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BackTable / VI / Podcast / Transcript #410
Podcast Transcript: True Lumen Re-Entry with Pioneer Plus
with Dr. Thomas Davis
In this episode of BackTable Podcast, host Dr. Ally Baheti invites interventional cardiologist Dr. Thomas Davis, Director of the Cardiac Catheterization Lab at St. John Hospital and Medical Center, to discuss re-entry devices, with a focus on the Pioneer Plus Catheter. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Approaches to Critical Limb Ischemia (CLI) Procedures
(2) Reorientation Essentials: Wire Selection & Techniques
(3) A Beginner's Guide to the Pioneer Plus Catheter
(4) From Schematic to Fluoroscopy: Ensuring True Lumen Navigation in Chronic Total Occlusion
(5) Troubleshooting Pioneer Plus: Common Issues & Solutions
(6) CTO Strategy: Subintimal Approaches & IVUS Guidance
(7) Anticoagulation Strategies in Peripheral Vascular Intervention
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[Dr. Aparna Baheti]
Welcome to the BackTable Podcast, your source for all things interventional and endovascular. You can find all previous episodes of our podcast on iTunes, Spotify, and backtable.com.
I'm your host, Dr. Ally Baheti, coming to you from Tacoma, Washington. My guest today is Dr. Thomas Davis. He's the director of the Cardiac Cath Lab at St. John Hospital and Medical Center. Dr. Davis, thanks so much for being on the show.
[Dr. Thomas Davis]
My pleasure.
[Dr. Aparna Baheti]
Our topic today is re-entry devices in CLI with an emphasis on the Pioneer Plus catheter. Before we get started talking about that, Dr. Davis, could you please tell me a little bit about your practice setting?
[Dr. Thomas Davis]
Sure. I'm a little bit of an old goat in this field, it seems. I started way back in 1993 in my current practice. I started getting interested in peripheral interventions around 1995. We did some in my fellowship, but weren't doing a lot.
I have an 18-man group right now, or I shouldn't say 18-man, 18-person group since we have a few ladies there. I predominantly became the one that started doing peripheral work, and so I've continued to do that, doing the bulk of that work for my group. We started off really doing more simple cases, non-total occlusions of iliac and SFAs, and then started doing more stenting. Then, I've really evolved into doing more critical limb ischemia in terms of limb salvage, and have been part of several different conferences such as amputation prevention, and NCVH in terms of being course directors for these two. My career sort of evolved over the course of time, but really now I do mostly CLI cases.
[Dr. Aparna Baheti]
That's so great. That's interesting to hear about your career trajectory there. Are you primarily in a hospital setting?
[Dr. Thomas Davis]
Right now it's both a hospital and an office-based lab. We started our office-based lab about six years ago, and it really, to be honest, blossomed more during COVID because no one could get their procedures done at the hospital. We had all these limb-threatening problems going on, and so we started doing them predominantly at the OBL, the office-based lab, and that's where a large trajectory started going. We learned to do more difficult cases there, I think, as an outpatient. Patients loved it. It was a much more comfortable setting for patients, and the safety seemed to be better than at the hospital actually, I think. That's where the majority probably have been going lately.
(1) Approaches to Critical Limb Ischemia (CLI) Procedures
[Dr. Aparna Baheti]
That's an interesting fact that it blossomed during COVID and that you've been able to keep that going. That's fantastic. Thanks for telling me about your practice. Let's get into the meat of our discussion. How did you first become acquainted with the Pioneer Plus catheter?
[Dr. Thomas Davis]
The more complex disease states that keep on occurring, we're seeing more and more and more of it, as you know, more total occlusions, multi-level disease being both infrainguinal and infrapopliteal. That in itself inspired me to look for other options to become true luminal and re-enter, certainly out of these total occlusions, out of the subintimal crossings that we had, I would say probably 95% of our cases now at least are CTOs. In many of the cases, you don't stay true luminal, especially for the lengthy lesions. We'll have 20, 30, 40 sonometer lesions that are CTOs so it's very, very difficult to stay intra-luminal. We found the crossing devices work for the most part, but they're very expensive to use. With that, went into using the IVUS-guided reorientation and reentry devices. That's how I got started.
