From seeing to treating: experiencing radiation-free precision and expanding IR possibilities in an Interventional MRI Suite

Episode Transcript

Recorded live from the Cook booth at SIR and featuring leading experts in the field of interventional radiology discussing a wide range of IR- related topics, this is the Cook@ SIR Podcast Series.

Good morning and hello from the show floor of SIR. Very excited to be having a conversation today. My name is Joshua Krieger. I’m the director of product management for Cook’s new iMRI division, and I’m joined today by Dr. Erica Knavel Koepsel, an associate professor of radiology and chief of IR at UW-Madison, and Dr. Cliff Weiss, professor of radiology and biomedical engineering at Johns Hopkins. So, thank you so much for joining us today, and I’m really excited to be able to speak today about interventional MRI, which is something that people have heard about for quite some time, but I think we’re really seeing a resurgence in interest and some really neat technological evolution that we’ll be able to talk about today. So, thank you so much for joining today. I wonder if the two of you, for those that may not know you, if you might give just a little bit of an additional introduction and your background with MRI as is relevant today. I wonder, Erica, if we might start with you.

Sure, sure. So, again, Erica Knavel Koepsel from the University of Wisconsin–Madison. I’ve been there for about five years now. I’ve been working in the MR space since probably about 2017, back when I first started my first job at the Mayo Clinic Rochester and had the privilege to study and train with Dr. David Woodrum on the job. So I did move to UW–Madison in 2001 and started an interventional MRI program there, and we’ve been just supporting that program for the last several years and watched it grow exponentially over the years. Our practice now includes about 60% prostate work, which is made up of mostly cryoablation of the prostate but also prostate biopsies, and the other 40%, we treat a lot of soft-tissue tumors like desmoids, vascular malformations, abdominal wall, endometriomas. We do some pelvic lesions, pelvic lymph nodes. So, a lot of areas that we explore in the MR space.

Fantastic.

Thanks for having us. I’m Cliff Weiss, I’m an interventional radiologist at Johns Hopkins, and I started in high-speed MR in cardiac in 1997 and 1998 and was in the interventional space in the early thousands. And in fact, David Woodrum spent a good deal of time with us, with Dr. Arepally and myself, as we were doing—at that point, it was developmental research in interventional MRI and experimental research to learn the basics. And then to actually take that to a clinical service is something that David then did at the Mayo Clinic and really brought it, I think, to the forefront in the United States.

So we’ve been involved with interventional MRI from the beginning. I started originally purely to ask some research questions, which is “Are there procedures I can do under MRI that I can’t do in any other environment?” And that eventually evolved into a clinical service, which primarily had been focused on vascular malformations and on, really, musculoskeletal and nerve-based procedures at Johns Hopkins.

Fantastic. I really appreciate that. Now, I wonder as we… I might give just a quick broad definition. So as we’re talking about interventional MRI, for those that have not encountered it, we think about an interventional procedure as a medical device manipulated by a healthcare professional under medical imaging. An iMRI, broadly, is an interventional procedure where the primary imaging modality is an MRI. That can be real time, that can be intermittent, like an in-and-out procedure, a whole broad range of options in that, but primary imaging modality is MRI.

I wonder if we could maybe start with what drew you to iMRI? What drew you to interventions under MRI? What did it provide you that, really, you saw clear clinical benefit in? And what are the kinds of procedures that really lend themselves to visualization under MR?

I might start on this one because I probably started on this one back in the day. I mean, originally, we really wanted to see, could we do things—and these were really experimental things, not necessarily in patients—that— So, I think about interventional MR procedures in two categories. One of them, How can we do it better—something that exists already—than either other specialists can do or than we can do in our own specialty using other modalities? And the other is, What can we do that can’t be done without MRI? And that was where I focused the first probably 5 or 10 years of my career, were developing procedures where I either needed to see something we were delivering under MR that you couldn’t see any other way, or I needed access to a vascular system that to do it in a clinical scenario using fluoroscopy or CT would be a grueling experience and was very quick under MR.

