Good afternoon, everyone, and welcome to day two of VEINS, and now moving into the VIVA area with the pre-courses. And I'm really pleased to co-moderate this with my friend Eric Sosemski. I'm Kush Desai. And what we're looking at is really answering the question, do I really need IBIS in my peripheral vascular practice? And it's on us up here to prove it to you. And hopefully, by the end of this, we do. Here's our agenda. And this is supported by Philips in an educational grant to SCI and then performed in collaboration with the Society of Interventional Radiology. We have a lot of great speakers here from multiple specialties covering the whole spectrum of arterial and venous disease. These are our disclosures. And again, just to acknowledge that this activity is supported by an unrestricted grant from Philips. What's great about this session is that you are able to earn CME through SCI here. And to ensure your complete successful completion of this activity, please scan the QR code at the door, participate, and then complete that evaluation that is sent to you by SCI that will come in your email. And then you have until New Year's Eve to claim your CME and MOC credit. So with that, I'm going to pass it off to our first speaker, who is not Sahil Parikh. Unfortunately, he was not able to join us. Eric Sosemski is going to be presenting on IBIS and why IBIS is needed for high-quality treatment of peripheral arterial disease, and where's the evidence? Great, thank you, Kush. I'm sorry you're not getting Sahil here, but he had to stay back, unfortunately. So I'm going to step in. So I'm going to talk a little bit about the evidence supporting, particularly for lower extremity arterial disease, why IBIS is really taken off. And we just presented some data last week at TCT that demonstrated that among Medicare patients, the older population, 30% of all peripheral vascular patients are using IBIS now on the lower extremity. So we're not anymore talking about when is this going to take off. It's now about how rapid and how amazing the adoption will end up looking after we settle out in this initial phase. These are Sahil's disclosures. So I talk a lot about this. This is a slide we put together in a review article for Circulation a couple of years ago, and just how we're being asked to do things differently in our procedural labs since we started. We're no longer getting those TASK-A lesions to treat endovascular. We're taking on what would be traditionally surgical disease, long CTOs, long complex, multi-segment, and anatomical challenges. And so as we encounter more difficult, complex lesions, we need more tools to really give us long, durable outcomes. And we've seen, unfortunately, in the US that despite greater awareness, more attention to PAD over the last few years, we've still not seen the full delivery of improving outcomes important to patients, in particular, extremity amputation. So we still have a long way to go to preserve the patency and success of the endovascular treatment, and how we can mimic other states, in particular, the coronary space, about improving our outcomes with using our advanced technology. This is a busy slide, but this is a meta-analysis of all the trials that have supported IVF use and coronary intervention. And we've seen that the data there doesn't only support acute outcomes for the stent or the device we place, but also for disease states and entities like MI, cardiovascular death, over the long term. So we've seen the real mechanistic improvement from a better stent outcome to a better clinical outcome for patients in the coronary space. And I'll show you some data where we're getting to that same place in the peripheral vascular. So this is a great study that was done. And I'll just walk you through this table. So in one column here, you see DSA, so digital subtraction angiography. And then the column next to it is intravascular ultrasound IVFs. And they size vessels. And this is really relevant, in particular, in the below the knee spaces. We have numerous IDE trials looking for new devices here. And we know a lot of these are drug-coated devices that rely on adequate sizing. And if you just walk through this table, proximal anterior tibial artery, the chart in my cath lab room says it's 2 and 1 half millimeters. DSA says it's 2 and 1 half millimeters. It's a 3 and 1 half millimeter vessel on average for patients. Tibial perineal trunk, we don't have a lot of devices that go past 3 millimeter, like drug-coated balloons for periphery, but we have them for above the knee. 4 millimeters is the average TP trunk. And I treat that with the DCP routinely in my practice. And even down into the perineal artery, which is usually forgotten, now labeled as a 2 millimeter vessel, we're seeing those can be as large as 3, 3 and 1 half millimeters. So relying on these benchmark anatomical averages based on angiography alone are incorrect. And we're learning this through intravascular imaging. We've done a number of work trying to summarize and add to the level of evidence to support IVFs. This was a study we did several years ago, a systematic review showing how many case series, cohort studies, and prospective studies have improved our understanding of the role of IVFs in the lower extremity. Now, we were missing at the time a lot of prospective studies. Most of this was driven on observational data and in large case series. And I'll show you how we're moving from a level 2B rating for the majority of our evidence, which is usually a high-quality observational study, to more prospective evidence. So this is the first randomized trial. If you're not familiar, this is 150 patients treated in Australia from a group who randomized to an IVF-based intervention with angiography versus angiography alone. This is just for a FEMPOP intervention. And you can see on the left here these KM curves, cumulative curves, going through one year. And red showing a primary freedom from binary reach to gnosis rate of 72.4%, which is about 17% higher than angiography alone. And there's now been data out to two years and beyond which have shown continued separation of these curves. Now, why is the benefit so pronounced? Well, one large part of it is how we sized our devices. And you can see on the right here for drug-coated balloons, if you saw IVF's guidance on sizing, there was nearly zero reach to gnosis rates compared to if you used angiography alone. So really dramatic improvement in our outcomes when we sized the vessel correctly, used the correct device. Busy slide here again, but I just want to highlight those items in red. The most important part of IVF is when you unmask yourself to the IVF images, what do you do differently? We've seen this on the venous side, and it's quite robust on the arterial side as well. On the left here, you can see that when operators were unblinded to their IVF images, they changed their total plan 78% of the time. So that means either they sized a bigger device, they sized a longer lesion length, but they did something different that obviously led to a better outcome in this study. And most of this on the right, when you get down to the granular data, was about reference vessel diameter size and lesion length, as well as post-procedure treatment was dissection rate. Keep going here. This is another study looking primarily below the knee space and looked at sizing of those tibial vessels guided by IVF versus angiography alone. And again, when IVF was used, there was larger mean balloon sizes with improved skin perfusion and better wound healing through one year. So again, we know lumen and blood flow is everything. If we feel comfortable pushing ourselves to a greater limit based on IVF, we're going to get better outcomes. Now, we've seen also other opportunities to expand our data to support what we're doing. And this one looks at appropriate sizing. This is a nuanced study, but they looked at different ways to size DCB treatment, whether you rely on just angiography alone, the EEM membrane, or the lumen membrane. And you can see that when you use really EEM-based measurements, you tend to get a trend or better outcomes. I'm sorry, this slide's pretty busy and small. But it's important for us to remember, again, that size is everything. And we feel comfortable being a little bit more aggressive when we have these type of measurements in hand to guide our treatment. Now, earlier this year in March, there was ACC, which is one of the cardiology conferences. And this is our second prospective randomized trial that looked at IVF-guided intervention. Again, now we have two randomized prospective studies, which means we're beating a lot of other devices. I won't name atherectomy out loud. But I will just comment that this was a really important independent initiated study of 237 patients that follow up that first trial I just showed you. And they randomized patients to an algorithmic approach to IVF, 119 patients, versus angiography