[Dr. Aparna Baheti]
I see. Had you had experience with IVUS before using Pioneer?
[Dr. Thomas Davis]
Our hospital, we were an IVUS training course and training center. We would do a lot of IVUS training sessions for both techs, physicians, and things like that. We would do those usually about once every couple months. We've been doing IVUS for a long time.
[Dr. Aparna Baheti]
You touched a little bit on how often you are true versus subintimal. Can you walk me through your algorithm for once you are subintimal?
[Dr. Thomas Davis]
Right now, when we are subintimal, or I feel like we're subintimal, especially if it's a calcified area outline that you're outside of, I will right then and there start getting the Pioneer because I think that once you start keeping out wiring, you get that subintimal space so large, you'll get a hematoma in there. Then, it can get to a point where it's almost impossible to re-enter the vessel at those places.
We did a study called a central study. We did it using a crossing catheter. We looked at about, I think we had about 70, 80 cases. It was a multi-center. We had about six sites involved. We did an ultrasound guided look at whether we were true lumen, whether we were subintimal, whether we extended the lesion beyond the total occlusion, proximal, distal, whether we had tears or dissections, and we scored these from a score of zero to eight. And what we found is that the worse the crossing, the worse the outcomes in terms of six month restenosis rates. If you had a clean crossing with no subintimal tears or anything, we had restenosis rates in the single digits. If you had a worse crossing, it was as high as 70%. You could predict which ones.
That's why I wanted to stay true lumen and that's where the IVUS catheter came in. I don't keep on trying to push the different wires or escalate different things. We'll just go right to try to cross. I don't extend my wire into where the re-entry site is, I'll go above that. In my IVUS catheter guide, I can see exactly where we went subintimal and I'll back up just a little bit and you can see the total occlusion. With a Pioneer device, you'd be orientated till 12 o'clock. Then when I puncture in there, the wire will go into the lumen, true lumen, and then I can just keep on advancing the wire. I may have to do that a couple times to ultimately get to the distal cap, but it's a way that I found that I can stay true lumen and the IVUS guided on that really does help.
[Dr. Aparna Baheti]
Just so I'm clear, so you bring your IVUS back up to where you know your true lumen, so before you've gone subintimal?
[Dr. Thomas Davis]
Exactly. If you're in the media of the vessel, if you're really deep in the media, it almost looks like a reverse snowman. The little small dot that your catheter is and then the big area where the lumen is, and if you're just minimally subintimal, it almost looks like an A shape because you're not as deep in the media. Once you see those looks of the IVUS catheter, you just pull back just a little bit so you'd see that you're truly true lumen, and that's where it is.
[Dr. Aparna Baheti]
Okay. That's a little bit of a different technique than I'm used to using. I've always understood it as once you're in the subintimal space, you can use that Pioneer device to get you back into true lumen from subintimal, and then you cross and connect the dots and stent across. Your idea is that you take it back to the true lumen and then puncture into true lumen without ever going subintimal.
[Dr. Thomas Davis]
Exactly, exactly, and I think you get better results with that. Certainly, if you have calcified vessels and if you're stenting into a subintimal area, sometimes you have a harder time expanding those stents. I think it really does work better in that sense. I find myself having better outcomes.
[Dr. Aparna Baheti]
Then no wire escalation. That's interesting too. A lot of folks I've spoken to, they'll try with a heavy weighted tip wire to get back into the true lumen, things like that, but that is not a part of your algorithm, right?
[Dr. Thomas Davis]
No. Like I said, again, once I started escalating wires and I'm in the subintimal spot, I think it's difficult to get back into the true lumen. As I said, if you take a look at your ultrasound and the subintimal space that you're putting your wires into, a lot of times they'll loop up and they cause a much bigger dissection plane. It's amazing how much that extra luminal area space gets. We've seen IVUSes where that space just hemorrhages into there and it can actually impact on the true lumen itself, so you'll see the true lumen being smaller on the IVUS. I think that that's why I don't escalate because I don't want to wreck that subintimal space so to speak, or tear or destroy it because I think it just leads to worse outcomes.
