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This episode breaks down the 2026 AHA/ACC/ACCP/ACPPE pulmonary embolism guidelines, highlighting the biggest changes to PE risk stratification, catheter-based interventions, and long-term follow-up. It also discusses how new randomized trials like STORM-PE and HI-PEITHO are shaping the future of interventional PE care.
Biggest Change: The traditional "massive" and "submassive" PE classifications have been replaced with a new A through E risk framework, placing greater emphasis on dynamic clinical assessment and early recognition of patient deterioration.High-Risk Patient: The guidelines introduce Category D2, or normotensive shock, recognizing that patients with normal blood pressure but elevated lactate or signs of end-organ hypoperfusion may require urgent intervention.New Data Shows: Recent randomized trials demonstrated that catheter-based therapies improve right ventricular recovery and reduce clinical decompensation in intermediate-high risk PE, although long-term mortality benefits remain under investigation.Safety Pearl: The guidelines strongly caution against routine deep sedation in acute PE, noting a markedly increased risk of cardiopulmonary collapse with propofol in unstable patients.Bottom Line: These guidelines shift PE management from static risk categories to continuous reassessment and reinforce that interventional specialists should play an active role in both acute treatment and long-term follow-up.Tune in to learn how the new PE guidelines could change which patients receive intervention and when. Wysdom recommends that you check out PECompass.org. It was founded by Dr. Mona Ranade from Stanford IR and also a co-author of this paper. It is a great app in which you put in the clinical information about your patient and it will calculate what category your patient fits into.
This podcast is generated using an AI model that has been trained in the context of endovascular surgery and interventional radiology in addition context of the article cited below. The content was reviewed and edited by multiple healthcare professionals in the field.Bulman JC, Ranade M, Sista AK, Lookstein RA, Wilkins LR. The 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults: Pertinent Points for the Interventional Radiologist. J Vasc Interv Radiol. Published online 2026. doi:10.1016/j.jvir.2026.108899
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This episode breaks down a 2026 Journal of Vascular and Interventional Radiology prospective case series evaluating transarterial embolization (TAE) as a minimally invasive treatment for chronic, refractory plantar heel pain. The study explores how targeting abnormal blood vessel growth may offer relief for patients who have exhausted traditional therapies.
Clinical Problem: Nearly half of patients with plantar fasciitis remain symptomatic even after 10 years, and no single conservative treatment has consistently outperformed the others.New Approach: Rather than treating the plantar fascia itself, TAE targets the abnormal neovessels that sustain chronic inflammation and pain.Headline Result: At six months, 71% of patients responded to treatment, with major improvements in pain, quality of life, function, and a complete elimination of missed workdays among affected participants.Safety Profile: The procedure was performed as an outpatient with zero reported major adverse events and no evidence of osteonecrosis or tissue injury on follow-up MRI.Caveat: This was a small, single-center case series without a control group, so larger randomized trials are still needed to confirm how much of the benefit comes from embolization itself.Bottom Line: For patients with chronic plantar heel pain who have failed standard treatments, transarterial embolization is emerging as a promising minimally invasive option that could reshape how we approach chronic musculoskeletal pain.Tune in to learn how interventional radiology is taking on one of the most frustrating conditions in sports medicine.
This podcast is generated using an AI model that has been trained in the context of endovascular surgery and interventional radiology in addition context of the article cited below. The content was reviewed and edited by multiple healthcare professionals in the field.
Gill S, Hely R, Harrison B, Hely A, Landers S. Transarterial embolization to improve plantar heel pain: 6-month results from a prospective case series. J Vasc Interv Radiol. 2026;37:108688. https://doi.org/10.1016/j.jvir.2026.108688
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Saknas det avsnitt?
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This episode breaks down a comprehensive 2024 Journal of Urology review on prostate artery embolization (PAE), exploring how it compares to transurethral resection of the prostate (TURP) and medical therapy for benign prostatic hyperplasia (BPH) and why it was added to the 2023 American Urologic Association guidelines. The episode also features expert commentary from Dr. Timothy McClure of Weill Cornell Medicine, who highlights the importance of patient selection in real-world PAE practice.