alone. Everybody got a drug-coated balloon in this trial. So that was their default treatment. And what you can see for primary patency, there was, again, a significant benefit that really mirrored what we saw in the other randomized trial for primary patency of 83% in the IVF arm in blue on the left there, and red angiography, 70%. So we saw about 17% difference in the first trial. This is now about 13% difference. And there was also a significant difference in clinically-driven TLR rates. Look at that, 92% at one year for a real-world population of FEMPA patients compared to 83% for angiography. Now, they've come up with some additional data here. And this is also clinical improvement through a year, hemodynamic improvement. But I want to show you one aspect to this that I think is important is the complexity of the lesion. So they just presented these data at TCT last week. And this is a subgroup of the same randomized trial. But they broke down whether you have more complex task lesions versus more simple task lesions. And really, these data really drive us to understand that complexity in particular is where we should start instituting this technology. So if you are in a country that has limited constraints and reimbursement, we found that the benefit of IVF is most pronounced when the task lesions are quite advanced. CD here, you can see on the left. So IVF guidance still led to a really acceptable outcome compared to angiography alone. And that was less pronounced in a more simple lesion subset, which was a minority of that trial. TLR rates, again, really favored IVF overall, but in particular for those complex lesions. So I'm just going to wrap up with some real-world data and some consensus to round out where we're at right now. This is 540,000 patients treated in the real world looking at long-term clinical events. And we saw in this study that patients who were treated with IVF here with red versus in blue, no IVF, they had better outcomes over the long term. This is out through almost three years. You can see reductions in major adverse limb events, acute limb ischemia, as well as major amputation. And we went back to do a consensus document on this. This is the below-the-knee data real quick, showing you a similar benefit for patients with BTK disease, same group of patients. So when we go down the row of what's next for this space, I think that this is really important data to show you in aggregate how we're doing. This is meta-analyzed data of about 600,000 patients who had angiography, 100,000 who were treated with IVF-guided treatment. Again, meta-analysis showing improvement in patency, as well as major amputation. This was published in the Journal of Vascular Surgery. And also, when you look at cost effectiveness with these same data, we saw that there was a really important mean reduction in the cost of the intervention over the long term. So I would say, if you can treat one patient and reduce an event, you're going to end up being cost-dominant for a technology that you only pay for upfront at the time of the procedure. I'm going to go a little bit over time here. I apologize, but I just want to highlight some of the work that really pushed where we're having this conversation today, which was a multidisciplinary approach to really incorporating IVFs into lower extremity. And this is a really proud document. Almost everybody up here played a role in this in some part. And it came together six societies that really dictate how we treat patients in the US. And overall, this showed really nice demonstration of what we've seen in the literature, which is consensus for use. Green here is meant to be go. And really, consensus for use for lower extremity IVFs across the arterial and venous system, as well as really dictating what's next in our field, which is coupling intravascular imaging with other aspects, including physiology. And so we're also going to start talking more and more about flow dynamics and flow limitation that feed in nicely to this technology. And overall, we're going to get to a much more evidence-guided practice. So I just want to end here. I know I went over, but obviously, we're very passionate about where this field has gone. I think the evidence is really a proud moment to say that we are not just bringing a technology without some sort of data to really generate our practice improvements over time. And I think our patients are going to benefit as this continues to get out into the full community and across this pond, as well. Thank you very much for the opportunity. Thank you all for being here today. Thank you, Kush. OK, our next speaker is Sara Sabri. She's going to be talking to us about how we protect access to care, appropriate use versus overutilization. Thank you. This is great, and it's great to see societies come together and to talk about this. So I'll just piggyback on what Eric just talked about here and talk more about the cost effectiveness. So as you heard, I mean, I was using vascular intervention. I mean, the role in the arterial intervention has been well-established. And improvement outcome of the use of IVUS. I mean, you just heard a lot of talks. You know, a talk now, a lot of evidence on the PID side. You're going to hear about the venous side. I want to focus mostly about the current utilization of IVUS now and is it cost effective to use IVUS. So as you heard, the use is mostly for balloon sizing, standard expansion, state patency, and reintervention rates. And all these, IVUS has significant improved, especially on the PID space, which is what I'm going to focus on the most. And many observational studies have showed that there's fourfold reduction in reintervention rate. It's not just only the patency, but the reintervention, the freedom from TLR. I really want to applaud Eric and everyone here who worked on this document. And you know, I recommend everybody to go and just pull this document and look into it. A lot of work went into it. And it's really great to see multiple organizations come together and come up with these documents to kind of drive the field forward. And I mean, out of it, there was a lot of good data. I mean, this is a slide from the article which quotes a different article talking about there's improvement in major adverse limb events, as well as major amputation, when you use IVUS. And these are important endpoints. It's not just patency, but also effect on amputation. So I asked our health care economic staff at SIR to get some data on the current use of the codes for IVUS. And I gave them the 37252 code, which is for first vessel, and to look at what is the current use. So we have data from 2021 and 22. And you know, the utilization seems to be steady. We have not yet hit the upward trajectory yet, but it's around 57,000 or so. This is Medicare data. And then if you look at the total charges, it's around 531 million. And that is the charges for the use of IVUS. So just to give everybody just a sense of what is the current utilization of IVUS and how much the charges. And it's across all regions. Of course, the more populous region will be more of it. Just to give you a sense of, so how much would we charge for the other procedures that we do. So if you look at the venous PTA and stenting, it's around 22,000 procedures. And the charges are at $119 million. And these are for two years. I have data from 2021 and 22. IVUS is around $350 million for that same period. And then for FEMPAP PTA, if you add PTA, stent, and etherectomy, it's around $3 trillion or so. So just to get a sense that IVUS is a good chunk of money. And it's a good part of our expense on these procedures. So it is something that is significant compared to venous PTA and stenting. It really is a small. We talked about on the venous space. But compared to the market of FEMPAP intervention, it's definitely a much smaller market. A very important aspect is, if you look at the different reimbursement based on location of service. So no secret here that if you look at the first column, which is talking about non-facility, it says here $927. That's for that first code. So that is the reimbursement for if you do that procedure in the OBL. Now, if you go and work and look at the hospital or ASC, that amount is not there. It's all bundled. So there is a major difference in the way the reimbursement happened, which definitely would affect practice. So if you're practicing in OBL, this is the amount of money that you're going to get. If you're practicing in the hospital, basically you're just going to trust that IVUS is going to provide benefit to your patient. But there's no direct reimbursement that's going to come out of that use. And if you look at this is data, earlier data in Medicare. And just looking at the increase in volume of procedures, and you see in the office-based lab, there's significant increase up to 300% increase of the work of the PAD that is being done. And the majority of that is in the tibial