• 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.

• 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!

• 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!

• 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.

• 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.

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

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

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.

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.

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

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.

Key takeaways:

• Only come in for life- or limb-threatening emergencies — everything else waits for morning team/staffing
• Perfect 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 fast
• The "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!):
  1. Consent – get it signed
  2. Coags – check INR/PT/PTT
  3. Creatinine – kidney function for contrast
  4. Contrast allergy – history? Premed?
  5. Contraindications – recent surgery, trauma, brain bleed (especially if tPA)
  6. 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

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.

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.

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.

• You Get Out What You Put In: Residency isn't medical school; there are no weekly tests. Success requires self-guided learning, reading every night, and showing up early to see as much as possible.

• Find Balance: It’s a long six years. Decompressing with hobbies and building relationships with co-residents is vital for sustaining your energy.

• Earning Autonomy: Don't expect full autonomy on day one. It is earned by mastering smaller cases first and proving you know your patients inside and out.

• The Power of Kindness: IR is a team sport involving nurses, techs, and staff. Being nice isn't just polite; it's a requirement for high-quality patient care.

• Stay Engaged: Don't drift away during your diagnostic years. Keep your foot in the door by joining research projects, attending social events, and dropping into the angio suite whenever possible.

Tune in for a roadmap to excelling in your training from a program director who’s been there.

This episode investigates the specific, aggressive liver injury that can follow Y-90 Radioembolization—Radioembolization-Induced Liver Disease (REILD)—defining it not as simple radiation necrosis, but as Hepatic Sinusoidal Obstruction Syndrome (SOS), essentially Veno-Occlusive Disease (VOD).

• The Clinical Picture: We identify the hallmark presentation appearing 4-8 weeks post-procedure: significant jaundice (Bilirubin >3) and ascites in the absence of tumor progression.

• The "Combined Insult" Theory: The discussion highlights that this injury is often synergistic, occurring when the liver is "primed" by prior systemic chemotherapy, making the tissue far more vulnerable to radiation.

• The Safety Limit: We detail the critical safety threshold found in the literature: keeping the dose below 0.8 GBq per liter of targeted liver volume significantly drops the risk.

• Protocol for Prevention: The episode outlines a proven modified protocol—including strict patient selection (Bilirubin <2), ursodiol/steroid prophylaxis, and a 2-month chemotherapy-free interval—that reduced the rate of severe toxicity from 13.3% down to 2.2%.

• Rescue Therapy: We explore why TIPS is often considered for acute management to decompress the portal hypertension caused by the sinusoidal obstruction.

Tune in to learn the dosimetry limits and patient selection criteria that keep your Y-90 practice safe.

Based on comments from experts, content on Wysdom, and the articles cited below.

Ruutu T, Peczynski C, Houhou M, et al. Current incidence, severity, and management of veno-occlusive disease/sinusoidal obstruction syndrome in adult allogeneic HSCT recipients: an EBMT Transplant Complications Working Party study. Bone Marrow Transplant. 2023;58(11):1209-1214. doi:10.1038/s41409-023-02077-2

Sangro B, Gil-Alzugaray B, Rodriguez J, et al. Liver disease induced by radioembolization of liver tumors: description and possible risk factors. Cancer. 2008;112(7):1538-1546. doi:10.1002/cncr.23339

Gil-Alzugaray B, Chopitea A, Iñarrairaegui M, et al. Prognostic factors and prevention of radioembolization-induced liver disease. Hepatology. 2013;57(3):1078-1087. doi:10.1002/hep.26191

• The Limitations of Meds: We discuss why systemic anticoagulation often fails, achieving complete recanalization in only 50% of patients due to the sheer volume of clot.

• The "Hidden" Drivers: Learn why an exhaustive workup is mandatory, as up to 52% of these patients have an underlying prothrombotic disorder (like JAK2 mutations) alongside local inflammation.

• Interventional Strategy: The conversation highlights the shift toward Mechanical Thrombectomy (MT) combined with Catheter-Directed Thrombolysis (CDT), which data shows can reduce the duration of dangerous thrombolytic infusion from 44 hours to just 22.7 hours.

• Critical Safety Caveats: We cover the specific management of VITT (Vaccine-Induced Thrombotic Thrombocytopenia), where heparin is strictly contraindicated, and the three "red flags" (Lactate >2, Marshall score >2, Bowel dilation) that signal irreversible necrosis and the need for surgery.

Tune in to master the decision matrix for saving the bowel when medical therapy fails.

Based on comments from experts, content on Wysdom, and the article cited below.