Clinical Question: Can PAE relieve moderate-to-severe BPH symptoms while avoiding the bleeding, recovery time, and sexual side effects of TURP?Headline Result: Across randomized trials, PAE reduced IPSS scores by 9 to 21 points, shrank prostate volume by 20 to 30%, and outperformed both sham procedures and medical therapy in symptom relief.Safety Advantage: PAE is a same-day outpatient procedure with no postoperative catheter, near-zero transfusion risk, and strong preservation of sexual function when performed with cone beam CT guidance.Trade-Off: Symptom relief is strong, but urinary flow improvements and long-term durability remain inferior to TURP, with recurrence increasing over time.Bottom Line: For patients with larger prostates who prioritize preserving sexual function, PAE is now a guideline-supported middle ground between medication and surgery. Dr. McClure also explains why identifying the right patient is key to success.Tune in to learn which BPH patients are best suited for PAE and when surgery still makes the most sense.
This podcast is generated using an AI model that has been trained in the context of endovascular surgery and interventional radiology in addition context of the article cited below. The content was reviewed and edited by multiple healthcare professionals in the field.
Mouli S, Salem R, McClure TD. Prostate artery embolization for benign prostatic hyperplasia. J Urol. 2024;212:216-219. https://doi.org/10.1097/JU.0000000000003976
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This episode breaks down a JVIR retrospective study on Thyroid Artery Embolization (TAE), exploring whether embolization can serve as a non-surgical alternative for high-risk patients with massive retrosternal goiters who are poor candidates for thyroidectomy.
Clinical Problem: Many patients with large compressive goiters are too medically complex for surgery, leaving few options when airway compression and hyperthyroidism worsen symptoms. Endovascular Strategy: Using a femoral approach with selective embolization of thyroid feeders, operators intentionally leave at least one artery patent to achieve volume reduction while avoiding total gland necrosis and hypoparathyroidism. Headline Result: At six months, dominant thyroid nodule size and retrosternal extension were dramatically reduced, with most patients experiencing meaningful mechanical decompression and improved airway anatomy. Hormonal Benefit: Among patients with non-Graves hyperthyroidism, most became euthyroid after embolization, suggesting TAE may improve both compressive and endocrine symptoms. Caveat: This was a small retrospective study with mixed imaging modalities, short follow-up, and real procedural risks: including transient hyperthyroidism, hoarseness, and a reported 1.8% 30-day mortality rate. Bottom Line: For carefully selected poor surgical candidates with massive retrosternal goiters, thyroid artery embolization may offer a promising minimally invasive debulking strategy, but long-term durability still needs prospective study.Tune in to learn whether IR may soon have a larger role in managing patients traditionally sent straight to thyroid surgery.
This podcast is generated using an AI model that has been trained in the context of endovascular surgery and interventional radiology in addition context of the article cited below. The content was reviewed and edited by multiple healthcare professionals in the field.
Yilmaz S, Arıoz Habibi H, Yildiz A, Altunbas H. Thyroid embolization for nonsurgical treatment of nodular goiter: a single-center experience in 56 consecutive patients. J Vasc Interv Radiol. 2021;32:1449-1456. https://doi.org/10.1016/j.jvir.2021.06.025
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This episode breaks down the newly published ARIVA trial (Circulation), a randomized study testing whether adding aspirin to rivaroxaban after post-thrombotic iliofemoral venous stenting actually improves stent patency or simply adds bleeding risk.
Clinical Question: For years, endovascular specialists have reflexively prescribed dual therapy (anticoagulation + aspirin) after venous stenting, but ARIVA asks whether aspirin is actually improving outcomes in low-flow venous systems.Result: Primary patency at six months was nearly identical, 94.8% with rivaroxaban + aspirin versus 92.4% with rivaroxaban alone, suggesting no meaningful benefit to routinely adding aspirin.Bleeding Trade-Off: While major bleeding was absent in both groups, clinically relevant non-major bleeding was more than tripled with dual therapy (8.2% vs. 2.4%), with menorrhagia emerging as a major issue in this predominantly younger female cohort.Why This Matters: When synthesized with C-TRACT, ARIVA suggests we may be overtreating venous stent patients by applying arterial antiplatelet logic to fundamentally different venous biology.Caveat: ARIVA was stopped early and excluded patients with active cancer or poor medication adherence, meaning high-risk populations still require individualized decision-making.Bottom Line: For most standard post-thrombotic iliofemoral stenting cases with good inflow and optimized IVUS-guided deployment, full-dose rivaroxaban alone may be enough without the added bleeding burden of routine aspirin.Tune in to learn whether it is finally time to stop reflexively prescribing aspirin after venous stenting.