part. So there is definitely an increase in use in OBLs, in interventions in general, and you'd assume that in the use of IVUS. I don't have data about the site of service for the charges for the site of service. But that's something we're going to be looking at. So is the use of IVUS cost effective? So if you just look at it from a hospital perspective, I mean, if you look at it from the OBL, you can look at your own finances and see, yeah, there's a direct reimbursement. How about from the hospital perspective? So this is a nationwide inpatient sample database and looked at the use. And this data was 2006, 2011. And the use of IVUS and PAD was only 1.4%. And so this is older data. And this is a very low number. And now the use is definitely much higher. And IVUS was a predictor of lower rate of forced procedural complications. And then definitely use of IVUS, basically it's around $1,000 more expensive than a regular case. So definitely there's an incremental cost, the cost of the disposables and such, around $1,000 or so. So this study looked at this predictable around $1,000 increase in cost per case for using IVUS. Here looked at ILLIAC intervention and looked at there's, yes, there is improved patency and less secondary intervention. So they postulated that the long-term benefit would be offset by the decreased rate of intervention. So the idea is because of the decrease of rate of intervention do you have a higher chance of actually recouping the cost that you had from the initial study. This is a retrospective study from Japan. I looked at IVUS guided procedures and had a mean reduction of around $18,000. This is something that you alluded to, in total cost per patient at 10 years, despite initial cost that was higher. So at 10 years, IVUS resulted in 13% cost reduction compared to angiography alone. So the idea is, yes, there's increased cost initially. You have to believe that there's decreased rate of re-intervention. So by 10 years, you're going to benefit this patient with that intervention. So now in an ILLIAC intervention, patients are going to live 10 years. It's kind of like CLTI, how long is the patient going to live? And so that's something you're going to have to look at. But the idea, these authors theorized that there's a long-term reduction in cost was attributed to a lower rate of re-intervention after the use of IVUS. This study actually, in Japan, looked at these propensity score analysis PID patients undergoing over a five-year period, and showed actually at one year there was actually a reduction in cost. And 60% of these patients received IVUS guided intervention. So there's a lot of penetration of IVUS use in this population. while in the U.S. it's much, much lower. So in this model of high use of IVUS, this group that had used a lot of IVUS compared to the ones, there was actually a benefit in cost effectiveness at one year. So this is the only study that showed that, but it's something to consider. So take-home points, you know, studies showing improved outcome, IVUS use definitely is on the rise in the U.S. The discrepancy in reimbursement based on site of service can affect adoption. So there's no question. Talk to your colleagues, and it's definitely easier to justify it in your head when you get direct reimbursement. The initial data suggests that IVUS use can be cost effective on the long run due to lower intervention. We definitely need large cohort studies to prove this. And, I mean, this is something that is from the study, and I really encourage everyone to look at it. It's really thoughtful about things that we need, data gaps in education, interdisciplinary collaboration to increase adoption of IVUS, and really congratulate you guys for all the work you've done. Thank you. Applause Wonderful. Thank you. That was a wonderful talk, and thanks for getting us some data even. That's always fun to see. We're next going to have Dr. Matastari tell us a little bit about how IVUS helped him in the case. So, Kumar, it's all yours. And did you get paid for it or not? Did I get paid for it? I work in a hospital, academics, so I don't get paid for anything. So, it's great. I'll just show you kind of where we go. It's interesting that we have to convince people to use something that shows you what you're doing, but yet here we are. Eric hates having to do that. So, disclosures. This is the Photoshop pictures of where I work. It's always that pretty. That's where I'm usually sitting in a tuxedo. So, I do wound care, and so we do these cool cases, angiograms, whatever. You guys have to realize if you don't do wound care, what these patients go through on a weekly basis. When we say we'll see you in one month and two months, every week they're having something done where it's failing, they're getting infected. So, I take this to the very heart when you do procedures, understand what they're going through. So, this patient in a wound care clinic has a wound on the toe. They did a little bit of amputation. It's not healing. Had an angiogram at an outside hospital. I couldn't see the images, but said there's really nothing to treat. This is not a vascular component. It's not the issue here. So, I did an angiogram, and I can't argue with them. On an angiographic study, which remember is a 2D study, this is not bad. Right, Eric? I mean, I think you think it looks pretty good, right? Yeah, I know I'm leading you into this conversation here, but it looks pretty good. But if you put IVUS in there, because something's not healing. Something's not right. The patient's A1C is fine. They're not infected. They're not combined venous disease. What is it? When you look at it, I think you guys can all see where the flow is relative to the entire vessel lumen. You're actually multiple areas that are not getting good flow. And if you look at that middle image, there's not heavy calcium there. You already kind of predicted that. So, this is soft plaque that is causing vessel flow dynamic issues. So, that's something that's there that's relevant to this patient. So, for that patient, decided to do ballooning. Also, in the proximal AT, if you look, one of the images on the IVUS on the far right is of the AT. Also, that's the perfusion angiosome to the wound. So, treated those. And if you look at the far right, I'm going to pick on Eric. It looks pretty good. Again, right? Like, it looks amazing. No. No. No. No. There's a bad dissection there. And that dissection is going to make my wonderful angiogram go down, possibly on the table. I could sit down on the angiogram, actually. You could sit with the glasses on. I know. Well, I will promise you, none of my fellows or residents saw that. And if you're standing in a case and the reps are like, looks great, Doc. You got to do better. If you do something, try to find out what it actually looks like. Because that tibial will not survive. We don't have a lot of tools for the tibials, other than ballooning, which we know POBA sucks. But, if you find something, when you look at IVUS, you can see a clear dissection. That dissection is going to be relevant to the patency of that vessel. It's going to be relevant to that wound not healing still. So, in that situation, you got to figure out what to do. Here, I used a tack. That made me feel better. That flap, I was able to tack up. I didn't have to put a longer stent in that case, and it looked better. So, that's what the tack looks like. And then, same thing happened in the SFA. This one, I know, saw here, can see a lot better. That one definitely had a big dissection there. So, I tacked that to DCB to help it kind of have the patency. That's what the data showed. But, this is a patient that had an angiogram. Nothing to do. And I don't argue with the pictures of the angiogram. It looked pretty good. But, if you don't do your due diligence and look for additional reasons why they're not healing, that patient may go on to get an infection, then they get a TMA, and then possibly higher. And that's what it looked like. And that's why that AT mattered, because the AT was the primary perfusion to that Alex. So, there's a reason why you have to use these tools and utilize the right way to get these patients to heal when you suspect something. You have to cross all those things. The last one I'll show you real quick, a patient, smoker, progressive claudication had worsened. ABI was .7. So, you know, when you have a training program, sometimes you walk, I mean, you're always supervising. But, sometimes you walk in and they crossed. You're like, okay, like either the training's really good because I trained them, or something else. But, it took a little effort by the time I got in there, it crossed. That's what was in there, which if you know what you're looking at, that's thrombus. So, remember that every patient doesn't develop a CTO overnight. Most of them have a lesion somewhere in the SFA pop, typically at hunters. And then you get progressive occlusion, and you might have thrombus