Lorenz J, Kwak DH, Martin L, et al. Endovascular Management of Noncirrhotic Acute Portomesenteric Venous Thrombosis. J Vasc Interv Radiol. 2025;36(1):17-30. doi:10.1016/j.jvir.2024.09.023

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

This episode uncovers the compelling evidence behind Intravascular Ultrasound (IVUS), a technology that is revolutionizing the treatment of Peripheral Artery Disease (PAD) by fixing the fundamental flaw of traditional angiography: its "2D shadow" limitation.

• The Problem with Angiography: Standard X-ray imaging forces doctors to guess the size of 3D arteries from 2D pictures, leading to poor device sizing and missed complications like dissections.

• The IVUS Advantage: IVUS provides a 360-degree blueprint from inside the artery, allowing for precise sizing and detection of calcified plaque that angiography misses.

• Real-World Impact: A massive analysis of 500,000 patients showed that using IVUS is associated with a stunning 27% reduction in Major Adverse Limb Events (MALE) and a significant drop in major amputations.

• The "Wow" Stat: In a randomized trial, IVUS findings forced doctors to change their treatment plan in nearly 79% of cases, proving that standard angiography leads to suboptimal decisions four out of five times.

• Barriers to Use: Despite this data, IVUS is used in only ~12% of cases due to poor hospital reimbursement policies that penalize better care, highlighting a critical need for systemic reform.

Tune in to learn why IVUS isn't a luxury—it's a necessity for better outcomes and limb preservation.

Based on comments from experts, content on Wysdom, and the article cited below.

Secemsky EA, Aronow HD, Kwolek CJ, et al. Intravascular ultrasound use in peripheral arterial and deep venous interventions: multidisciplinary expert opinion from SCAI/AVF/AVLS/SIR/SVM/SVS. J Soc Cardiovasc Angiogr Interv. 2024;3(1):101205. doi:10.1016/j.jscai.2023.101205

This episode provides a rapid-fire masterclass on the four foundational tools of Interventional Radiology and how to navigate the complex sizing systems that dictate their use.

• The Sizing Headache: We demystify the three conflicting measurement systems—Gauge, French, and Inches—that every interventionalist must juggle simultaneously.

• Needles (The Gauge Paradox): We explain why lower numbers mean bigger needles (e.g., an 18-gauge is larger than a 21-gauge) and how to use the "Fit Rule" to match needles to wires (e.g., a 0.035" wire needs at least an 18-gauge needle).

• Catheters vs. Sheaths (The French Confusion):

  • Catheters are measured in French by their Outer Diameter (OD), indicating the size of the hole needed in the vessel.

  • Sheaths are the critical exception; they are measured by Inner Diameter (ID), meaning a 6 French sheath is designed to fit a 6 French catheter inside it.

• Safe Access Technique: We walk through the micropuncture exchange, a safety-first method that starts with a small 21-gauge needle and 0.018" wire to create a track before upgrading to standard 0.035" tools.

Tune in to master the essential "grammar" of IR tools for safer, more effective access. 

Based on comments from experts and content on Wysdom.

This episode breaks down the mechanics of two foundational interventional skills—drainage catheter deployment and arterial compression—where proper technique is the only line of defense against complications.

• The Pigtail Mechanism: We explain how the "locking loop" secures the catheter to prevent migration and the critical deployment rule: hold the internal stiffener stationary while pushing the catheter off it to ensure it curls correctly inside the fluid collection.

• The Anatomy of a Stick: Effective hemostasis requires understanding that the hole in the artery is superior (higher) and deeper than the hole in the skin due to the angle of entry.

• Common Pressure Mistakes: Most failures happen because operators press too low (at the skin incision) rather than at the actual arterial puncture site.

• The 10-Minute Rule: We detail the strict protocol for manual compression: 10 minutes of consistent pressure followed by a crucial 5-minute weaning period to ensure the clot holds.

Tune in to master the "simple" mechanics that keep patients safe.

Based on comments from experts and content on Wysdom.

This episode moves beyond basic instrument knowledge to focus on the subtle physical habits and organizational tricks that distinguish expert operators from novices, aiming to maximize efficiency and safety.

• Air Bubble Management: We review the three techniques for removing deadly air bubbles—inversion, flicking, and the "push-pull" vacuum method—and why you must always hold syringes horizontal or tip-up during injection.

• Expert Grip: Learn why precise tools (scalpels) need a "pencil grip," while clamps should be "palmed" (avoiding the finger loops) to utilize the thenar eminence for instant 360-degree rotation.

• Back Table Hygiene: We cover the cognitive-load-reducing rules of the back table: keeping sharps in the top left corner and ensuring the table stays strictly dry to maintain sterility.