This podcast is generated using an AI model that has been trained in the context of endovascular surgery and interventional radiology in addition context of the articles cited below. The content was reviewed and edited by multiple healthcare professionals in the field.Barco S, Jalaie H, Sebastian T, et al. Aspirin plus rivaroxaban versus rivaroxaban alone for the prevention of venous stent thrombosis among patients with post-thrombotic syndrome: the multicenter, multinational, randomized, open-label ARIVA trial. Circulation. 2025;151:835-846. https://doi.org/10.1161/CIRCULATIONAHA.124.073050
Vedantham S, Kahn SR, Marston WA, et al. Endovascular therapy for post-thrombotic syndrome — a randomized trial. N Engl J Med. 2026. https://doi.org/10.1056/NEJMoa2519001 -
This episode breaks down the landmark C-TRACT trial (NEJM 2026), a phase 3 randomized study testing whether iliac vein stenting plus enhanced antithrombotic therapy actually improves outcomes in patients with moderate-to-severe post-thrombotic syndrome (PTS).
The Clinical Question: Does restoring iliac venous outflow with stenting meaningfully improve symptoms and quality of life? Result: Endovascular therapy significantly improved symptom burden, with a meaningful reduction in VCSS severity and a striking 14.5-point improvement in quality-of-life scores. Mechanical Win: Stent thrombosis was remarkably low at just 0.9%, reinforcing the importance of rigorous inflow assessment, mandatory IVUS, and aggressive stent sizing in chronic venous disease. Trade-Off: Bleeding complications were substantially higher in the intervention arm (11.6% vs. 3.6%), largely driven by prolonged dual antithrombotic therapy rather than the procedure itself. Bottom Line: For carefully selected PTS patients with good inflow and significant iliac obstruction, iliac vein stenting can deliver meaningful symptom relief, but success depends heavily on patient selection, IVUS-guided technique, and thoughtful post-op management.Tune in to learn which post-thrombotic patients actually benefit from venous stenting—and where the limits of the “open vein hypothesis” begin.
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This episode breaks down a randomized controlled trial from Hepatology exploring whether prophylactic embolization of large spontaneous portosystemic shunts (SPSS) during TIPS can prevent post-procedural hepatic encephalopathy (HE).
The Core Problem: Even successful TIPS can trigger HE by shunting toxins away from the liver, especially in patients with large preexisting SPSS. The Key Strategy: Embolizing SPSS before stent deployment improves visualization and avoids catastrophic coil migration after portal decompression. A High-Impact Result: Overt HE was cut nearly in half (21% vs. 48%), with a remarkable number needed to treat (NNT) of just 4. No Increased Bleeding Risk: Closing these shunts did not increase variceal rebleeding or compromise TIPS function. The Trade-Off: The procedure adds time and briefly increases portal pressure, requiring operator confidence and careful execution. The Bottom Line: In a highly selected subset of patients, combining TIPS with SPSS embolization is a powerful, anatomy-driven approach to reduce HE risk.Tune in to learn when this added step is worth it!
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This episode breaks down the landmark HI-PEITHO trial (NEJM, March 2026), a multicenter randomized controlled trial of 544 patients that finally brings clarity to the category of intermediate-risk PE.
The Inclusion Criteria: HI-PEITHO mandated a strict "intermediate-high" entry bar: RV:LV ratio > 1.0 plus dual objective signs of distress (e.g., HR > 100, BP < 110). It isolates the cohort most likely to crash.The 7-Hour Rapid Protocol: We discuss the operational shift away from the legacy 24-hour ICU drip. The trial utilized a concentrated, bilateral 7-hour infusion of ~17mg Alteplase via the EkoSonic system.61% Risk Reduction: The headline result: US-CDT achieved a massive relative risk reduction in the primary composite endpoint (cardio-respiratory collapse or decompensation), with an event rate of 4.0% vs. 10.3% in the heparin-only arm.The Safety Holy Grail: In a major win for the "local low-dose" strategy, there were 0% intracranial hemorrhages (ICH) in both groups. Major bleeding rates were statistically insignificant (P = 0.64), validating the safety of this sub-20mg protocol.Mechanical Thrombectomy Question: While HI-PEITHO establishes a modern benchmark for lytics, it does not address the rise of large-bore mechanical thrombectomy. It sets the safety and stabilization bar that future MT trials must now cross.Tune in to learn about the March 2026 data!
