Podcast Transcript: Inside the IR Suite: A Clinician's Own Battle with Portal Vein Thrombosis

[Dr. Brian Hartley]:
Cool. No, I think that's a good answer. Let's get to the meat of this. You had a pretty important case on one of your call nights. Maybe you can share that story with us.

[Dr. Jason Hoffman]:
Sure. Absolutely. It happened a few years ago and I remember the date pretty well actually. It was a Friday night, December 15th, 2017, so a number of years ago, just before the holidays. I happened to celebrate Christmas and my wife's birthday is typically right around Thanksgiving, so it's right in the middle of all these things happening. I was working that Friday and actually I was, I think if I remember correctly, I was interviewing for the radiology residency program, and I had started to take call on Friday. In the middle of the night, Friday night, got involved in a case, a young to middle-aged patient.

It happened to be a male who had pretty severe abdominal pain, came to the ER, described it as pretty acute, excruciating pain, 10 out of 10, and ends up getting worked up in the ER and gets a CT and is diagnosed with pretty massive portal vein thrombosis. The pain was acute mesenteric ischemia from-

[Dr. Brian Hartley]:
That's not very common.

[Dr. Jason Hoffman]:
Yes, not super common. It's one of those things that I've been involved in treating, certainly not dozens of times. I've been involved in some cases over the years. I guess just to set the landscape. My hospital is a 600-bed hospital. It's a level one trauma center, pretty busy oncology practice. We do all sorts of different things, you're right, this is not the type of patient that walks into the ER for us five times a week or something. I was on call and the consult comes through. Now at this point it was a Friday night going into Saturday morning, so about 2 AM, there's a submergent IR consult, and I guess if I had to give a sentence summary, it's at the time it was a 39-year-old, I think, patient.
Again, severe abdominal pain, found to have acute mesenteric ischemia, massive portal vein thrombosis, and conversation happens about getting started on systemic anticoagulation and heparin IV infusion. Again, here IRs involved, and I ran into a little bit of a snag then because I was on call, but I needed some help because the story here is unfortunately the patient was me. I was on call for this and started to have abdominal pain about a day or day and a half earlier, and thought I could fight through it. I went to work and was doing my work and went home that Friday night, and my wife looked at me and she's like, "You look like you're dying. Why are you home? You were just at the hospital."

We had a four-year-old, we have a son still, he's not four anymore, but in my mind I wanted to come home and see him and try to put him to bed. It was actually, this is all 100% true, I promise you. It was the night of our holiday party as well, and I'm one of these people who even though I was on call, I think it's really important to get out there and enjoy a time with the staff and just everybody together and celebrate the community that we have. I didn't show up for the party that night. I think everybody knew that something was up. One of my partners knew I wasn't feeling great.
None of us ever would have suspected this was what was going on. Here I am almost writhing on the floor in pain, and I'm at home right now actually while we're doing this recording, and I'm in an office that's 10 feet around the hall from where I was smiling and reliving it a little bit here. It's a miracle I'm alive, I guess. Anyway, my wife fortunately convinced me that I was at the wrong place, I needed to get back to the hospital. I drove myself back to the hospital, which is probably also not a great idea, but I live real close and I got to the ER.

It was at that point very early Saturday morning, and I saw a colleague that I knew right in the ER and explained what was going on and got worked up pretty quickly and got that scan. We mentioned earlier that obviously as an interventional radiologist, I have my board certification in DER and IR, and I was laying on that CAT scan table, got off the table, and the CT tech who I knew well said, "Hey, do you want to look at your images?" I said, "Sure, I'll take a look." I had never received any narcotic pain medicine before in my life, so I definitely had a pretty decent dose of morphine in me at that point, because the pain was pretty-- I wouldn't have wished that on anybody, the pain was intense. I looked at the scan. I remember scrolling up and down, and it's something just strikes you that something's missing, meaning I don't see a portal.

[Dr. Brian Hartley]:
You're missing. You know something is wrong.

[Dr. Jason Hoffman]:
At that time, we did even then, we had 24-7 in-house attendings and sometimes our attendings are remote now. So much has changed over the last few years, but the attending radiologist that was on and the resident, I remember I called them, and they thought I was pranking them, because years ago we were known for maybe a mild prank or two on the night of the holiday party and that sort of stuff. I was like, "No, guys, my name's on the work list. Please take a look." They come running into the CT scan area. Couldn't believe what they were seeing either. Anyway, then I was right unfortunately, when I did the wet read on my own scan, that it was the entire portal venous system was out, splenic vein was out, SMV, everything was out.