• Mastering Wires: We detail specific techniques for handling slippery hydrophilic wires—pinch with fingernails, not pads, keep them wet, and use the "J-tip trick" to straighten curves for easy loading.

Tune in to learn how standardizing these physical habits frees up your brain to focus on high-level clinical decisions.

Based on comments from experts and content on Wysdom.

What you'll learn:

• The "Why": Why filters are not first-line therapy and are only used to prevent PE.
• The "When": The two absolute indications for filter placement (contraindication to anticoagulation and failure of anticoagulation).
• The "How": The cardinal rule of placement: always deploy infrarenally and why this is critical.
• The "What's Next": The new standard of care—why filters are retrievable and the serious complications (thrombosis, perforation, migration) that can occur if they are left in too long.
• The "Mantra": Why the person who places the filter is responsible for its entire lifecycle.

This episode explores the cutting-edge, minimally invasive world of Musculoskeletal Embolization.

Discover the science behind how this procedure targets abnormal blood vessels (angiogenesis) and nerves that contribute to chronic pain.

Tune in to learn about:

• Genicular Artery Embolization (GAE): A deep dive into the procedure for knee osteoarthritis. Learn about the evidence supporting it, who makes a good candidate, and how it provides durable pain relief and functional improvement.
• Shoulder Embolization: How this technique is used to treat conditions like adhesive capsulitis (frozen shoulder) and rotator cuff tears, significantly reducing pain and improving range of motion.
• Emerging Frontiers: Explore the exciting use of embolization for stubborn sports injuries and tendinopathies, including tennis elbow, plantar fasciitis, jumper's knee, and Achilles tendinopathy.

This is an essential listen for anyone interested in safe and effective new options for managing musculoskeletal pain and improving quality of life.

We break down the core principles, "why," and critical safety rules for:

• Particulates (The "Downstream" Stuff): Learn the difference between temporary (Gelfoam) and permanent (PVA, Embospheres) agents. When do you use each for trauma, UFE, or TACE?
• Coils & Plugs (The "Proximal" Blockers): Master mechanical occlusion. We cover simple pushable coils, high-precision detachable coils, and the "big guns" like vascular plugs. We also cover the golden rule of 20-30% oversizing.
• Liquid Embolics (The "Casting" Agents): Get a high-yield overview of the advanced stuff. Learn the "lava-like" control of Onyx versus the "superglue" speed of n-BCA (glue), including the critical, can't-miss safety steps for DMSO compatibility and catheter management.

This episode explores Cryoneurolysis, a cutting-edge interventional radiology technique that uses extreme cold to precisely disable nerves and stop chronic pain without addictive opioids.

• The "Sweet Spot" of Freezing: We break down the critical science of achieving a Sunderland Grade 2 injury (axonotmesis). This requires freezing the nerve to a precise temperature range (below -20°C but warmer than -100°C) to destroy the pain pathway while preserving the nerve's outer structure, allowing for healthy regeneration and avoiding painful neuromas.

• The Role of Advanced Imaging: Learn why CT guidance is essential for deep nerve targets. Unlike ultrasound, which is blocked by the "ice ball," CT allows interventional radiologists to see the entire freeze zone and protect vital organs using techniques like hydrodissection (injecting fluid to create a safety barrier).

• Policy Shifts Driving Access: We discuss the landmark 2015 CMS decision to approve new CPT codes for cryoablation, transforming it from a financially unviable procedure into a mainstream option for cancer pain, osteoarthritis, and nerve entrapment.

• Beyond Pain Relief: Discover surprising new applications, including trials targeting the vagus nerve for weight loss, where patients saw significant appetite reduction and weight loss.

Tune in to understand how this precise, regenerative therapy is changing the landscape of pain management and beyond.

Based on comments from experts, content on Wysdom, and the article cited below.

Sag AA, Bittman R, Prologo F, et al. Percutaneous image-guided cryoneurolysis: applications and techniques. RadioGraphics. 2022;42(6):1776-1794. doi:10.1148/rg.220082

This episode of Morning Rounds delivers a direct line to critical research on Bronchial Artery Embolization (BAE), the life-saving procedure used to stop massive hemoptysis (coughing up blood).

• CF Patient Effectiveness: We analyze a long-term Stanford study on BAE in adults with Cystic Fibrosis (CF), revealing that while BAE is highly effective at stopping the immediate bleed (89% technical success at 30 days), the patient's underlying disease severity remains a major factor in overall survival.

• The Crucial Role of Non-Bronchial Arteries: The CF data highlights the need for optimized BAE procedures, showing that nearly 75% of successful procedures involved targeting abnormal vessels recruited from outside the lung's main supply. This suggests a shift toward mandatory pre-procedure imaging (like CT angiography) is necessary for high success rates.