And so the example there was—and this is way back on a 1.5 tesla system—not such a short bore. It was actually—they don’t make it anymore—it was an old SIGNA system, short, long bore, narrow. And we were doing mesocaval shunt creations to deliver islet cells into diabetic animals, right, and to protect those with a capsule you could see. So, all of a sudden, we could do things a surgeon would have to do, with a 10-minute procedure, but they were all handmade equipment. And the other thing we were trying to do is cross the heart from the right atrium to the left atrium without guessing, right, without having to kind of—and so that’s where we started this whole thing, was “What could I do that you couldn’t do anywhere else?”

Now, the barrier always was, we had the hardware, but we never had the disposable, so we couldn’t get it out of animals into people. And then as we then took our comfort with these very complex procedures, we started thinking about what are the procedures that we are having trouble doing in people that we could do better, now, with clinical-grade equipment?

And that ended up being for us, since we’re a large vascular anomaly center, is troublesome vascular malformations that we couldn’t treat either anymore with ultrasound and with fluoroscopy, or that we couldn’t see at all. And the other was very detailed neurologic structures that needed to be blocked in patients who were in chronic pain, when you couldn’t see those nerves or those branches of the nerves using CT and clearly not with ultrasound. So that’s sort of where we came—and I came at this from a very, we need to develop the software, the visualization software. We came from a very BME perspective in the late ’90s, early thousands, into now it being a clinical tool that we can use today, which is really exciting.

Yeah, I agree wholeheartedly with that. And that’s an important part of why we do cases in the MR. The other thing that really got me into iMRI is, when I watched my first cases, the detail that you could see of the tissues and of your treatment zone or where your needles were placed was like—nothing else could compare. And I think that’s what really opened my eyes to interventional MRI.

And it’s interesting, kind of changing this paradigm a little bit. Not everything has to be done with MRI, but I was showing a case to a colleague. It was a rib lesion, and he said, “Well, I could do this in CT because I can use the calcifications.” I was like, “Yeah, you could do that.” And then I said, “But I can do it in the MR and I can see the whole mass so then I can make sure I’m treating the whole thing.”

So I think that, for me, really solidifies why I use this product, because I think we are treating patients more accurately, and I think an improvement in patient care, because we’re able to see the whole tumor, we’re able to see our whole treatment zone and be really accurate with that. So I think that’s really what drew me into this practice, and also lesions that are hard to see. Maybe a 1 cm liver lesion, which is lost on ultrasound or not visible on CT. We use landmarks now like, “Oh, I could put it here, but I think it’s by this portal vein branch and maybe that’ll be fine,” but when you’re in the MR, you actually see it and you can put the needle in it and treat it.

And I think you’d also agree, it’s a lot of fun to work in the MR space. There’s nothing more exciting than taking off your lead to go do a procedure. That is really fun.

Yeah. I’ve not encountered anybody that has missed their lead.

Yeah. And honestly, you rarely miss the target either, right? There’s no more guessing.

And I think that… I’d love to bring up an example of that here in a minute, but I think the field has even been pointing to this. Cook came out with needles in 1996, and we’ve been bringing them back off slowly due to lack of adoption. There have been some real technical challenges, but even in that time, the industry has broadly pointed to the value of the soft-tissue visualization that MR brings, in the context of intervention, with some of the fusion systems that we see out in the world today, and I wonder if you might speak to that just a little bit.

So I will say—again, I’ll take it back to personal experience. I was working with one of the imaging vendors as a research fellow a while ago—a long while ago—and one of the projects they placed me on as a company was a deformable registration matrix for MR fusion to prostate to be used in the urologist’s office, right?

Yeah.

Which just goes to show you when you start a job, you never know what it’s going to end up doing. And what it brought home to me was very clear, which was, many specialties, especially urologists, want this MR data, and most of them were completely uncomfortable in the MR scanner and were never going to be able to afford an in-office “MR scanner,” and so they wanted the data without the machine.

And so we went through—and it’s become very good fusion and is being used in other areas now too, but we went through iterations and iterations of figuring out, how do you deform a matrix for MR that’s going to look completely different with a transrectal ultrasound probe? And you can imagine a prostate in the native space that’s being imaged from outside the body versus one where you have something pressing on the prostate and deforming it. We had to actually work through that math and that processing, which shows me that those are hoops you jump through when you can’t use the MR but want your MR data.