[Dr. Aparna Baheti]
Is this basically what you're describing to me? Is this the reorientation technique?
[Dr. Thomas Davis]
Exactly. I'm not reentering the vessel, I'm reorienting the wire, so I never leave the vessel.
(2) Reorientation Essentials: Wire Selection & Techniques
[Dr. Aparna Baheti]
Do you have a wire of choice you like to put through once you have your needle in?
[Dr. Thomas Davis]
It varies. I like to use a little bit of a stiffer wire, so it can puncture into the vessel there. A lot of times you'll find micro-circulation in there, micro-pores, channels, that you can actually get that wire through. I usually use an Astato 20. With that device you need to have an 014" wire, so that's a fairly stiff 014" wire, and it works very, very well. That way it doesn't buckle up so much and I can put a little bend on it, I can try to steer it. Once you get into those microchannels, a lot of times you only have to reorientate once and you'll just pop right down and get into the distal cap.
[Dr. Aparna Baheti]
I feel like I've destroyed like a million Astatos trying to do that but that's a really good idea to use a heavier wire. Still cannot have the tip be nitinol coated because you're worried about shear.
[Dr. Thomas Davis]
Right. Because anything with a coating on it, if you push the needle out-- Because a lot of times until you get used to this, you're not going to be putting it into the true lumen and you're still going to get into that subliminal space. If you pull that wire back and it's a coated wire, yes, you can shear that off very easily. That's why you really need a non-coated and a heavier wire is better.
[Dr. Aparna Baheti]
Are there any other things about the reorientation technique that you'd like the audience to know if they were going to try it?
[Dr. Thomas Davis]
Sure. I think the biggest thing is, like I said, once that you're subintimal, I think go down there. The way the device works, we haven't talked about that yet.
(3) A Beginner's Guide to the Pioneer Plus Catheter
[Dr. Aparna Baheti]
Yes, this is a great time. If you were a DeNovo Pioneer user, how would you explain it to somebody who was using it for the first time?
[Dr. Thomas Davis]
It's a monorail system. You can put that over your wire that you have parked down there. You're watching the IVUS as you go down and usually your true lumen is for a period of time, sometimes short, sometimes much lengthier. Once that you're starting to get into the media, that's where I'll pull back. The end pull port is the needle port. That's where I put my Astato wire in and I park it just before where the needle port comes out. You orientate the true lumen or where you're looking at the true lumen because usually if it's an SFA, it's going to be 5, 6 millimeters in size. The nice thing about it is you can get IVUS depth with this too. You orient the needle to twelve o'clock, then you can count the lines in terms of how big the vessel is, so if it's 5 millimeters, you can set your depth to say 3 millimeters and then puncture it through.
When you push your wire out, it looks like a bright tip coming out by the IVUS because the IVUS is in front of your needle port. You can see if that needle actually went into the lumen or if it went too deep and went into the subintimal space more at 12 o'clock, or if it never made the true lumen but it stayed in your false lumen, and you'll see that bright light next to your catheter as well too.
That's the best way. That way you can tell for sure when you actually look at that picture where your wire is. Sometimes you'll have to rotate it a little bit. Sometimes it's going to be one o'clock, sometimes it's going to be eleven o'clock that you have to reorientate that turn so you get into the lumen. Once you do, and you can get that wire in there-- Once I get my wire down a little bit, I'll retract the needle just so I don't have to worry about shearing anything or doing any problems like that. I'll just keep on pushing the wire down until I get that where I've either exited or I think I may be subadventitial again. Then, just take the device out. You can now use that needle wire that you push out the needle as your monorail and go back down. Sometimes the trick that I'll use because OBL, you're trying to be cost conscious, once I've used the Astato to poke through and I'll go down again with my device over his monorail. When I get to the point where I know I'm subintimal, I'll pull that monorail wire back out, the Astato, and then use it again to puncture. You can actually save wires in terms of reusing that wire multiple times on your punctures.
[Dr. Aparna Baheti]
No, that definitely would not fly with the wires that I've been using through that. That sounds good.
[Dr. Thomas Davis]
Yes, I've been there where I've gone through a lot of wires.