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This brief covers a massive 950-patient study identifying how to predict Post-TIPS Liver Failure (PTLF), which occurs in approximately 18% of cases.
The 18% Problem: With nearly 1 in 5 patients failing after TIPS, this study provides a vital roadmap for identifying high-risk candidates before they hit the table.Baseline Red Flags: Older age, a history of Hepatic Encephalopathy (HE), and celiac stenosis were found to be independent predictors of PTLF during pre-procedural workup.The Real Signals: Forget static numbers; the focus post-op must be on the peak MELD score and the percent change in INR. These are the dynamic predictors that actually matter.The AST/ALT: This study debunks "enzyme panic." While startling, AST and ALT spikes are like loud car alarms—scary, but they do not independently predict whether the liver will fail to recover.The Bottom Line: Combining clinical history with dynamic post-TIPS labs is the key to identifying candidates for early transplant evaluation before a clinical crash.Tune in to learn which post-op "alarms" are worth investigating and which you can safely ignore.
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This episode highlights the MILESTONE study, a ground-breaking first-in-human trial presented at the Society of Interventional Radiology (SIR) 2026 Annual Meeting. The research explores a novel endovascular approach to "rewiring" the body's metabolic control center to treat Type 2 Diabetes Mellitus (T2DM).
A Safe Metabolic Rewire: Using a novel six-electrode catheter system, researchers performed endovascular denervation of the celiac artery and nearby aorta. The study achieved a 100% technical success rate with zero severe treatment-related adverse events, proving the safety of targeting the splanchnic sympathetic nerves.Dramatic Glycemic Control: The six-month data showed a significant metabolic shift, with average HbA1c levels dropping from 9.9% to 8.0%. Additionally, fasting plasma glucose and insulin resistance (HOMA-IR) plummeted, marking a major clinical improvement without lifestyle changes.Reduced Insulin Dependency: Patients saw objective improvements in liver and beta-cell function. Most notably, daily insulin requirements were reduced from an average of 24 units down to 19 units, suggesting a future where IR interventions could minimize or replace heavy pharmacological regimens.The New Frontier: This Abstract of the Year signals the potential for Interventional Radiology to move beyond traditional vascular work and into the primary management of chronic metabolic diseases.Tune in to learn how interventional radiology is positioning itself at the center of the diabetes care team.
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The COLLISION Explained
This episode breaks down the practice-changing COLLISION Trial (Lancet Oncology, 2025) and explores how the IR community must scale its skills to meet the new standard of care.
The Mic Drop: For decades, surgical resection was the undisputed gold standard for Colorectal Liver Metastases (CRLM). The COLLISION trial randomized patients eligible for both surgery and thermal ablation. The trial was stopped early for benefit, proving that ablation is non-inferior for overall survival (Hazard Ratio 1.05).The Staggering Cost Difference: While survival was equal, the physical toll was not. Surgery resulted in a 46% adverse event rate and a 4-day median hospital stay. Ablation cut complications to 19%, reduced the hospital stay to just one day, and had a 0% treatment-related mortality rate.The A0 Margin Mandate: To match surgical success, IRs must achieve an A0 margin—a visible 5mm buffer of ablated tissue surrounding the tumor on post-procedure imaging. Achieving this margin ensures the absence of local progression in 95% of cases.Scaling the Skillset: We discuss how the platform Wysdom (founded by Dr. Rusty Hoffman) is replacing the outdated "see one, do one, teach one" model. Through bite-sized "Clinical Pearls" and private "Morning Rounds," Wysdom provides just-in-time digital mentorship, allowing community IRs to learn complex techniques (like hydrodissection) necessary to achieve that critical A0 margin.Tune in to hear why the default question at the tumor board is shifting from "Can we cut it out?" to "Why wouldn't we ablate this first?"
Based on comments from experts, content on Wysdom, and the article cited below.
Puijk RS, Ruarus AH, Vroomen LGPH, et al. Colorectal liver metastases: surgery versus thermal ablation (COLLISION) - a phase III single-blind prospective randomized controlled trial. BMC Cancer. 2018;18(1):821. Published 2018 Aug 15. doi:10.1186/s12885-018-4716-8
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AHA/ACC 2026 Guidelines for the Evaluation and Management of Acute Pulmonary Embolism
The alphabet soup of societies (AHA/ACC/ACCP/ACP) has officially released the 2026 Multi-Society PE Guidelines. These guidelines move the field away from the blunt submassive labels and into a new era of granular, physiology-driven care.