And we’re seeing fusion across interventional radiology now in the angio suite for transvascular procedures, in ablation areas, and all different types, and bringing in different imaging modalities, including PET as well. So there’s no question, the more data you have now, the better; the cleaner your margins or the more inclusive your margins are for tumors, the better. The question is, Why not just do it? Why bring the mountain to Mohammed when you can bring Mohammed to the mountain, or vice versa? I don’t know the saying, but why not just go and do it at the right modality rather than bringing the modality sort of into your procedure?

And I think there has been, in fairness, that—you spoke about a challenge with devices. For that interventional procedure, you need to be able to see both your target tissue and your device to be able to navigate it accurately to the target. And I’m excited by some of the advances that we’ve seen here recently in the imaging to be able to push to real time in some of the devices, to be able to really support not just having that exquisite soft-tissue contrast in a diagnostic mode, but now being able to take those interventional steps in the same bore that those exquisite images are taken.

Right, because I think all of our fusion imaging is our best estimation of the truth. But it’s still not the truth, so the truth is seeing it in real time and getting contemporaneous imaging that’s up to date. You can see the tissue deformation. You can see how the structures are moving. That’s really like the gold standard, right? So that’s what we have in the iMRI, which kind of sets us apart from fusion imaging.

I think, Cliff, there was an example of this here recently that I’d love you to speak to.

Sure.

You were able to visit us in the research suite that Cook has built to be able to enable R&D and research and workflow work. And you were joined by, I believe, a first-year resident.

Correct.

And I wonder if you could speak to how that worked, chasing a 5, 6 mm liver lesion up in the dome of the liver.

Yeah. I’m sad to say that my resident did better than I did and within five minutes had needle to target. I think his musculoskeletal system is a little more intact and he’s able to move a little better than I am. You know, I brought a first-year resident who had never put needle to target, who had not done his first IR rotation yet—he’s an IR resident—and the response was pretty spectacular. I mean, learning how to move your hands in three planes independently and yet in a serial fashion fits to my very linear thinking when it comes to procedures, and I think it comes very naturally. I think when I watched him do it without having to say, “Okay, now do the axial; now do the sagittal; and now your coronal is your confirmation plane, or paraxial, parasagittal, paracoronal.” He naturally, as a Gen-Z person, had that video game kind of mentality already, so it was second nature to him. He was dead on target I think 5, 10 minutes with his first pass, and then the second pass was perfect, and the third pass was perfect at different targets. That’s a skill set that, if we teach on ultrasound—and I use MRI as an example of “move your hand in one plane at a time; don’t think about moving in three dimensions”—that would take me, if we have a good resident, two or three weeks. A resident who is struggling a little bit could take six months to teach ultrasound skills. And most of my clinical practice where I’m not doing work in the MR is primarily ultrasound based for vascular anomalies.

And so to watch that happen in 10 minutes with—I didn’t train him. I think you trained him, right? That’s pretty special. And what it shows me is that, when you have a functional system where all the pieces are working, this is an extraordinarily “easy” technical modality because there’s just no guessing anymore. Either you’re seeing it and you’re in the right place, or you’re not seeing it and you shouldn’t be where you are. It’s not a challenge once everything works, but “everything works” has been a 20-year slog.

Yeah, and I think—you know, I love ultrasound. At the University of Wisconsin, we’re heavy ultrasound utilizers. It’s a great modality, but I think for real-time imaging, that’s the best we’ve had. We haven’t really had any advanced imaging that is real-time guidance. Even in our CT scanners, we’re moving the needle, scanning, moving the needle, scanning, so there’s none of that continuous feedback. I feel like with real-time MR imaging, it’s faster, it’s more accurate. You’re watching exactly where you’re putting the needle instead of kind of doing some cognitive fusion. You can actually see where the needle is going, so I think that in itself is a pretty big revolution for imaging or for interventions.

I think the in-and-out technique of CT is completely antithetical to how we really think as interventional radiologists, right? I mean, a liver lesion where a patient’s breathing, I have to teach someone to estimate the end of the respiratory cycle so they can advance their needle. I actually learned that, by the way, on my interventional MR, because you can watch the breathing in real time. And so being able to adjust in real time and with multiple-frames-per-second imaging, to be able to actually watch where everything’s moving as things are breathing in the upper abdomen and be able to immediately adjust and move is very much within what we would train in in ultrasound and in our normal interventional practice. So it inherently fits with our interventional mindset.