somewhere in there. If they didn't present with an acute leg, they're getting what turns into a CTO. So, at what time you caught that patient, that CTO may have multiple components in there. Focal heavy PAD disease, but also subacute acute thrombus. So, in that scenario, that I have this, you know, I said you're pretty good at crossing congrats, but let's just check it. Saw a thrombus, so then instead of what I normally would do, which is we get a long balloon, maybe atherectomy if you're crazy, I guess, and then maybe de-severe stenting, but here did aspiration. And once you do aspiration, if you look at that far right image, that was the initial inciting lesion. That lesion is what led to the CTO thrombus, subacute thrombus. Then I would do laser and DCV, whatever you want to do at that point. But the key is, this is what came out of that. If I had just gone ahead and done what we typically would do, there's a good chance something of that would shower down, and I'd be the one that turned a claudicant to a claudicant. And that's not something you want to do. You like how I used that word? Yeah, it was pretty good. It's a play on words. I was going to think about it for a second. So yeah, so the point is that, use it. We've had many cases of stents that are under-expanded in the arteries. When you do it, Ivis, after they come to you, you see that stent never fully expanded. These questions of stent migrations, it's something that shouldn't be happening if you're sizing things well. We're all using bigger balloons in the petal arteries than when I first trained, because we know the size of the vessels are bigger. There's no way in hell when I first trained that I would ever thought I'd put a three millimeter balloon in the petal arch. But I do now if I see that the size is relevant to it. Because how else are we supposed to choose an atherectomy? How else are we supposed to choose a stent? How are we supposed to choose a balloon without that information? So Eric and the team has put together a great paper saying, this is relevant, and we can't always use cost as a reason. We should fight to get the cost reimbursed to us so that we can use it appropriately. You can't run a negative business, right? So I think we have to use that. But use the tools. When you're not sure of something, use it. If you want to use atherectomy, why are you choosing that device? Why did you choose orbital or directional or laser? What was your basis that you can document when you're in court, because you'll be the only one in court by yourself, that I chose this because of this? So it helps you kind of make the right decision for the patient and selection criteria of all the tools that we have. So with that, I'll end it, unless any other questions. Always entertaining, Kumar, and I feel sorry for myself that I live in the same town as you to deal with this all the time. So we have about six minutes for some panel discussion. I'll just kick it off with a question. One of the things that we just dealt with actually a couple months ago is this possibility of having to do pre-authorization, right? And let's just talk about that briefly, like what that would mean for workflow and access to care for patients and all that. I mean, it would have been a huge issue. Yeah. I mean, for everybody in the room who are not familiar, and by the way, we have microphones in the galley here if anybody has any questions, but we were being challenged with whether IVIS should be considered investigational or there should be a prior authorization component to it. And it's also kind of tagged along with what's happening with Atherectomy right now for prior authorization. And, you know, the two things that came out of these meetings with all the insurers that were challenging this was, one, you know, there's not enough, this device would just not be used because of prior auth. It was clear that that would be a barrier to use because the time and cost to go to the prior auth for what the charge and the reimbursement is on this would never make sense for the average operator. So then you're just going to be restricting the device for a patient population that could benefit from it. So that became really clear. And then the second thing that I was most proud of is when we were able to show them much of the data that I presented and what will be presented up here, you know, they cherry-picked the data when they do their own internal reviews for these insurance coverage decisions, and they were surprised by how much evidence was there to support this. So, you know, it also spoke to what are the needs in the peripheral vascular space in particular, whether in venous, pulmonary embolism, artery, that we need to have exactly what SAR showed us also. We need to have good evidence, good data, larger cohort studies, keep building the evidence to support what we're doing because we will be challenged eventually time and time again, especially if we have $300 million or whatever the costs are for a device. We've got to justify it. Yeah, and I still agree with this. I'm just going to shift a little bit, ask Peter. I mean, just in the adoption of the coronary space, whether it's IVAS or RCT, and it's really, you know, you see it routinely used while the adoption in the peripheral space is always tied to the reimbursement and the issues of availability and the time. Can you just give us the experience, why do you think that there's still that hurdle of adoption? Is it just the data is strong enough in the coronary to justify it, or do you need more data to do it, or just the workflow? What do you think is why the adoption in the peripheral space is not as much as the coronary space? It's probably a combination of all those things that you just mentioned. You know, one of the things that I'm proud of as an interventional cardiologist is that we do these really well-run huge trials where we can really generate data that's very compelling and is powered enough to be able to answer some very important clinical questions. So it is, I don't think it's an exaggeration to say that IVAS or OCT imaging for coronary interventions is really now standard of care, and in fact it's a quality endpoint in NCDR. So in our lab, we pretty much routinely image every single coronary intervention that we do, and we've moved dramatically towards doing the same in our peripheral interventions. And I think that data that was shown earlier with task A and B versus C and D, and that's really where the rubber meets the road, where there's such a dramatic improvement in terms of clinical outcomes. And so in our practice, we routinely now IVAS over 50% of the time. So I was shocked that that slide that you showed was 1.4%. That is abysmally small. I mean, that really, in my opinion, should be a call to arms. I mean, that is a grossly small number, and it should be somewhere around 50% of the time, because that is about the incidence of when we see task C and D lesions in the periphery. So I think any complex lesion in the periphery should be imaged. I mean, we almost always change our plan. We typically find that there's more calcium. We end up doing more calcium modification. And almost invariably, we find that the vessels are a lot larger than we thought they were by angiography. So we are getting to that point, again, to the thanks of a lot of people on this panel, especially my little brother Eric there up the street in Boston. Just phenomenal work that has really opened up our eyes to how important IVAS is, and we clearly have a long way to go, but we're getting there, and this is the kind of data, and especially that cost data that you showed, Sahar, is really important to go back to our administrators and tell them, look, we're dramatically changing patient outcomes with this five-minute procedure which, comparatively speaking, is really, really cheap compared to a lot of the other devices that we use, and we should really be, you know, the use of IVAS really at this point should be ubiquitous. And actually, just to build on that comment real quick, I mean, does this make us think about reexamining all the literature that we rely on for device efficacy? You know, positioning one device against the other because, as you pointed out in your slides, there's significant differences just with the same balloon but if you size it differently from IVAS versus angiography. It's hard to go back and recreate everything, but I think, Kumar, you made up a good comment also is we're seeing a lot more of using IVAS to exactly demonstrate why you're doing the next step, and I think that's probably the most important thing. We should be justifying, again, why are we taking that thorectomy? Here's the image of the calcium. Why am I bringing a thrombectomy device? That was Kumar's case with thrombus, and so I've seen people actually take still images of the IVAS and put it in their report and say, I picked this device because of this. And, again, if we want to be thoughtful