(4) From Schematic to Fluoroscopy: Ensuring True Lumen Navigation in Chronic Total Occlusion
[Dr. Aparna Baheti]
Is there anything in the slides that you want to show me based on that reorientation slide where you show where the wire is wrong and the wire is right? Do you mind walking me through that picture?
[Dr. Thomas Davis]
Sure. Is it the schematic drawing that I have?
[Dr. Aparna Baheti]
Yes, let's do the schematics first.
[Dr. Thomas Davis]
That's a schematic. It shows where your wire initially goes. I call it sub-adventitial rather than subintimal because you're below the true lumen and the adventitious somewhere in the media. One of my vascular surgery friends from New York taught me that. He corrected me every time I said subintimal. That wire, as you can see, goes in there. Then the device is coming in over the wire and you can see where it's actually in the true lumen itself. The IVUS is looking upwards so that's the 12 o'clock orientation. Then you can see the needle going in and then the wire on another diagram going out of the needle, and you can see one of those where it never makes the true lumen. It stays within the false lumen, so that's a wrong orientation, so you have to reorientate. Again, you may have to go a little bit deeper with your puncture. Then I think the last one will show the wire going into the true lumen as it goes out. Then as you take the device out, you can see that the wire is now true lumen the whole way down in the CTO.
[Dr. Aparna Baheti]
Got it. Then, you have a picture, a fluoroscopic image. It shows the wire down through the needle site.
[Dr. Thomas Davis]
Exactly, exactly. Then the nice thing about it is because it's an IVUS catheter, once you're through all the way, you can actually pop that as the monorail again over your wire that's through and then IVUS the whole thing and get an idea of your type of plaque that you're dealing with, the size of the vessel, which I think is important to properly size for post, whether you're ballooning or stenting. I think that there's a lot of things that we garner from IVUS. That's why I always push it down there just to make sure that, a, we're in the true lumen all the way down, and b, to just get an idea of what's going on in that vessel.
(5) Troubleshooting Pioneer Plus: Common Issues & Solutions
[Dr. Aparna Baheti]
Do you ever have trouble with trackability of the Pioneer device over your wire, especially once you've done this, crossed this really tiny plane with the needle as compared to just the regular IVUS catheter?
[Dr. Thomas Davis]
Yes and no. I think it depends what type of plaque you're dealing with. Sometimes because that needle puncture site is pretty small, sometimes I'll have to take a balloon, a short 20 millimeter balloon, just to dilate that puncture site into the vessel so I can get the device down there. Sometimes when I get it there, I'll almost corkscrew the device a little bit, trying to spin it through that tight lesion. Once you get through that area that you punctured and dotted it, so to speak, whether it's the balloon or the device, it usually goes down pretty easily after that.
[Dr. Aparna Baheti]
We talked about how you pick the needle deployment length that's based on the lumen size you see on IVUS. We talked about if the wire is correct on the IVUS picture, what are the pain points for the device? Where do most new users get bungled?
[Dr. Thomas Davis]
I think the IVUS portion of it, you really have to understand at least a good basic concept of IVUS and I think that's your starting point. The other thing is people get hung up on how deep I have to put that needle. The other thing that I find is that cork, the length of the shaft of the device, if as you're turning it, you're trying to torque it and going around, sometimes that will put a lot of tension on it and when you start to try to push the needle out, it doesn't go because that shaft is now twisted a little bit. You sort of have to reorientate the shaft to neutral and then try turning around again in a gentle area because that's a frustrating thing I've seen users in my hospital do when I have to come in and give them a hand, I can't get the needle to go out. It won't go out.
[Dr. Aparna Baheti]
Because you have a wire wrap?
[Dr. Thomas Davis]
Exactly, because you're pushing that needle out on that shaft, and if there's too much tension bound up in there, when you rotate it around and it's tight, it's like if you take a dish rag and it's straight and you take both ends, candy wrap it, and now all of a sudden there's a lot of torque in that, that's where the needle will have a hard time coming out. You can fix that by just getting rid of all that tension that's in the catheter and also maybe pulling back sometimes because again as you're pushing these devices through a total occlusion, it generates a lot of torque and pressure on the catheter and so again, that'll have a problem on the shaft as you're pushing the needle out. Again, you may have to pull back a little bit just to take all that tension off the catheter. Catheter works well if there's not a lot of tension. If there's tension, then you can have problems.