Categories Classifications A–E: The 2011 AHA labels are officially retired. We now use a spectrum from Category A (Subclinical) to Category E (Cardiopulmonary Failure). Key for IR: Advanced therapies are now strictly reserved for Categories D and E, while most Category C patients (even with RV strain) remain on medical management unless they deteriorate.The "R" Modifier: A new suffix for patients whose primary threat is respiratory failure rather than hemodynamic collapse (e.g., Category C2R), allowing for a more nuanced triage during PERT activations.Reading Room Mandate: The guidelines emphasize that clot volume does not equal risk. Radiologists must now prioritize reporting RV dysfunction parameters—including RV:LV ratio, McConnell’s sign, and TAPSE—as these are the data points that actually drive the A–E categorization.IVC Filter Pullback: In a major shift, routine IVC filter placement in anticoagulated patients is now a Class III: Harm recommendation. They are strictly limited to patients with absolute contraindications to anticoagulation or those failing therapy.The "Clot in Transit" Data Vacuum: For the 2-4% of patients with floating intracardiac thrombus, the guidelines admit a lack of randomized data, mandating a multidisciplinary PERT decision rather than a fixed surgical or interventional algorithm.Tune in to master the new rules of engagement for the IR suite and ensure your reports meet the 2026 standard.
Based on comments from experts, content on Wysdom, and the guidelines cited below.
Writing Committee Members*, Creager MA, Barnes GD, et al. 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. Published online February 19, 2026. doi:10.1161/CIR.0000000000001415
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Stanford IR's Dr. Lynne Martin on PAVM Treatment
This episode covers the critical paradigm shift in treating Pulmonary Arteriovenous Malformations (PAVMs) as detailed by Dr. Lynne Martin from Stanford Interventional Radiology. We discuss why the old "block the pipe" method is obsolete and how to achieve durable, definitive occlusion.
The Silent Neurological Threat: We explore why intervention isn't about hypoxia—it's about preventing paradoxical emboli. With stroke risks up to 32% and a 40-50% prevalence of silent brain infarctions, the lung's broken filter puts the brain directly in the firing line.
The Odontogenic Connection: A crucial clinical pearl: routine dental cleanings can cause brain abscesses in PAVM patients because transient oral bacteria bypass the lung filter. Lifetime antibiotic prophylaxis for dental work is mandatory.
The "3mm Myth": The old rule of only treating feeding arteries >3mm is dead. Modern guidelines dictate that any measurable, safely catheterizable PAVM—even 2mm feeders—must be treated, as they still carry significant stroke and abscess risk.
Why Proximal Coiling Fails (The Jailed Nidus): Placing a coil proximally creates a low-pressure, ischemic environment that triggers massive VEGF release, recruiting tiny collateral vessels to feed the sac. This creates a "jailed nidus"—a growing AVM that is now impossible to access and treat.
The New Standard ("Pack the Bucket"): Dr. Martin advocates for complete mechanical occlusion of the nidus itself using soft, high-volume detachable coils ("liquid metal"). We discuss why vascular plugs are contraindicated inside the sac and how to hunt for the hidden systemic feeders (bronchial/intercostal arteries) that cause recurrence.
Tune in to learn why we are moving away from being "catheter plumbers" and how to definitively protect your PAVM patients.
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TIPS for TIPS: The "Best Chance" Protocol
This episode tackles one of the most technically demanding procedures in IR, breaking down Dr. John Louie’s protocol to transform the traditional "blind stick" of a TIPS procedure into a visualized, scientific process.
The Visualization Crisis: Standard iodinated contrast fails to opacify the portal vein 75% of the time because it washes out with flow. We discuss why CO2 digital subtraction angiography is the superior alternative, achieving an 87% visualization rate by using buoyancy to backfill the portal system.
The "Targeted Puncture": How using CO2 turns a missed needle pass into a roadmap, allowing you to correct your angle based on visual feedback rather than guessing.
IVUS as the Great Equalizer: We review data showing that Intravascular Ultrasound (IVUS) significantly reduces radiation and capsular perforations. Crucially, the data shows IVUS benefits inexperienced operators the most, allowing them to match the speed and safety of veterans.
