careful. I haven't gotten my hand slapped yet because it's recognized as a novel device. But in my opinion, you have to be smart where you think about putting it because if you talk to Phillips, they'll tell you got to treat every dissection, every dissection is flow limiting, but they're not. You don't need to treat everyone, but you need to think about them.

I kept hearing over and over, "Well, our docs just leave it and they'll reassess it later." In my mind, I'm like, "I don't know when's later. You either get it done now or don't do it, frankly." So just be aware that they're expensive. If you're going to do them for the first time, try a couple of simple dissections, get a feel for it. Don't be putting in 15, 20 of these things in because that's not going to help anybody, but use them judiciously, then you'll be all right.

[Dr. Aaron Fritts]
Yeah to Ally's point earlier, maybe like if it's going to be a complex case where you expect a dissection almost, is this how the rep there-- for that case, whether you place it or not right? It seems like that would be a next best step.

[Dr. John Phillips]
I got the sense that a lot of reps are coming to cases and twirling their thumbs because they're not getting deployed. They'd be jazzed just to get invited, I think.

[Dr. Aaron Fritts]
Just to be invited, yes, to the party. Well, that's a great place to finish it, unless, Krishna, you got any more questions?

[Dr. Krishna Mannava]
No, this is great. Great little pearls and technical little things. I appreciate it. John's selling himself short, Aaron. John is one of the most respected interventionists in Columbus, so it's awesome to have him on the show. I'm on the east side of town and he sort of runs the entire-- everything around me, he runs it. It's a privilege.

[Dr. John Phillips]
No, it was a pleasure. I appreciate the opportunity to speak with you guys. I've heard great things about your podcast, and I think it's just cool, again, to just spitball about complications and things and how to learn and how to get better. Krishna, we'll have to get together sometime and chat.

[Dr. Krishna Mannava]
I know. I know. Definitely. Maybe we'll all do it over the next Buckeye home game here.

[Dr. John Phillips]
Yes. That'd be a good idea. That'd be great actually.

[Dr. Aaron Fritts]
Thank you so much for listening. If you haven't already, make sure to subscribe. Rate the podcast five stars and share with a friend. If you have any questions or comments direct message us at, @_backtable on Instagram, Twitter, or LinkedIn. BackTable's produced and hosted by myself, Aaron Fritts, and co-host

Podcast Contributors

Dr. John Phillips

Dr. John Phillips is an interventional cardiologist with OhioHealth in Columbus, Ohio.

Dr. Krishna Mannava

Dr. Krishna Mannava is a vascular surgeon and medical director at Vive Vascular in Columbus, Ohio.

Dr. Aaron Fritts

Dr. Aaron Fritts is a Co-Founder of BackTable and a practicing interventional radiologist in Dallas, Texas.

Cite This Podcast

BackTable, LLC (Producer). (2023, April 17). Ep. 312 – Which Dissections Matter, and How to Treat Them [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.