Absolutely. And it’s such a visual hand-eye coordination. I mean, I hear repeatedly, “Our best tools will always be our hands.” And to be able to—just to paint a picture in an audio medium—we’re watching orthogonal biplane, double oblique, and axial. Doesn’t make a difference. You’re working with two, you’re working with three planes in real time, running two to five frames a second, and when you make an adjustment, you see that adjustment and you can continue to make that adjustment to move at the end of a respiratory cycle, to move when it’s most advantageous for that specific lesion. And it’s just taking a lot of the guesswork out. You’re looking at it directly, and you’re not having to estimate a lot of things.

And I think I would say something that has been incredible, being a part of Cook and being a part of the program with iMRI from its early incubator days, now into this more commercial phases, being able to work really closely with Siemens to bring together that environment. We have seen—those of you working in the space—just an exceptional effort at bringing all of these pieces together.

There have been many groups that have pushed this forward: individual physicians or an imaging company or a device company. We brought out needles in ’96, I mentioned, but there was not a coordinated effort between all of those groups. And I think we’re at a really neat moment where that coordinated effort allows there to be a turnkey solution, the way that you build your other interventional rooms, to be able to provide that to an institution without having to piece every block together on your own, of your own effort, of your own time while you’re trying to set up a practice.

Yeah. I think this partnership is really going to push iMRI forward across the finish line. Starting from experience, when we built our own suite, David Woodrum’s program, well-oiled machine. I come to my university, I got a different room, I’m retrofitting a diagnostic scanner; he’s got his own suite. Some of the resources that he had, I may not have. Even like the same device. We tried to, for the warming catheter, like, “What are you using for this? I try to replicate it exactly, and still it’s not perfect.” So, it’s just, having a focused thought about putting a suite together with all the tools just makes that lift so much lighter. It’s just a lot of work to pull all these things together and a lot of niche markets, so I think having everything in one out-of-the-box solution really will make a big difference so we can spread this to other sites, because I think it is valuable for our patients that they have the opportunity to be treated in this manner, but not everyone has all of the resources to do that independently. So, having a solution that really gets that off the ground for them quickly is going to advance the field.

And a new site that hasn’t had the advantage of training at one of the centers that does this in high volume may not even know the words to use for what they need in their room, which is an impossible barrier. It’s already hard enough in the modern era to put in a new room. You need space, you need money, you need expertise. Now try building something where everything’s custom, right? You can’t just say, “Deliver me an angio suite, please, and yes, put it there,” because that’s not how MRI works. And when you don’t know how to see things and hear things and protect your ears and what do you need in the room? It was fascinating to me—and it was one of the major barriers to our systems at the interventional MR symposiums, which happen every other year in the fall, either in Leipzig, Boston, or Baltimore—everyone had a different system.

David Woodrum’s system would be different than my system, different than Dr. Busi’s system, different than Dr. Wacker’s system. And around the world, depending on vendor and what they put together, they may have a capability to do something I don’t have. That’s not really true in a pretty mid- to high-level angio room or a CT. We can all do the same thing, which means we can all speak the same language; we can all collect the same data; we can all move the field forward. iMRI has always been a massively collaborative field, both within our teams and across our team, sharing technology, but there’s been a very difficult barrier, which is, I can’t really speak to what you do if you’re on vendor A with your own really cool setup, because you have different regulations in Europe than vendor B in the United States with totally different money, finances available, and different regulations.

There was a—very difficult to cross-collaborate when you can’t speak to the same equipment. And then the fact that there were, for a very long time, extraordinarily limited disposables to use. You can image all you want, but if you can’t put something into the patient, you have nothing to do, and so, I remember speaking to one—Again, I was working at one of the imaging vendors, and I brought them back to Baltimore because we were supposed to be building our iMRI, and he walked into our supply room, which at the time was the size about half of a football field—soccer field, right—big supply room, and it was just stacks of equipment. It was like that scene out of The Matrix. And he kind of looked at it and said, “We can’t win, because there’s no equipment. We can’t put anything in the patient.”