A little bit of some mild bowel, a small bowel thickening in the left upper quadrant near the duodenum. My vitals were good, and my lactate was slightly up. It was pretty benign exam, shall we say, I didn't have a surgical abdomen, per se, per exam, but I was definitely hurting. I got whisked back down to the ER, and here I was on call and reached out to my partners, and, "Hey, guys, great news, cool case, right? Bad news, bad news. I hope somebody can come and help me." They did, of course. They, actually, both of these guys, unfortunately, for me, have moved on in their careers in other places now, but one still works on Long Island.

His name's Nick Giorgio. Thanks, Nick, if you're hear this one day. He knows a lot today. Mani Hanz, another colleague and the two of them together, a friend, that really, for days, just dropped what they were doing to do a lot of procedures on me to get me through. I know we, of course, we would do that for patients, any patient, right? That's what our job is. I was the one on call, and it started on a Saturday morning and went for days. I was in and out of procedures in the IR suite, and they did trans-hepatic access, and did thrombolysis, and did a lot of angioplasty.

I think we were on the verge of whether or not I would need to tap tips and have flow restored that way. Fortunately, for me, they were real persistent, and I think we pushed the line of how aggressive to be, but probably used more TPA for many more hours than maybe conventional wisdom would have told us. Anyway, that's what-- I say we did. I didn't really do it, I was laying there.

[Dr. Brian Hartley]:
You weren't holding guidewire, and you didn't get access?

[Dr. Jason Hoffman]:
They took care of all the hard work. I had to lay there, although I guess in my own way.

[Dr. Brian Hartley]:
Do you remember much of it?

[Dr. Jason Hoffman]:
I remember parts. Yes. There were parts that it was pretty extreme, the pain. We did have anesthesia there, and there were parts that I was more deeply sedated than others.

[Dr. Brian Hartley]:
How many times were you on the table?

[Dr. Jason Hoffman]:
I joke that now I've seen every table in my department for various reasons in terms of the workup and follow-up, because there was a whole other question as to why it happened. That's a whole other story. I was in and out of the IR suite probably four times, so four different days, and multiple days of lysis and interventions, thrombectomy, angioplasty. They chipped away at it. Clinically, I was holding on, so we went that path. Ironically, what hurt the most at the end, I'll never forget, I was in the SICU and after they were done, and I ended up actually, I had an A-line. I have trans-hepatic access, and I ended up, ironically, here I am, the PAE guy, I end up in urinary retention requiring a Foley.

I have a newfound appreciation from seven years ago about unexpected urinary retention, but I think it just went along with being immobilized, and a lot of sedation, and meds, and potty's out of whack, shall we say, for a period of time. When they were done with the procedures at the end, did some track embolization on the way out. I think that there was probably some diaphragmatic irritation there that was pretty intense. The pain there at the end was almost like back at the beginning, but a different type of pain. I'm super lucky. I didn't need other surgical interventions, or going down the tips bath, and other things.

Now, I realize in 2024, we might handle this a little differently compared to 2017. We have other tools, other techniques, we know more, we may approach this a bit different. I'm pretty lucky. My splenic vein, my main portal's open left, portal's been open now for years, and have some chronically occluded right portal branches, but I've had some left-sided hypertrophy, and my intestines are working just fine. I'm, again, unlucky that it happened, but super lucky that a great team of people took awesome care of me, and not just the IR team, so many other specialties as well, and still now managing long-term.

[Dr. Brian Hartley]:
Now, tell me, did they ever find out in etiology, or is there some type of hypercoagulable state?

[Dr. Jason Hoffman]:
Yes, I'm full of stories that don't really make sense, or you might laugh a little bit. I'm in the ER and they started a heparin drip, and I said, "Oh, I forgot to tell you, my dad was diagnosed 30 years ago, or maybe 25 years ago with DVT, and ended up with Factor V." I actually have it, and I knew about it since I was in medical school. At the time the thought was, it's heterozygous, just to not to do anything. That being said, most patients that I've seen, this was a pretty unique way to present. The thought was maybe there's more to it than just having a hypercoagulable state, because the portal system is a pretty big vasculature, somewhat relatively decent flow, and you think about DVT, things like that.

Now, that being said, every patient's different. The thought was probably that I had some biliary dyskinesia, and not cholecystitis per se, but that maybe I had a little bit of inflammation or something that might have triggered this. I had all sorts of work up to make sure I didn't have any malignancy and things like that, which fortunately, no, I don't. I still follow with my hematologist and get imaging and GI. My IR team is aware of what's happening. Luckily, since literally December of 2017, I have not needed any other IR procedures relating to this, which is great.