The Anatomy Hack: Dr. Louie solves the "Parallel Vein" illusion (where the Right and Middle Hepatic veins overlap) with one simple move: Check the Lateral View. The RHV will always be posterior.
The "Backdoor" (DIPS): When standard access fails, Direct Intrahepatic Portosystemic Shunt (DIPS) is the alternative. We discuss why it's a last resort due to the risks it poses for future liver transplantation.
Tune in to learn how to stop "poking and praying" and start seeing your target.
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Thyroid Interventions: RFA vs. Microwave & The Embolization Solution
This episode breaks down the evolving landscape of benign thyroid management, pitting the two thermal ablation titans against each other and exploring the vascular solution for massive goiters.
The 12-Month Divergence (RFA vs. MWA): A 2025 meta-analysis reveals that while short-term results are similar, Radiofrequency Ablation (RFA) proves superior at one year (83.3% vs 77% volume reduction). The reason? Microwave Ablation (MWA) creates high-heat carbonization ("charring") that the body struggles to resorb compared to the softer coagulative necrosis of RFA.
The "Thermal Overshoot" Risk: MWA is less forgiving, with a steeper thermal gradient that risks injury to the recurrent laryngeal nerve. RFA remains the safer "workhorse" for operators with less than 10 years of experience.
Solving the "Unavoidable" with TAE: For massive retrosternal goiters invisible to ultrasound, Thyroid Artery Embolization (TAE) is the only option. The study showed a 69% volume reduction and critical retraction of the retrosternal mass, restoring the patient's ability to breathe and swallow.
Managing the Hormone Dump: Infarcting a large goiter releases a massive wave of T3/T4. We discuss the critical management protocol: beta-blockers, methimazole, and the "pearl" of using bile acid sequestrants (Cholestyramine) to clear the hormone surge.
The Holy Grail of Euthyroidism: Unlike radioactive iodine or surgery which often lead to lifelong hypothyroidism, TAE showed an 86% success rate in returning hyperthyroid patients to a normal euthyroid state without medication.
Tune in to decide which tool belongs in your thyroid toolkit: the precision of RFA, the power of Microwave, or the vascular reach of Embolization.
Based on comments from experts, content on Wysdom, and the articles cited below.
Lim H, Cho SJ, Baek JH. Comparative efficacy and safety of radiofrequency ablation and microwave ablation in benign thyroid nodule treatment: a systematic review and meta-analysis. Eur Radiol. 2025;35(2):612-623. doi:10.1007/s00330-024-10881-7
Yilmaz S, Habibi HA, Yildiz A, Altunbas H. Thyroid Embolization for Nonsurgical Treatment of Nodular Goiter: A Single-Center Experience in 56 Consecutive Patients. J Vasc Interv Radiol. 2021;32(10):1449-1456. doi:10.1016/j.jvir.2021.06.025
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Provocative Mesenteric Angiography: Safety and Efficacy in Occult GI Bleeding
This episode tackles one of the most frustrating clinical challenges in Interventional Radiology: the patient with a recurrent occult GI bleed who has failed endoscopy and standard imaging. We analyze the largest retrospective cohort study to date (22 years of data) on TPA-based Provocative Mesenteric Angiography (PMA) to determine when to use this aggressive diagnostic maneuver.
The Safety Surprise: Despite intentionally provoking bleeding with TPA and Nitroglycerin, the study revealed zero major bleeding adverse events, thanks to "first-pass hepatic metabolism" clearing the drugs before they hit the systemic circulation.
The "Secret Sauce" for Selection: We identify the two independent predictors that increase the odds of a positive study by nearly sevenfold:
Hematochezia (bright red/maroon stool).
A Prior Positive Radiologic Study (CTA or Tagged RBC), even if the bleed appeared to stop.
The Hard Stop: The data provides a clear exclusion criterion: zero patients with Melena (black tarry stool) and negative prior imaging had a positive PMA result, suggesting these procedures are likely futile.
Technical Mastery: Success relies on super-selectivity. Injecting from a distal, third-order vessel yielded a 63.6% positivity rate, compared to just 21.5% from a proximal injection.
Tune in to learn how to safely provoke the bleed on your terms and identify the source when all other methods fail.
Based on comments from experts, content on Wysdom, and the article cited below.