And that part of the collaboration—putting together a plug-and-play room where you can order a room and it gets delivered and you can get equipment and start working day one—that takes 90% of the barrier away. Then it’s just showing someone you can put needle to target, which you can do in 10 minutes, as you’ve proven to my resident. And for everyone listening, it was a phantom. There was no patient on the table.

Yes. I would like to emphasize that I do not touch patients. Speaking of patients, something that we’ve—we’ve talked about that best-in-class visualization. I think there are some other components worth talking about, and I think one of them is safety. And I think of two parts of safety and some advantages that we see within the iMRI suite. One is a lack of radiation. MRI is our primary imaging modality, is radiation free from the jump. And then we have also got ultrasound in zone 4, which lends an additional familiar imaging modality, some real advantages. If you’re setting a new vascular line, that’s very straightforward. Doing that under the MRI has a little bit more of a lift and some training to it.

But I wonder if you could speak to, a little bit more, the lack of radiation for you, for the patient, for the team that you work with, but also then maybe some of the safety that comes from having that very high-quality soft-tissue visualization, the ability to avoid structures because you can see them.

Yeah, I think there’s a lot of safety benefits on multiple levels. So, I think, starting with the radiation, obviously no radiation dose is really important for our vulnerable populations, pregnant women, children. This takes that out of the equation completely. And also for your staff. My other part of—my other hat is doing procedures in the CT scanner or under fluoroscopy, so I’m immersed in radiation all day long: long cases, lymphangiograms, venous free canalizations. When I’m in the scanner, I don’t have to wear lead, I can move around freely, I don’t have to worry about my radiation dose that day, or do my staff. So I think that’s a huge benefit, especially as I’m aging a little bit. I’ve had some injuries of my own. It’s nice to have a couple of days that give me a break from lead.

As far as safety, I think the precision in which we can perform certain procedures in the iMRI really is more safe for patients. When I do my prostate cryoablations, I got a question, How long do you run your freeze cycles for? And I say, “Well, I watch it until it covers my target and I don’t get anything I don’t want to get into, and then I turn it off.” So that’s kind of like very opposite to our typical cryo paradigms that we use in lung and kidney, where it’s a specified time protocol, you set-it-and-forget-it kind of thing, but this is watching with real-time updated imaging about every 10 seconds so you watch that ice ball grow over time. And the margins are exquisitely clear. I mean, I feel comfortable growing my ice ball out to the serosa of the rectum without getting too nervous, because I know I can stop it and we can turn it off and thaw right there.

It strikes me that, particularly working in the prostate, in the pelvis, there are just a host of structures that you do not want to get into, be that the rectum, the ureters, nerve bundles. I mean, how often are you near those sensitive structures when you’re doing this work?

Yeah, I would say for any of our lymph nodes in the pelvis or for the prostates, for working and doing like a posterior lesion, then I have to hydrodissect for those. So yeah, it comes up very commonly in our practice, and being able to really precisely form your ice ball, place your needles, really is the best solution for the patient.

We speak to radiation, and we speak to seeing structures. I think when you do interventional MR—and by the way, for a long time, colleagues wanted to call it MR-guided interventions, and I think if you’re on a diagnostic scanner, it might sound like that. But an interventional MRI, to me, brings up the concept of a dedicated suite, so that’s why I like using the term, because I think we now really are looking at the era of a dedicated suite, whereas before, we kind of were doing MR-guided interventions. Most people didn’t have a dedicated suite. These are now dedicated systems,sSo I will keep calling it interventional MRI.

From a radiation perspective, this is a no-brainer for pediatric hospitals, who are now doing less and less CT anyway to image their children. Why would we then put them into a CT scanner to do a procedure we can do under MR? And this isn’t saying MR replaces everything, right? It’s not going to, and it shouldn’t. It’s a tool in our tool belt. To me, the two components of safety beyond anatomy, which I’ll get to in a minute, not having the strain on your musculoskeletal system as you get older, and I will admit I’m older than Erica. I’m starting to feel it. I’m having back pain and neck pain, and this happens over time. There’s a tradition amongst interventionalists in private practice of working for 10 or 15 years and then doing diagnostic because their bodies start to fall apart, right? My dad, who was a radiation oncologist, stopped doing seed implants because he couldn’t wear lead anymore. This is a real thing. It’s a big thing that the SIR is really focused on right now is our radiation safety, seems to be interventional MRI is a great solution to that, both for our patients and for our staff.