[Dr. Brian Hartley]:
Any anticoagulation? Did you mention that?

[Dr. Jason Hoffman]:
Yes, so I didn't mention, so I am on Xarelto. I joked, I have a picture that I've shown at times when I've spoken about this of me in a package insert of Xarelto. It makes me think all the time I talk to patients about meds, whatever it may be, whether it's in the BPH space or IO space, wherever. I opened up the package insert from Xarelto, and it's, I don't know, four-point font, some tiny font. It's the equivalent of probably 100 pages of information. I thought, wow, if I read this, I'm certainly never going to want to
take it. I can imagine.

I thought, oh, I imagine if I didn't have any medical knowledge, I start reading this, it's pretty scary. It's important for it to be on, and I'm on a half dose now, so we did full dose for a while. I'm on the 10 to 10 milligram dose now, and been doing great for years, which is, I'm really lucky.

[Dr. Brian Hartley]:
Tell me, during the experience, how did you feel?

[Dr. Jason Hoffman]:
I've had ultrasounds and things done, and there's almost like a, it's not a helplessness, but you just feel like this is not where I'm supposed to be.

[Dr. Brian Hartley]:
How did you feel emotionally going through that? Vulnerable, I assume.

[Dr. Jason Hoffman]:
Yes. I was there at the hospital for about seven nights, and most of that was ICU level care. Again, I came to the ER. I knew something was wrong. By that point, I knew I had a problem, but I just never would have thought I had what I had, if that makes sense. Over that experience, it was a shock to be diagnosed with what I had. All these little micro-experiences have happened, particularly over that week, and even since then of bringing myself to the ER, not being able to say goodbye to my son.

This happens to our patients all the time when crazy things happen. I didn't have any idea what grave danger I was in or could have been in. Maybe I should have. Maybe I just was neglecting the fact that I knew I was in a lot of pain. Calling my partners, I'll never forget, everybody showed up, extra nurses techs. One of my nurses was pregnant at the time, and we had been joking about, just about the timing of her delivery. I remember she was there for one of my procedures, and just-- Again, these are people I worked with for years. These are your friends, these are your extended family, and it was just overwhelming in terms of the emotion.

That being said, I wanted to see my son, so they figured out a way before I went into one of the procedures that my wife brought my son, and people brought little things that I could give to him, and tried to cover up any lines that I had. It was hard to hold myself together for that, truthfully. Watching my parents watch me do that, no parent ever wants to see their child suffer or expects to see their child suffer. My parents watched that, and my wife too. Of course, seeing me try to do that for my son, but not let him realize how sick I was, but just I needed to see him before one of these procedures a certain day.

Again, I was surrounded with people. My residents, colleagues, I've worked at the hospital for years by that point. There was an outpouring of support, but there were also times where you just need to be alone because you don't want people to see you suffering or see you in pain either. Sometimes, you're just not in the mood to put the big smile on your face. What happened in IR, it was incredible, I was out of the hospital after a week, and I felt like I could go back to work a couple of days later. Again, my partners were like, "You're nuts.

You have to take a week." I think it was either the first or second case back was a PAE I was doing. I remember being halfway through it thinking, all right, I'm physically not 100%. Mentally, I was fine. I said, I just have to just think this through. I had a speaking engagement at an event in Vegas, ironically, just a couple of weeks later. In my mind and in my body, I said, "You know what? I need to get there. I want to show myself that I'm back," so to speak, or that I survived, at least in the short term. Yes, so I think early January, mid-January of 2018, I was out speaking at the event I was supposed to be teaching at.

For me, it was really meaningful. Everything happened so fast. Again, the care I was lucky. The care I had was awesome. I've thought a lot about over the years about going back to work fast. A lot of what we offer patients in IR is relatively fast healing. That's one of the, or at least physical healing, that's one of the things that's great about what we can do for our patients, do amazing procedures, offer excellent outcomes, and often, again, of course, minimally invasive, low risk, but not no risk. Then sometimes the healing though is more than just physical.
I went back to work a week later, I think in the grand scheme of things, I'm glad I did it, but it didn't mean that I was 100% mentally prepared for what was going to happen when I was back at work. That's opened my eyes a lot to that as well.

[Dr. Brian Hartley]:
How did it change the way you practice medicine and work with your patients?