and data-driven, I think this is a great way to do it. Again, Peter is, you know, head of the game on the coronary side, but I'll tell you, we've struggled on coronary adoption, and it's not because of data, reimbursement, cost, or anything. It is laziness. We sit there on these meetings. If you go to a coronary meeting, an average should be imaging, and it's about 25%, and it's been slowly coming up. It needs to come up much more, and so it's a different conversation sometimes when you have these peripheral meetings, but, Kumar, have you done any, you know, do you feel like the documentation part of this with IVAS is helping you in terms of I put it in there because I think I'm trying to explain why I did something, especially when I take on second, third opinion cases. It's good to say, hey, whether something good happened, bad happened, this is the reasoning why I chose this because we're living in this tumultuous time of error right now where you kind of, everyone's questioning what you're doing, people are losing trust, so why not try to back up what you're doing with some kind of additional evidence than I did, I squinted at the screen and it looked good. I think that's kind of not good. I think trials need to incorporate IVAS more. The trials I have going on right now, I think only one of them says IVAS is part of it, so I think we need to figure out a way to tie those two together. Great, okay, that was a wonderful conversation. Again, I'd love to have some questions for the next panel discussion, but until then, we're going to have the vein boss come up here and give us a little conversation on really how IVAS can be effective for deep vein. Dr. Erin Murphy, thank you. Thank you, and nice reference. Dr. Medassari made me that name. I'll try to refer to you as much as I can, Eric, during the talk. I see the trend, so we're switching to Venus. So as some of the other talks alluded to, as I go through, I'll kind of reference this paper, but it basically goes through, I'm trying to approach it from a clinical and practical approach, and most of what I say is actually covered in this consensus document that was, I think, very valuable. These are my disclosures. So certainly I use venography, right, but it only gives so much. It's going to give us an idea of what we're up against and ideas of paintseed, chloralization. It'll clue us in to maybe there's pancaking, maybe there's underlying the pancaking picture at the May 30. You can see there's probably some scar there in central iliac vein. You're making me very nervous, Steve. Imaging is two-dimensional, and you certainly are going to miss things. And in veins, there's very specific reasons, even different from our arteries, of why we really need this. We really are not seeing what we think we're seeing with venography. So first, you have the very nature of veins and their role to be distensible, compressible. It's because it has this thinner media layer. It's necessary for function, but when you look at different gantry angles in your 2D image, you're going to see very different things. So here, you may see the same thing as kind of here, roughly. You look in this plane, it's grossly different, right? Then the disease type is different. So these compressive lesions are going to look large in one realm and maybe narrow in another. Maybe it's not that narrow, and it's just, you know, oval, and the area is fine. But you really can't tell that unless you're using IVAS. On the bottom, that's a completely stenosed, long segment of vein that has more than a 50% stenosis throughout, but on venography, it looks totally normal. Next, when it rotates through the pelvis, you may see different lesions and different angles. So even if you line it up so you see the correct gantry angle for a certain portion of the vein, it may not be the best gantry angle for another portion of the vein. So getting it all in the same plane is near impossible. When you're looking at how they move, that also is asymmetric. So looking at the bottom, that's how the cava moves. The gantry angle to figure this out in every patient is different. Compression lesions, as we know, are very dynamic. And this is, you know, using IVAS and parking it right under the lesion and doing breathing maneuvers is exactly how we decide, is this a real lesion? On venography, there's no way to do that. And then lastly, you know, we think about veins being a little bit more forgiving, although they are more forgiving in that, you know, if you have a rupture or something like that, you're not as likely to die on the table and not as likely to lose your leg, but that low flow that protects you from those complications is the same low flow that sets you up for thrombosis if you leave anything that's not perfect. So those subtleties that you see on IVAS that may affect your stent patency, you don't see on a 2D image. So what do you use IVAS for? It's basically everything. I shoot one venogram at the beginning, one venogram at the end, and that's it. Everything else in between is IVAS. And we'll go through a couple examples here. So for wire path, the, you know, certainly you can get into collaterals, you can be in the wrong place, and yes, if you get the right angles and you always should have a lateral and you should always be checking, you might miss being there. With that other picture in the middle where it says no in the arrow, that's in the spinal canal. What you should be seeing, I don't know that I can, oh yeah I can, here is, you know, even in an occluded vessel, you're going to see on the left side, you're going to see it go underneath the artery, you're going to see that your vein travels next to the iliac artery, or to the external iliac artery. As you come in, that kind of thing shows you're in a septated vein, not a collateral, because you see multiple septations in there. When you come down into the common femoral, you're going to find your healthy landing zone, you're going to see your GSD, you're going to find your profunda, you're going to see your circumflex there, you're going to know you're in the right place. And it makes it much safer. The degree of stenosis, I'm not going to go in too much, because I think we're talking about the nipple consensus too, and we'll be talking about it during Dr. Elias' talk, but you can tell that this is much more accurate, and again, this is that patient that looks like they have a pretty smooth vessel, but it's pretty diffusely stenosed if you look at those areas only in the 50s and 60s throughout on the bottom. When you get into the next step, like yeah, you prove you need a stent, you know, 70% more lesions detected with ivis and venogram in the video trial, but also you use it to define your anatomy. Where is your iliac confluence? When we looked in my last practice at the difference between venogram and ivis, it was almost a full vertebral body off in some patients, because the gantria angle is so off, and that's if you look at AP only. Can you figure out a gantria angle to open up the confluence to be able to tell accurately and put a catheter? Sure you can, but this way is pretty accurate every time without all that extra fuss. And this is ideally how your stents should look, like not crossing that confluence and preserving it bilateral and unilateral. So why do we care? Well, we know that it matters. In the old wall stents, we told people, oh, 15 years, we said, don't worry. You're not going to get contralateral DVT. Just take it up into the CAVA. And then 15 years later, we're like, well, it's not high. But 2% to 4% of people will get this contralateral DVT over time, can be higher in cancer patients, usually in patients who have their blood thinner. The newer stents do have bigger interstices, but I don't think it's going to be all that protective. We see the filter occlusions, right? And those have pretty big interstices. But we'll see in 15 years what we say. But ideally, we use IBIS to determine and avoid that. Certainly, missing lesions is possible. You want to find your profunda distale. This is the one mistake I don't fix anymore when patients come to me and the stent's into the femoral vein. I no longer attempt to fix those because they're really not fixable long term, acutely maybe. But this is a stent going across the profunda and directly into the femoral vein. Next, you want to find out your landing zone. You know where your anatomy is. So what's the healthiest segment to land it in, right? Which is in post-thrombotic is almost always past the ligament. You don't want to leave stuff like this. Again, it's a setup for a thrombotic event if you leave imperfections. You're not going to see this on your venogram. But that does lead to these stent occlusions. Use it to determine your stent sizes and lengths. And again, I'm going to let Dr. Elias talk about the nivel consensus and how exactly we do this. But you're going to be doing this by parking your ivis catheter in there and marking from your