[Dr. Aparna Baheti]
Makes sense. Then, are there any situations where you would prefer a different type of reentry device rather than the Pioneer?
[Dr. Thomas Davis]
I think that the really problematic ones are the very heavily calcified vessels because again, what you end up doing is, that needle will have a hard time going through thick calcium. You either have to go beyond the calcified spot, make a subintimal area for the short term until you get beyond the calcium that you see it on the IVUS where you can puncture. Again, you've got to remember that IVUS is a little bit in front of the needle so what that IVUS is seeing it's just a couple of millimeters back of it. That's why if you're seeing calcium on there, you're probably puncturing into it.
I think the other thing that's difficult is when you get infrapopliteal into tibial vessels because, a, the length of the catheter has a hard time getting down there, and b, the depth of that needle can be very, very tricky because your tibial vessels are much smaller and if you're going into a subintimal plane that's a big catheter to go in there, so you might have a little bit more difficult time.
The other places I've said before where I think users have a problem is when they've done so much trying to wire or put a big loop on their glide wire and just push down, that subintimal space becomes so large that the catheter as it sits there you push the needle out and all it does is push the catheter back towards the back of the walls and the needle doesn't come out so because you don't have anything in the back of the needle to sit against. That's the other problem too if you get in spaces like that you just have to go beyond where you're at or above it to try to reorientate.
[Dr. Aparna Baheti]
Got you. No, once you go subintimal, there's a bunch of different ways you can do things but this is a novel one that I haven't heard yet so super exciting, super excited to try it next time I have this issue.
[Dr. Thomas Davis]
I think the other options for Outback or Intere, which are the other ones that we'll use every now and then. I think the Outback is nice because it's a little bit stiffer of a catheter so with deep spaces, it can have a better chance of puncturing. I think Intere works much better with below the knee vessels, the tibial vessels where you can do that.
(6) CTO Strategy: Subintimal Approaches & IVUS Guidance
[Dr. Aparna Baheti]
I guess we skipped this part but what is your algorithm from the beginning of starting a leg especially in a CTO where you're probably going to go subintimal at some point? Walk me through your setup.
[Dr. Thomas Davis]
I usually do a crossover from right to left, so I'm doing antegrade up and over, that's typical. We do a lot of ad hoc so we don't have a CT angiogram or we're dealing with critical limbs, so we try to get them on the table quickly, so we're trying to do all of that. We kind of get an idea by our ultrasound, but sometimes they'll just have ABIs when we start because we know they have to go in. I find that CTAs are useful for iliacs, SFA, popliteal, but I think once you get down to the tibial vessels and into the foot, I think CT angiograms are not as good at defining the spaces and things, so I think a good angiogram is better than that at that point.
We go up and over and we'll shoot our pictures. Depending upon where my CTO is, if it's in the SFA or popliteal below, I try to get my catheters for my imaging down as low as I can. If it's popliteal below occlusions, I try to bring my catheter, I'll usually use an IMA catheter, I'll try to bring it down to the knee and do my digital subtraction imaging from there so I have the catheter all the way down. I'm not getting washed out, and I get a better image of some of the collaterals and things like that so I can see communicating vessels and everything.
Then I decide what I'm going to use. If I use a shorter sheath 45 or 55, if I'm doing SFA work, if I'm doing popliteal below, I'll go with a longer sheath. Again, I think I use less contrast that way. All these patients, better pictures, less contrast, so I use a 70 or even sometimes a 90 sheath going down there depending upon how low it is. In the hospital, I'll sometimes use crossing devices but I'm an image geek as you can tell so I use OCT guided catheters going through there sometimes to help stay true lumen because my goal is to always be true lumen at least for 95% of that crossing.
Then in the office space lab, I'll just bring a stiff guiding catheter with gliders and I'll just pop through. In many cases once you get past the cap, if you're in the true lumen right away, you can just keep on pushing that catheter. I just push it all the way down until it stops. I may use my glide wire at that point.