[Dr. Jason Hoffman]:
Yes, over the years, our clinic infrastructure has definitely evolved and gotten more robust. I think I have more opportunities now than before, even to really develop those relationships. It's something that I've been, I think, typically known for in terms of the interactions I have with patients, and just really trying to build that rapport because I really do value the trust that our patients put in. I think I've always been like that, but make no mistake about it. When you're on the table and you have an adventure like this, it certainly opens your eyes.

I do try to reflect on it pretty regularly because I don't want it to just be the past. I want to learn from it and carry it with me, and try to just remind myself we're human beings taking care of human beings. We want to do the best we can for our patients. We want them to trust us. We want them to let us do what we think is appropriate. A lot of what we do is educating our patients, and understanding where they are in their care, why they're interested maybe in some of the procedures we have to offer. Or if they're not interested, why, and not judging them, but just helping them make decisions that they're comfortable with that we also hopefully, agree with are appropriate for them.

It's opened my eyes about, again, I think that relationship as well. Over the past few years, I've done more reflection and talking also about what it really means in terms of the phrase, the patient experience, because sometimes I feel like that gets over-utilized. Again, I think that our presence at a lot of hospitals and IR on the floor are much more present maybe than we would have been 15, 20 years ago, certainly more robust clinics across the country. I'm sure many of us could still do better than we do, but being present not just for those procedures is certainly important.

Again, a lot of the procedures we do, patients are awake. It's a different environment. We know this already. I realize we've all gone to medical school. We're talking as radiologists and intervention radiologists, people know this already, but I don't know. I think it's easy to forget that at times that, yes, we're taking care of patients or they're feeling vulnerable. We understand that. The fact that they're awake or awake-ish, if we can use that term, in a way, that's a great thing that they don't have to have general anesthesia and be intubated for everything that we're doing. It does add a different dynamic for some patients that they can hear and see, and that could be a great thing. For some patients, it can be really difficult for them to handle.

[Dr. Brian Hartley]:
Yes. It sounds like you really just need to be aware of these things. Certainly, an experience like yours will make you acutely aware of all of these things. It's a great reminder for everyone else as well, that there's a patient that has emotions underneath there and you need to put yourself in their shoes to treat them in the best way.

[Dr. Jason Hoffman]:
Yes. Another ironic thing or not ironic, I guess, and unfortunately was a relatively devastating thing that happened to me a few years later in life during the COVID pandemic is my dad got sick. He, ironically, years later, ended up with some degree of portal vein thrombosis. Not the extreme that I had, but it was relating to, unfortunately, he was diagnosed with pretty aggressive, large HCC, probably diagnosed a little late relating to COVID and delays and just him seeing docs. He unfortunately passed away from this disease, but the same docs and including myself, I know so many other docs in my institution helped take care of him.

Then being his family member, being his son watching him come into our IR same rooms, he's on the same table as I was or tables. That concept of waiting for a procedure and a delay that may happen because we're helping another patient. Sometimes our patients don't quite get that. I know we don't have endless amount of time to go and apologize to every patient when there's a delay, but it can be hard to make every patient feel that they're the center of attention all the time. That's what they want. In a way, that's what we all deserve as human beings, but we're stretched thin.

We're doing a lot of work and we're trying to take care of a lot of patients and teach and do all sorts of different things. Sometimes patients feel judged. I know, I remember sometimes people that my dad and saw they had heard that HCC, I could tell a few of them right away were like, "Oh, he must've been a drinker." Or, "He must've been this." Obviously it doesn't really matter, first of all. Second of all, he wasn't, but there's some other things that were going on genetically we've come to learn. It's so easy, we have different biases in life, and we don't want to judge people, but we only know what we know.

We know we've experienced. Watching a few people's faces over a few visits my dad had into IR where I could tell they had HCC and they just make certain assumptions. I've always tried not to do that. I don't think I do. I'm sure I'm not perfect. We all fail at times. There's always times in life we could do things better, but that was a whole 'nother complexity to my path over the last few years of having my eyes open with Dad as well. It is a bit ironic. I'm lucky because I had portal vein thrombosis and survived. My dad's was a whole 'nother different reason, but he didn't survive.
A lot of patients don't survive due to all sorts of different things that happen and bad hands they're dealt, so to speak. It's hard. It's hard on patients. It can be hard on the docs, but that being said, I think again, in IR, one of the things I love is that I work with a lot of different types of patients, a lot of different types of providers. We're not 100% successful, but make no mistake about it. Every day in an IR practice, you have the opportunity and the honor in many ways to help patients and their families. I think overall, IR does a great job at that. It's something we have to try to hold it in our hearts