inflow to your outflow and figuring out your overlap in the middle and using it to determine your stent diameters in the area of your fixation. Completion imaging, making sure that everything's opposed, that you've got good apposition, that you've got good flow, and that there's no defects that's going to later cause a problem. I also look at the profunda and make sure there's no flaps of tissue covering it at the end. So how are we doing? This is Eric actually presented updated data. I should have asked for your slide. But I did get that reference in at TCT. And this was from 2019, showing that cardiology had some of the highest use and IR some of the lowest. Highest in the OBL, probably tied to our reimbursement that we were talking about earlier, was in the inpatient hospital setting. Oops, I didn't mean to have an animation. Barriers to use, they were talked about in that paper among the expert opinions. And some of the solutions, limitations of technology, the need to continuously improve and not rest our hat, operator comfort, the need for continual education and discussion, cost issues and reimbursement on a global level. As Black will tell you, we just don't have, I think, the proper reimbursement across the pond. Continued evidence production and incorporation into these consensus statements and guidelines. When we look at where we are with guidelines, briefly, we have little references before some of these newer documents. Like, oh, it may be better to use this. Maybe, it says. And then here, again, in 2022, just the use should be considered, level C. SIR, it probably is better in detecting thrombus. Nothing really solid for us to rest our hat on, which is why we have to keep having these discussions with insurance and our hospitals. And Eric put out the appropriate use criteria. And you can see, almost all the experts agreed that every step of the pathway in venous disease is necessary to use IVUS to get a good result. The Sky Guidelines, similar, and the Delphi Consensus, they're all saying, we need this every step of the way in venous. There aren't exceptions. So in conclusion, IVUS is essential for deep venous procedures. Usage is appropriately increasing, and value is getting acknowledged. We do need more progress so that we can continue to use this and progress effectively. Thanks. Thanks, Erin. Our next speaker will be Steve Black, who's going to be talking to us about a case of DBT intervention where IVUS made the difference. Thank you very much, and thank you for having me. We've had some great PAD cases. And I have to say, I echo the comments made earlier about, it continues to be a mystery as to why IVUS is not used more. And your comments about laziness might be appropriate. So these are a couple of cases where we've used purely mechanical thrombectomy to treat some cases. And I found that IVUS, in all DBT cases, really makes a big difference to the decision making that we make in these patients in getting good outcomes and obsessing about the end result to make sure they're right. In our practice, we use mechanical thrombectomy when you can't really use lytic. I'm not a believer that all lytic is bad. I think you make decisions based on each case. We're trying to get this concept of subacute chronic clot. That's a term that I absolutely hate. I'm using it here because it seems to be what people use. But there is no such thing as chronic clot, really. It's scar tissue that is formed in the vein. We try to clear large vessels when we can't, and sometimes it's about speed and single-session treatment. So the moment we have NRE Penumbra Pounce, which was the V-TEX device in the UK. It's not coming back to the UK, much to my disappointment. It was really a good device. We were involved in the first in-man clearances, JETI. And we have something, Argonne, on bringing out a cleaner device, which may or may not work. We'll see. This patient's a patient with chondroenducation lytic, 46-year-old female, 16A, history of right-sided iliafemoral DVT. CDT had been started via right popliteal vein puncture, but her fibrinogen dropped quite quickly to 0.3 the next day and increased only slightly after two pools of cryoprecipitate. So based on the dropping fibrinogen, we moved to mechanical thrombectomy in this patient. This particular case, we used the NRE device, which some of you will be familiar with. And you can see, let's see if these play. Have we got any runs of it? This is the clot that you see from the femoral vein. The NRE device is coming up with the sheath pox in the femoral vein. This is the popliteal puncture. We do these patients prone. And you can see, this is the clot triva moving down through the iliocaval segment down into the femoral vein. I must say, I'm still a little bit out on whether or not this device damages the femoral vein. We've had a few patients where that's certainly been an issue afterwards. You can see much better flow through the femoral vein thereafter. But there's still sort of static contrast sitting higher up, which we've now sort of plastered up with a balloon, still to the point that Erin was making these vessels don't look perfect at the end. So this is where IVUS comes in to try and make decisions. And there's a couple of things we're looking at on the IVUS. One we're trying to see, is that just vessel spasm that we've got? You can see, as you come back down through these vessels, in particular, this point here, which I'll try and pause the image, what you see often in acute DVT is this wall looks like this. You can see this edema in the vessel wall. This is from the chronic acute DVT changes. You can see you get this sort of halo effect. And we see on IVUS. Now, it might be a normal vessel, but our experience is often that ends up being fibrotic later. And then the other thing we're trying to check at the bottom end, which I think is really important, particularly when using mechanical devices, is these devices pull clot down. And that clot snow piles into the profunda. And if you don't concentrate on the end and get that clear, you're going to see that we're not really getting clear views of the profunda at the end of this case on IVUS. So while the venogram might look fine, if you don't have the profunda in circuit, this will all go down. So we spend a little bit of time at that point in getting an aspiration device into the profunda just to clear that out. And I normally just, you can actually sometimes just put a C2 or a Virtu over the top, swirl it around a bit, just inject a bit of lytic. And you clear that profunda out or come into it from the bottom to clear. And this was the duplex of the patient thereafter. And you can see the point about all these devices is the iliac vein is cleared up nicely. There wasn't a compression there. It was just that edematous vessel wall. So we didn't need to stent it. But you can see what the femoral vein looks like on a duplex that we performed afterwards. There's reflux the whole way down the scar tissue through it. So while it's patent, this is where I think we've still got to figure out what the long-term effects of pulling these devices through these veins. This is the second case, an 18-year-old female. She was initially treated at another hospital that was referred into us. She had a three-week history of left leg swelling and pain. She had an ILI cable DVT and imaging. And she was started on CDT in this referring center. And after 72 hours, there's no change. So they then sent her down to us. And this is what the venograms look like at that point after 72 hours of lytic. So you probably get an idea that lytic isn't going to work when you've got that three-week history. And particularly, if you run lysis for 72 hours, it's not going to make a difference if you keep going there. So again, mechanical thrombectomy, you can see a couple of pulls through the vessel. This is what it looks like. And then the final, that venography, you can see there's still clearly disease in this vessel. So you can see now we've positioned the ivis catheter. This is going to tell us that we still had more clot. And we needed to do a couple more passes with the thrombectomy device to pull that out with access from both sides. And hopefully, I'll get to the ivis pictures in a second. So much better results after a few more pullbacks. You see the collaterals have disappeared. You've got flow in the femoral vein again. This has all been ballooned up. I've lost the ivis on this. That was the whole point, isn't it? It's gone. So I'll show you this last case here, which does have some good ivis pictures. Again, this thing, if we pause on the ivis runs, you can see what we're trying to do in clot. And I think this is particularly important for angiojet. So this patient, we're using angiojet. And I think when you start to use the pharmacomechanical devices, if you use angiojet in static blood or flowing blood, you massively increase the rate of getting AKI afterwards. All these patients have a