• The Rare but Feared Risk: Spinal Cord Infarction (SCI): We break down a massive 9,000-patient Japanese study focused on the risk of SCI, a devastating complication with a low overall prevalence of 0.19%.

• Safety vs. Speed: Material Matters: The key finding reveals a statistically significant, more than tenfold difference in SCI risk based on the embolic agent used.

  • Coils (mechanically placed, controlled): Lowest SCI risk at 0.06%.

  • Gelatin Sponge (flow-dependent particles): Medium risk at 0.18%.

  • N-Butyl Cyanoacrylate (NBCA) (liquid glue): Highest risk at 0.71%.

Tune in to discover how these findings demand a critical appraisal of standard clinical practice, balancing the documented safety profile of embolic agents against perceived speed and ease of use.

Based on comments from experts, content on Wysdom, and the article cited below.

Ishikawa H, Ohbe H, Omachi N, Morita K, Yasunaga H. Spinal cord infarction after bronchial artery embolization for hemoptysis: a nationwide observational study in Japan. Radiology. 2021;298(3):673-679. doi:10.1148/radiol.2021202500

Lynne N. Martin, Luke Higgins, Paul Mohabir, Daniel Y. Sze, Lawrence V. Hofmann,
Bronchial Artery Embolization for Hemoptysis in Cystic Fibrosis Patients: A 17-Year Review,
Journal of Vascular and Interventional Radiology, Volume 31, Issue 2, 2020, Pages 331-335, ISSN 1051-0443, https://doi.org/10.1016/j.jvir.2019.08.028.

Martin LN, Higgins L, Mohabir P, Sze DY, Hofmann LV. Bronchial artery embolization for hemoptysis in cystic fibrosis patients: a 17-year review. J Vasc Interv Radiol. 2020;31(2):331-335. doi:10.1016/j.jvir.2019.08.028

This episode breaks down the critical differences between the two main endovascular strategies for managing variceal bleeding in patients with portal hypertension:

• TIPS (Transjugular Intrahepatic Portosystemic Shunt): A procedure that acts as an internal bypass to lower the overall portal pressure.

  • New Guidance: Covered stents are now standard, and smaller 8mm stents are preferred to minimize the risk of Hepatic Encephalopathy (HE).

  • Trade-Off: It reduces the risk of bleeding but increases the risk of HE (brain fog/confusion).

• RTO/ATO (Retrograde/Antegrade Transvenous Obliteration): Procedures that physically block and obliterate the specific bleeding veins (varices).

  • Key Difference: RTO/ATO increases portal pressure but is preferred for patients with pre-existing HE or heart issues, as it often improves liver function and has a lower HE risk.

  • Technological Leap: Newer methods like PARTO and CARTO (Coil/Plug-Assisted RTO) are replacing older techniques, offering a safer, faster, and more targeted approach that eliminates the need for prolonged ICU stays.

The Clinical Crossroads: We detail how specialists choose between TIPS (pressure-lowering) and RTO (obliteration) based on patient factors like underlying HE, cardiac health, and the location of the bleeding varices.

Based on comments from experts, content on Wysdom, and the article cited below.

Lee EW, Eghtesad B, Garcia-Tsao G, et al. AASLD practice guidance on the use of TIPS, variceal embolization, and retrograde transvenous obliteration in the management of variceal hemorrhage. Hepatology. 2024;79(1):224-250. doi:10.1097/HEP.0000000000000530

⚡ Key Findings

• Rapid Decompression: The trial compared standard anticoagulation (AC) alone to AC plus Computer-Assisted Vacuum Thrombectomy (CAVT).

• Superior Efficacy: CAVT was significantly superior to AC alone, resulting in:

  • A greater than twofold reduction in deadly right ventricular (RV) strain within 48 hours.

  • A threefold higher chance of RV normalization.

  • A 100% resolution of high heart rate (tachycardia) in the CAVT group within 48 hours, compared to 56.5% in the AC group.

• Safety Profile: The decisive finding was that this aggressive intervention achieved superior clinical results without increasing the rate of major adverse events (like bleeding).

💡 Clinical Impact

This is the strongest evidence to date supporting mechanical thrombectomy as a first-line consideration for intermediate high-risk PE, safely preventing clinical collapse and stabilizing patients far faster than traditional methods.

Based on comments from experts, content on Wysdom, and the article cited below.