Benvenuti TA, Chisholm M, Cline B, et al. Provocative Mesenteric Angiography for Obscure Gastrointestinal Hemorrhage: An Update on Outcomes, Safety, and Predictors of Success. J Vasc Interv Radiol. 2025;36(10):1558-1566. doi:10.1016/j.jvir.2025.06.022
Featured Commentary: Dr. Charles Kim (Duke University)
We are honored to include exclusive commentary from the study’s senior author and Chief of IR at Duke, Dr. Charles Kim. Dr. Kim provides a candid look at the last-ditch nature of this procedure and the future of the field:
A Last-Ditch Essential: Dr. Kim argues that while we may have reached the limit of what retrospective TPA data can tell us, PMA remains a vital tool for "desperate patients" that every major hospital IR team should be comfortable performing.
Navigating the TPA Paradox: He acknowledges the "referral friction" IRs often face, as TPA is technically contraindicated in patients with recent GI bleeding. Understanding the safety profile is key to managing these inter-departmental relationships.
The CO2 Frontier: Dr. Kim highlights the potential of CO2 Provocative Angiography. While his team currently uses it in their sequence, he notes that the extremely high positivity rates reported in some literature have been difficult to replicate—leaving the door open for future CO2 experts to refine the technique.
Tune in to learn how to safely provoke the bleed on your terms and identify the source when all other methods fail.
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Dr. Rusty Hofmann, Professor of Interventional Radiology and founder of Wysdom, drops essential night-call wisdom after 25+ years of taking call: when & why to come in, how residents/fellows should present cases, and his famous 6 Cs mnemonic to never forget critical prep at 2–3 AM.
Key takeaways:
Only come in for life- or limb-threatening emergencies — everything else waits for morning team/staffingPerfect case presentation format: Lead with the problem (“GI bleeder in ER, likely needs TIPS”) Then age/sex, vitals (BP 90/60, HR 120), pressor requirements, blood products, and imaging/findings. This gets the attending engaged fastThe "Rule of 100": if the pulse is >100 or systolic BP is <100, the patient is likely bleeding. However, strongest predictor of finding active extravasation on an angiogram is whether the patient is actively being transfused.The 6 Cs checklist (memorize this!):Consent – get it signedCoags – check INR/PT/PTTCreatinine – kidney function for contrastContrast allergy – history? Premed?Contraindications – recent surgery, trauma, brain bleed (especially if tPA)Can the patient be still? – anesthesia needed? (Most important at night!)This quick, practical framework has saved countless chaotic night cases. A must-watch for every IR resident, fellow, APP, and attending who takes call.
#IRCall #NightCall #InterventionalRadiology #RustyHofmann #IRtips #6Cs #EmergencyIR #TIPS #GIBleed #StanfordIR #IRad #IRfellow #IRresident #IRcommunity #MedicalEducation #OnCall #Wysdom #IRpearls
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Y-90 High Lung Shunt: The Mitigation Playbook
This episode is inspired by Professor of Interventional Radiology Dr. John Louie from Stanford IR and moves beyond the standard safety guidelines to provide a practical "playbook" for managing the high lung shunt patient, focusing on how to prevent fatal Radiation Pneumonitis (RP) without canceling the case.
The Hidden Threat: We define the stakes of Radiation Pneumonitis—a rare (0.1%) but highly lethal (40-60% mortality) complication with a delayed onset of 1-2 months.
Predicting the Shunt: Learn to spot the "Phasic CT Sign"—early venous streaming during the arterial phase—which signals a massive tumor fistula before you even order the MAA scan.
Mitigation Strategy A (Balloon Occlusion): We detail how placing a compliant balloon in the hepatic vein can reduce shunting by an order of magnitude (e.g., 20% down to 2%), effectively converting a contraindicated patient into a candidate. Pro Tip: Don't forget to occlude the accessory Inferior Right Hepatic Vein.
Mitigation Strategy B (Embolization Trap): The discussion reveals a critical counter-intuitive rule: Never use small particles to plug a shunt. This actually increases the shunt percentage by increasing resistance in healthy tissue. You must use large embolics (Gelfoam, large coils) to physically plug the fistula.
Glass vs. Resin: We explore real-world data suggesting the standard "30 Gray limit" may be too strict for Glass (which tolerates higher doses) and potentially too loose for Resin (where RP is more common).
Tune in to learn the specific techniques that let you safely treat the "untreatable" shunt.