degree of renal impairment at the start. But then you get hemoglobinuria. Then you get hemolysis. So you really want to be targeting the clot. And you can see in this ivis pullback here, we can see where the clot starts as we come into that common iliac vein under the vessel. And then at these points there, you start to get indeterminate stuff. There's areas where there's flow lumens in it. You can't pick that up on contrast. And you start to get down to vessels where actually this bit is just static blood sitting in an occluded vessel. It's not clot anymore. So you don't really want to be running an angiojet catheter through that, because you've got to start getting hemolysis. So I really find it useful to try and pick that up. And you can see the ivis pullback afterwards. After a few runs, there's still some clots around. But now you're starting to see a flow lumen. You get that same halo effect as before. So we know that bit of vessel is damaged. That's what's been pulled out here. And again, you start to see flow through these. Right, let's try and get to the end of these ones here. How much time have I got left? We're running out of a minute. So I'll flick through these images. The ivis pictures on this one. What we're trying to get out of ivis is, again, IVC, vessel crossing point. You can see bits of clot are sitting around. And when you're doing anything with aspiration, don't try and go after that stuff. This responds to balloons. You can see the lumens come up. Sometimes if I look at this, and I've done several passes of the mechanical device and it's still not right, these are the kind of cases where you go, there's some material hanging around. It's not a case I necessarily want to stent, but there's still thrombus. I put a CDT catheter in overnight just to drip some more clot lytic into these patients. That's pretty safe. We must remember that the major bleeding described in A-TRAC was pretty much transfusion of blood rather than anything more significant. So the bleeding risk is not quite the same. Again, this ivis pullback, we still see a bit more clot hanging around. But we didn't end up stenting this patient despite the outflow compression, because actually the flow was pretty good. And that's helped to make a decision on should I stent or not. The compression wasn't terrible. There was a bit of chronic scar material left behind, and we left that patient alone. So I think I'll stop there before I get killed for time. Too many cases. Right. OK. Thanks, Steve. Thank you. All right. We'll have another Steve up now. Steve Elias. He's going to talk to us about moving towards consensus in the treatment of nivel. Right. OK. Thank you. I had to walk up, because nobody saved me a seat up here. OK. Anyhow, I'll talk to you about some of the consensus statements that came out in the most recent article, which is this article here. And we're specifically talking about nivels here, OK? We're not talking about anything else. We're kind of honing down just on nivels and multi-society consensus statement. And Kush was the lead author here, but a lot of us on the panel had something to do with this as well. So we're going to talk about, Erin told you about some of the other things in the consensus statement about why we should use it and some of the technical tips when you're using it. But here we're going to talk about two things, a little bit about patient selection, as well as some of the imaging and stuff. So let's go down to patient selection. Here's our five statements, and I kind of highlighted them. So again, we're just talking about nivels. May be appropriate for asymmetrical edema, significantly affecting the quality of life when you've excluded all other causes, OK? And let's preface this by saying, outside the United States, there's much, much less treatment of nivels than there is inside the US. Now, that's not because we have an enormous amount of people in the US with nivels, and they have nobody outside the US with nivels. It's because people have not been following these statements here. So let's keep this in mind for most of us who live in the United States. Scent placement may be appropriate in the presence of advanced disease, again, or venous claudication, once again, when either there's minimal superficial disease or you've already treated that superficial disease. And look here, we're using the words may be appropriate. There is nothing here that says absolutely 100% appropriate. But there is something that says that it's inappropriate, and that's when patients don't have any symptoms, OK? It's also inappropriate in asymptomatic patients to prevent future VTE, all right? Some people are making their living in the United States. Oh my god, you have a narrowing. We better get it before you have a clot. The same people that are ablating saphenous veins, because they say, oh my god, we better do that, or else you'll get an ulcer. So it's inappropriate to prevent something. However, as a caveat, there are people who we've seen cases here that they have an acute thrombotic event, and the underlying cause, or one of the underlying cause, you see a significant nibble. That is one you should consider placing a stent. That's not in our consensus statements, but it's not the opposite, that if they have something and they've had a problem, you need to place it. And it also may have a role, in some cases, with quality of life limiting chronic pelvic pain. When it's decreasing, you have proximal common iliac obstruction, refluxes into the internal iliac, into the pelvis, may have a role in those types of patients as well. So in terms of imaging, there's some considerations. In a patient considered for nipple treatment, complementary use of venography and IVUS is recommended. We're recommending. It's not like you should think about it. You really should do it. And dynamic IVUS is really very, very important. We're becoming more and more understanding. The difference between a fixed lesion for nibbles and a lesion that moves with intra-abdominal pressure, moves with position, moves when you ask the patient to valve salvo, versus those that are fixed. And the ones that are fixed are the ones we really think are significant. Just as on the bottom there, a comment. It's my comment, and others in the faculty. Think about hydration. We just had a really nice paper in the last session, which most of us were doing that already. These patients need to be hydrated, so you get what I've called a false lesion. The balloon test, if you can get an 18 balloon through a lesion, it's not significant. And it'd be nice if we could see these patients standing as well. So also, the threshold, greater than 50% error reduction, or 61% diameter stenosis on IVUS is correlated with symptom improvement. And you should not really intervene below those levels. Venography alone is not the way to do it. You need IVUS. Axial imaging can help confirm that. Remember, axial imaging, people are NPO, may show you some of the anatomy. But also, you may look for some other reason why, like a tumor. It would be embarrassing to place a nibble on someone who really has a tumor, which is the problem. And I just, as a sidelight, intend to treat versus doing a diagnostic study. I tend to only do diagnostic studies and nibbles, sit down, think about it, talk with the patient, and then decide if I'm going to stent or not. The hardest thing for any interventionalist to do is to do nothing. So you're there, oh, we see a lesion. Let's just put in the stent. You need to have a discussion with the patient as to what their responsibility is afterwards. That's my bent. It's not in our statement, but that's I don't do it at the same time. Post-thrombotic, totally different thing. I will do it the same time. Medical therapy, it's routine use of anticoagulation in untreated nibbles is not supported. We're basically recommending, unless you don't have any other reasons to give anticoagulation, don't give it for a pure 100% nibble. Now, the nibble patients who have had no previous DVT, there's no consensus. That anticoagulation is necessary, and then we're really kind of a cop out on numbers three and four in here, is that assess the patient's thrombotic risk separate from the nibble issue, and then you can decide if they need it. If they have a thrombotic risk that takes precedence, then yeah, they should do this. And you do need to image these people, and that's another reason why you need to have that discussion with them before you place the stent. So here we go. One case, and that's it. Nibble case, history, 36-year-old female, 24 years old. She's had varicose veins since she was 24. Left low extremity pressure, some discomfort, some throbbing, there is definitely swelling as the day progresses, it's in the calf. Compression helps somewhat, but you really can't tolerate by mid-afternoon. And there's no history of SVT or DVT. Gloria, pay attention, you're gonna have to tell me what to do, okay? Gloria. All