[Dr. Aparna Baheti]
Just to pause you for a second because we speak slightly different languages between cardiology and IR, but when you say like a stiff guiding cath you're not just talking about like a regular 5 French burn or vert or something. You're talking about something stiffer than that?
[Dr. Thomas Davis]
I usually use an 035 crossing catheter such as Bards crossing catheter. I like that because it's a little bit stiffer, but usually the 035 crossing catheters, one of them. I just like the Bards because it's a little bit stiffer and goes through total occlusions. Sorry about that I keep on forgetting sometimes there is a difference.
[Dr. Aparna Baheti]
That's what's great about these though. I get to learn cardiology lingo, I get to learn vascular surgery lingo. I learned about sub-adventitial today apparently instead of subintimal, so there you go.
[Dr. Thomas Davis]
See, that's vascular surgery I think.
[Dr. Aparna Baheti]
I interrupted you, so you have your 5 French crossing catheter and then a 035 glide wire.
[Dr. Thomas Davis]
Right. Then I'll go down and when I get to the point that I think I'm not having a difficulty, then I'll immediately switch out to a Pioneer. Several times though you would cross without a difficulty, the catheter will go all the way down with that. I'll always IVUS. I think IVUS is imperative for doing CTOs, long CTOs. Like I said, not just for sizing, but the morphology of what you're dealing with, whether it's mixed, it's calcified. A lot of times we'll see calcium on the image and it's just all in the media and there's no luminal calcium.
I think that those are important things because if you go to balloon something like that, that vessel is not going to expand because when you balloon something, that vessel has to expand. There's nowhere for that plaque to go so I think those are places where debulking is important or appropriately sizing your stent to properly prep the vessel. Again, doing drug coated balloons even there. I think a lot of that morphology is important to know so I'll always IVUS when I'm doing that.
[Dr. Aparna Baheti]
Back up for one second so I can make sure I clarify a point. You basically try to cross with your 035 system. If that's not working and you get subintimal, you just go straight to the Pioneer basically, right? You don't mess around with trying to do stuff with an 014, don't do anything like that. You're like, "All right, I'm bagging this, Pioneer time."
[Dr. Thomas Davis]
It's faster. Time is money so the more time you stand in there, the more radiation you burn on yourself, the more frustrated you get. I just find it's just faster trying to re-enter with wires, and eventually if you fail, you have to do something different anyways. I will do that right away on all my cases. I don't have to use Pioneer all the time but probably maybe 50% of the time, but that's where I'm quick to use that so I can stay there.
Now, infrapopliteal is a little bit different because again a lot of your crossing catheters don't work down there. Our re-entry catheters are difficult down there so my go-to wire below the knee is really going to be a gold tip glide, an 018". With an 018" crossing catheter try to keep a small loop and keep on going down. Again, if I get subintimal, and I really can't get back in, I'll typically come from below and try to do like a finger of God or something to that degree to come from above and below and balloon both, and then try to get into that subintimal plane that you created with your two balloons.
[Dr. Aparna Baheti]
Similar techniques for below the knee too over here. Okay, cool. Let's say you've crossed, you do your IVUS, how often are you stenting in this situation?
[Dr. Thomas Davis]
It depends. I seem to get a lot of calcified vessels in that sense and very long lengthy lesions when we're dealing with it. If it's above the knee, or we'll have total occlusions at the popliteal, or certainly below, so therefore, I don't stent a lot, but I do because I hate putting in 35 sonometers of stent in someone, or stents across the popliteal. I try to avoid that certainly unless I have to and if a popliteal tibial vessels there's not a lot of places where stents available, you can use off-the-shelf drug-eluting stents, but now we have a trial going on. Obviously, I'm not sure if you guys are involved in it all but for drug-eluting stents below the knee, which I'm very excited about.
(7) Anticoagulation Strategies in Peripheral Vascular Intervention
[Dr. Aparna Baheti]
That's great. That's definitely a space that I could use some help with. That's fantastic. Then say all is successful, you've improved flow, everything comes out, what is your post-procedural anticoagulation management?