Lookstein RA, Konstantinides SV, Weinberg I, Dohad SY, Rosol Z, Kopeć G, Moriarty JM, Parikh SA, Holden A, Channick RN, McDonald B, Nagarsheth KH, Yamada K, Rosovsky RP; STORM-PE Trial Investigators. Randomized Controlled Trial of Mechanical Thrombectomy With Anticoagulation Versus Anticoagulation Alone for Acute Intermediate-High Risk Pulmonary Embolism: Primary Outcomes From the STORM-PE Trial. Circulation. 2026 Jan 6;153(1):21-34. doi: 10.1161/CIRCULATIONAHA.125.077232. Epub 2025 Nov 3. PMID: 41183181.

This episode dives into the high-stakes management of Parastomal Variceal Bleeding (PVB), a rare but life-threatening complication of portal hypertension, often seen in patients with significant comorbidities (like metastatic cancer) where a TIPS procedure is initially contraindicated.

• The Clinical Dilemma: We explore a case study of a patient ruled out for TIPS due to metastatic disease, shifting the entire burden of hemorrhage control to local embolization techniques like Percutaneous Antegrade Transhepatic Venous Obliteration (PATVO).

• Technical Mastery: The episode breaks down the critical need for a multimodal embolic approach—combining mechanical coils, sclerosing foam (STS/Gelfoam), and a final "cap" to ensure immediate and durable stasis against high portal pressures (mean 33 mmHg in our case).

• The Recurrence Reality: While technical success for embolization is high (88-100%), the recurrence rate is stubbornly high, reaching up to 50% within the first year due to the recruitment of new collaterals.

• TIPS vs. Embolization: We review data showing that TIPS—which treats the underlying portal hypertension—reduces recurrence risk by a staggering 78.5% compared to embolization alone.

• The Provocative Question: We end by challenging the consensus: In cases of catastrophic, life-threatening bleed, when is a palliative TIPS justified purely for hemorrhage control, even in patients with poor oncologic prognoses?.

Tune in to master the technical nuances of PATVO and understand the critical decision matrix for treating these complex, high-pressure bleeds.

Based on comments from experts, content on Wysdom, and the article cited below.

Romano J, Welden CV, Orr J, McGuire B, Shoreibah M. Case Series Regarding Parastomal Variceal Bleeding: Presentation and Management. Ann Hepatol. 2019 Jan-Feb;18(1):250-257. doi: 10.5604/01.3001.0012.7934. PMID: 31113601.

Nadeem IM, Badar Z, Giglio V, Stella SF, Markose G, Nair S. Embolization of parastomal and small bowel ectopic varices utilizing a transhepatic antegrade approach: A case series. Acta Radiol Open. 2022 Jul
5;11(7):20584601221112618. doi: 10.1177/20584601221112618. PMID: 35833193; PMCID: PMC9272059.

Pabon-Ramos WM, Niemeyer MM, Dasika NL. Alternative treatment for bleeding peristomal varices:
percutaneous parastomal embolization. Cardiovasc Intervent Radiol. 2013 Oct;36(5):1399-404. doi:
10.1007/s00270-013-0588-0. Epub 2013 Mar 13. PMID: 23483282.

Pennick MO, Artioukh DY. Management of parastomal varices: who re-bleeds and who does not? A systematic review of the literature. Tech Coloproctol. 2013 Apr;17(2):163-70. doi: 10.1007/s10151-012-0922-6. Epub 2012 Nov 14. PMID: 23152077.

This episode unpacks the long-awaited results of the CREST-2 Trial, a landmark study that challenges the standard of care for treating asymptomatic carotid stenosis (narrowing of the carotid artery without recent stroke symptoms).

• The Big Question: Does adding invasive revascularization (Endarterectomy or Stenting) to Intensive Medical Management (IMM) prevent more strokes than medication and lifestyle changes alone?

• The Clear Verdict: After 10 years of research, the trial was stopped early for "futility," meaning the results were conclusive: there was no significant difference in stroke or death rates between the surgery/stenting group and the medication-only group.

• The Power of Medical Therapy: The study proves that modern medical management—including tight blood pressure control (target <130/80) and high-intensity statins—is incredibly effective on its own, rendering the risks of procedural intervention unnecessary for asymptomatic patients.

• The Procedure Gap: While Endarterectomy (surgery) matched the safety of medical management, Carotid Stenting (CAS) performed worse, showing a higher rate of immediate, non-disabling strokes compared to medication alone.

Based on comments from experts, content on Wysdom, and the article cited below.

Brott TG, Howard G, Lal BK, Voeks JH, Turan TN, Roubin GS, et al. Medical management and revascularization for asymptomatic carotid stenosis. N Engl J Med. Published online November 21, 2025. doi:10.1056/NEJMoa2508800