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Portal Vein Embolization, Liver Venous Deprivation, and the DRAGON Trial Data
This episode synthesizes the latest CIRSE standards and DRAGON trial findings to guide Interventional Radiologists in maximizing the Future Liver Remnant (FLR) and minimizing Post-Hepatectomy Liver Failure (PHLF).
The Limitation of Standard PVE: We discuss why Portal Vein Embolization (PVE) alone often isn't enough, with a sobering 15-20% failure rate where patients never reach resection due to insufficient hypertrophy or tumor progression.
The "Combined" Solution (DVE/LVD): The discussion explores why adding Hepatic Vein Embolization (HVE) to block outflow prevents collateral formation ("the enemy of hypertrophy"), creating a faster, more robust regenerative signal.
DRAGON 0 Results: The retrospective data is a game-changer: combined embolization achieved a 92% resectability rate (compared to just 68% for PVE alone) and significantly better long-term survival.
The Paradox of Speed: While the prospective DRAGON 1 trial showed massive growth speed (Kinetic Growth Rate of 8.3% per week), it revealed a critical warning: 22% of patients still developed liver failure despite hitting volume targets.
The New Standard: The takeaway is clear—Volume does not equal Function. To prevent failure in these rapidly regenerated livers, we must move beyond simple volume ratios and demand functional assessments like KGR and mebrofenin scintigraphy before surgery.
Tune in to understand why "making volume" isn't enough and how functional assessment is the new safety frontier.
Based on comments from experts, content on Wysdom, and the articles cited below.
Bilhim T, et al. CIRSE Standards of Practice on Portal Vein Embolization and Double Vein Embolization/Liver Venous Deprivation. Cardiovasc Intervent Radiol. 2024 Aug;47(8):1025-1036. doi: 10.1007/s00270-024-03743-8. Epub 2024 Jun 17. PMID: 38884781; PMCID: PMC11303578.
Korenblik R, et al., DRAGON collaborative study group. Safety and efficacy of combined portal and hepatic vein embolisation in patients with colorectal liver metastases (DRAGON1): a multicentre, single-arm clinical trial. Lancet Reg Health Eur. 2025 Apr 10;53:101284. doi: 10.1016/j.lanepe.2025.101284. PMID: 40255933; PMCID: PMC12008670.
Korenblik R, et al., DRAGON trials collaborative. Liver regeneration after portal and hepatic vein embolization improves overall survival compared with portal vein embolization alone: mid-term survival analysis of the multicentre DRAGON 0 cohort. Br J Surg. 2024 Apr 3;111(4):znae087. doi: 10.1093/bjs/znae087. PMID: 38662462; PMCID: PMC11044894.
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GAE for Knee Osteoarthritis: The Resorbable Solution
This episode explores the first-in-human trial of Sakura, a novel resorbable alginate microsphere designed specifically to solve the safety trade-offs of Genicular Artery Embolization (GAE) for knee osteoarthritis.
The Problem with Current Agents: We discuss why Interventional Radiologists have been stuck between using permanent particles (risk of skin ulcers/long-term pain) and off-label temporary agents (unpredictable resorption, antibiotic resistance).
The Bio-Innovation: This new device features an "internal timer"—an enzyme trapped inside the bead that activates upon hydration, ensuring predictable degradation within just 1 to 2 hours.
Safety Game-Changer: The trial showed zero serious adverse events. Crucially, non-target skin redness resolved in just 2 hours, compared to weeks with traditional agents, drastically improving the safety profile.
Efficacy vs. Speed: Despite the rapid resorption, patients achieved a 77% reduction in pain at 3 months, and 93% stopped taking pain medication entirely, suggesting that a brief ischemic "reset" is all that is needed to stop the pain cycle.
Tune in to see how this "self-destructing" particle could redefine the standard of care for chronic knee pain.
Based on comments from experts, content on Wysdom, and the article cited below.
Little MW, Agarwal S, Khikmatovich IM, McCabe J, Pandey M, Lewis AL, Farrissey L, Iskhakov SA. First-in-Human Evaluation of a New Resorbable Microspherical Embolic Agent for Genicular Artery Embolization to Treat Pain Secondary to Knee Osteroarthritis. J Vasc Interv Radiol. 2025 Nov;36(11):1658-1666. doi: 10.1016/j.jvir.2025.07.010. Epub 2025 Jul 18. PMID: 40685121.
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