[Dr. Thomas Davis]
I usually use DAPT, Aspirin, Plavix, typically. In some cases, if I've had a lengthy lesion, and I think there's some thrombotic area to it, I will use a DOAC along with Aspirin or Plavix, always two. I'm using more DOACs, I think nowadays, low-dose DOAC in these cases. I don't know if you are doing that too or if you've tried it towards that.
[Dr. Aparna Baheti]
It depends on the patient population and the availability of DOACs for them. That's what I've seen as the main issue is cost.
[Dr. Thomas Davis]
Yes, exactly. Exactly. I'm using it a little bit more frequently now. When I say frequently maybe 10%, 15% of the time, but it's usually Aspirin, Plavix. When Plavix was not generic, we had the same problems as you said after that. Certainly in tibial vessels, I don't usually use it, it's almost always a dual antiplatelet therapy. I'm a lot more aggressive on my re-imaging of my CLI patients, especially, so I usually get a post-Duplex about six to eight weeks afterwards. I'll see them beforehand just to make sure they're doing okay obviously. Then if they seem to be doing okay, I'll get a Duplex just to see where we're at, and I follow them every three months with a Duplex really for the first year or until their wound heals and I'm pretty aggressive in getting them back in if there's any problems, not so much problems with the Duplex, but I'll see them more frequent follow-up too if the Duplex starts looking bad, or your TBIs, or whatever, but typically, like I said, about every three months until it's healed.
[Dr. Aparna Baheti]
This has been a really great introduction to the reorientation technique and the Pioneer device. I'm excited to use it in this new way. Any other advice for physicians who are looking to gain footing in the peripheral vascular space?
[Dr. Thomas Davis]
When you're asking that, do I have any advice for young physicians getting into it?
[Dr. Aparna Baheti]
Yes.
[Dr. Thomas Davis]
I think, especially on the peripheral side, you really have to commit to it. I've seen so many people that are dabblers and they hurt the patients, I think more so when they're just dabblers, especially when you're talking about critical limb. I think you really have to commit to doing it and try to do a lot of it.
I know when I first started out, I used to jump in cases all the time of competing groups. We were in private practice, so I used to go in competing groups and just jump in cases with them to learn more because I think the more not just doing it, but seeing it, I think really educating yourself and building your confidence as you're doing things. If you've seen something once, it's not a problem. If it's the first time you're seeing it, that can be difficult.
I think that's the thing I tell a lot of young people. I usually train four fellows every year, interventional fellows, and usually one of them will go out and build a successful peripheral vascular program someplace, and that's because they've committed to it. You really have to make that commitment.
[Dr. Aparna Baheti]
Awesome. Cross-specialty collaboration is one of the tenets of BackTable, so I'm glad you spoke to that. That's really important to us. One of the other tenets of BackTable is, "Don't be a jerk." We've also accomplished that during this podcast.
[Dr. Thomas Davis]
You know what, do you ever go to some of the meetings, like one of our meetings, AMP?
[Dr. Aparna Baheti]
I've never been to that one. Yes, that is my goal to go to that.
[Dr. Thomas Davis]
That's a great meeting. It's in Chicago. It's always in August. It's my favorite meeting that I do. It's really a lot of like minds. There's multi-specialty vascular surgeons, IRs, cardiology. Among the faculty, sometimes I forget who's what, to be honest with you. Someone's an IR, someone's a vascular surgeon. We talk the same language, which is nice. I think when you become an expert, and I think many people can become experts, most people talk the same language, and I think that's what's great about it. We cross over.
[Dr. Aparna Baheti]
Perfect. Awesome way to end. Dr. Davis, thanks so much for coming on the show today.
Podcast Contributors
Dr. Thomas Davis
Dr. Thomas P. Davis is an interventional cardiologist in Saint Calir Shores, Michigan.
Dr. Aparna Baheti
Dr. Aparna Baheti is a practicing Interventional Radiologist in Tacoma, Washington.
Cite This Podcast
BackTable, LLC (Producer). (2024, January 25). Ep. 410 – True Lumen Re-Entry with Pioneer Plus [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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