right, here we go. History continues. CT scan in two separate facilities said that the patient has a left nibble. Two separate physicians said to the patient, you need a stent. No endodontitis or venography. On physical exam, she has varicose veins, medial and posterior calf, 67 millimeters. The calf is swollen, is slightly tender, a little bit tense, no skin changes, and she's got pulses. So here you can see the imaging here from our lab. Big saphenous vein down to the knee level, actually down to the proximal calf. Lot of reflux, and it's incompetent. And there are varicosities connected to it. And here, the left common iliac vein was visualized. There was narrowing, suspected compression. Further correlation is recommended. Here's the ibis. As we start our way from the vena cava, we come on down. Sorry, we did this, the fellow was doing this a little slowly, he was so excited. The hardest thing to tell the fellows is don't follow with x-ray, just look at the screen instead. So I had to take his foot off. Anyhow, we're coming down. We're still coming down. I could have cut this shorter, I'm sorry. Anyhow, we're getting, believe me, we will get to the confluence, there, here we go. Here's something coming over, here's a little compression here, here's more narrowing, and then I will just let you know as we go down below, everything else, once you see here, is really fine. So it opened up here. And we did some measurements, clearly, it's very small here, diameter's a three by eight, you couldn't see that, 23 square. Here's our reference vessel here, 144, the mid-external iliac plane, so area reduction is 84%, diameter reduction is 81%. Gloria, what do I do next? That's a very good case. I would do first the ablation, superficial ablation, observe the patient. Of course, I'm assuming you already hydrated the patient and you did the evaluation. Everything we're supposed to do, 1,000 mLs, dynamic, you know, we did the whole bit. This is a real lesion. She doesn't have pelvic pain, right? She doesn't have pelvic pain or not? No, zero pelvic pain. And please, no POTS, right? No POTS. No POTS. Okay, good. So I would just do superficial treatment first, follow up, and then discuss the possibility of stent in the future if she doesn't have full improvement. Why superficial first? Anybody? I think, to Gloria's point, sometimes if you've got a big refluxing vein, which it is big, and it's refluxed the whole way through, if you treat it and the patient's better, then they're not being committed to a stent. That's totally reasonable to take. You don't close the door by doing that first. It's about treating those cough symptoms, which could well be related to the varicose veins. Yeah, and I think a lot of it is also based on the patient's symptomatology. The symptomatology was not a pure obstructive symptomatology. It was really a kind of semi-mix in terms of tense calves, swollen butt. She also had reflux symptoms as well. And so the point is, and when I do something like this, sometimes if I think they have a problem up above, but they have a big vein, I have told, and this in this case is what I said, even if we find something, we're going to ablate the saphenous first, and then we'll sit and talk about it. So in this case, I accessed down below and did my ablation after I got this study all in one sitting. So that was going into it, I felt her symptoms were more, you know, reflux. So anyhow, you still can use IBIS, you still can find it, doesn't mean you have to always act on it. That's it. Thank you. We found Steven Seed. Thank you. So we have just a few minutes now for Q&A before we have to be out of here. I'm not convinced anybody to ask a question yet, but if you're willing, take the opportunity. I'm going to ask Gloria, now that you've been on the spot, one more question for you. Sometimes people look at IBIS and they're like, I have no idea what I'm looking at. And you know, for people like us who have been up here staring at this for years now, it's intuitive. But, you know, you've been so involved in, you know, resident fellow education, you know, how are people learning right now? And what do we need to do differently in terms of introducing this technology, this specialty? This is a great question. I was going to comment, like, the utilization of IBIS, at least in venous disease, which is what I do, it goes hand in hand with also over-utilization of therapies. We're just talking about appropriate indications. You can create an elision in IBIS, particularly if the patient is not well hydrated. So I think education is extremely important to understand which patients would need the therapies that they need for. And education is still lacking. I did not train with IBIS, but I used IBIS as first year attending when I, when I started working so I'd learn on myself or with myself, with other colleagues that were already using it. I think education should be more standardized. We should be able to also educate about how to measure, how to determine elision is significant. And I think we still need to work on that because as Sahar showed the data on the OBL reimbursement, and I cannot help but think that, you know, people are being driven by different sort of, sort of concepts. And then you end up having over-utilization of stents. By utilizing IBIS, you actually see more, as Kumar said, but then is it real and is it clinically relevant? So maybe, Kumar, you know, on that same note, you know, from a PAD standpoint, you ran a course recently on, you know, procedural competency and training techniques. How do we pull this out so that we're having different conversations in the future where it's more ticks and trips, tricks and tips and trying to convince people? I think it's about repetition. I mean, how do we get, how do we get our fellows or any specialty trainee to do a T-bar? I mean, how is that so easy to teach, train with 15 devices, 16 French axes, but putting in a small catheter to look at some images is so tough. I mean, I don't know. I think you just have to use repetition. I think when you're using IBIS, you have to do a good 30, 40 cases on the PAD spectrum to really understand the different kind of nuances of what you're doing because the pictures you see on the table won't be exactly what we show as educational opportunities. Those are perfect pictures, right? But in reality, you have to learn the nuances. So I think it's about repetition. It's about documentation. It's about explaining why. But if you can do a ileal cable double-barreled reconstruction, you can do an IBIS in your sleep. Yeah. Great. Thank you. Thank you. Any other questions? No. Okay, yeah, my question was basically the use of IVUS after you do an intervention. So I routinely use IVUS pre-intervention as well, because of time, things like that, I don't routinely use it afterwards. Is that something people do? Do you guys do that regularly afterwards? Have you found things that you thought, well, maybe I should have done something else? I think you should. I'll just use my example. This week, right before coming here last week, I did a spree, the resorbal step, dropped it in there, did everything right, and then we said, let's just look at IVUS, and part of the stent in the proximal tibial was not expanded. On the 2D angio, it looked good, but it was pancaked. So I went back and touched it up. I would have missed that 100% just by quickly trying to get out of the case, but that critical step would have been the reason for my patency to go down. Yeah, no, I'm. Do you do it regularly after every other? If you already pulled it and you're using it, why wouldn't you use it to just double check? I think everybody's saying the same. I mean, you say, of course, the time and everything else. I mean, an extra three, four minutes there is going to save you a couple of hours with the patient coming back with an occluded stent or whatever. So yeah, I mean, and to your point, the more you look at things that are normal and good, you will notice when they're not normal and good. So the more you put into your head with all these images, so even if you don't think you need it, that's when you need it because that's how you're going to learn when you see something that's not quite right. Yeah, I think I routinely use it on venous, but I'm probably going to do that on arterial too. You should talk to Fisher. When he does the PAD and the tibial, he keeps the ivis from the tibial axis and does the work from above. So he does something, runs the ivis from below. He just. Thank you. All right. Thanks, everyone. Thanks for, of course, to Philips for supporting this through unrestricted grant to the sky and SIR for collaborating. Please scan the QR code for your CME credit and enjoy the rest of the meeting.

intravascular ultrasound

peripheral vascular

peripheral arterial disease

venous issues

treatment precision

Medicare patients

economic considerations

case studies

surgical outcomes

clinical practice standards