And the staff feels is as much as we do. They may wear lighter lead, but in the end, they’re still standing and twisting and turning. And we know when a patient’s in trouble, whether you’re wearing 20 or 30 pounds on your back, you have to bend and twist, you’re bending and twisting. And I look at my senior colleagues, especially in cardiology, who maybe don’t think as much about radiation like we do, and they’re wrecked by the time they hit 60. And it’s really nice to not have to do that. It is truly a pleasure to take your lead off to go do a procedure. I can’t tell you how weird it felt the first time, and I love doing it now.

In terms of anatomy, there’s not a question as an interventionalist that if you can see it and get to it, we can treat it. Why guess? I mean, why guess? If I can see that there’s a vessel I don’t want to go near, I can bypass it. I can choose a different plane. If it pops into view because things have shifted, I can adapt. If I know I have to hit a functionally part of the tumor, why biopsy or sample a part that might be necrotic? So to me, that part is a no-brainer. If you can see it, it’s safer. That’s the whole concept of image overlay, whole concept of fusion. But you really can’t underestimate the ability to do a procedure out of the radiation field. I used to be six foot two and have a full head of hair. It’s all radiation. No, I’m just kidding. I’m just kidding.

Yeah, that brings up a thought. Even having a room that’s designed like a typical interventional suite, like a CT suite or a fluoro suite, really makes the interventionalist more comfortable in this space. I feel like sometimes when it’s a little bit more piecemeal, you don’t have all the equipment that you need, you don’t have the monitor booms, all of the things that you rely on in your IR suites, that makes people uncomfortable. And I feel like when you’re uncomfortable, you’re making mistakes, you’re not thinking things clearly. It’s really shifting your mind to a different way of doing procedures. But in a full functional suite, you have all of the tools that are in your other areas and you feel like you’re right at home in the scanner.

Absolutely. And I think those spaces are just designed for different things. Think about the number of people that are regularly operating inside of a diagnostic MR room, and it’s not very many. Think about how many people can operate inside of an interventional suite in a more complex procedure. You’ve got one or two techs. You’ve got nurses. You may have even multiple attendings. You have the ability, if you’ve got general anesthesia, to have patient transfer, to have all of the safety around, should something not go the way that you’re hoping.

I think the spaces just have different demands. You’ve got different—even down to different air changes per hour and, in more advanced procedures, the ability to have laminar sterile airflow. You’ve just got very different demands from these spaces. And I think it’s truly incredible. And I feel like we—coming to the iMRI symposium every other year, looking forward to it this year in October in Boston—it was, when I went for the first time a couple years back in Leipzig, it was a moment where I recognized and knew that we are standing on many, many shoulders of people who have made this work in less-than-ideal spaces that were not built for their purposes. And I really appreciate that.

We’ve talked about the patient. We’ve talked about you as the physician. I wonder if you could speak to maybe the institution side. Somebody’s thinking about this and going, “Okay, how do I bring this to my institution? Is there an advantage to the institution at being able to provide these therapies or this image-guided therapy?” How did the two of you think about that from more of an institutional perspective?

Yeah, when I first started thinking about opening our interventional suite, interventional MRI at UW, one of the procedures that I was bringing was prostate cryoablation. So our urologists were not doing that in the OR. No one in the state was doing any prostate cryo, so this was a novel procedure in general just to bring to UW, so I think for our leadership and admins, it brought a new procedure. It increased access to this procedure for patients, provided them a different option, especially for our salvage prostate patient, salvage prostate cancer patients who don’t have a ton of options, and I think it also brings a lot of patients into the system. So, we did a little brief news blurb for the program that went out to the state, and the urologist kept saying, “Everyone wants to come in and get cryoablation.” But not all those patients were candidates, but then they saw the rad oncs, they saw the urologists, they saw the oncologists, so it really drew in a whole different patient population to our center.

I think there’s no question when you offer something that is new with data, with clear benefit to the patient, and a clear safety and clear efficacy, right? And I’m being very careful with my words because there have been a host of devices that have come out in the world that claim therapeutics, which may not happen, may not have the safety, but this is really a version of what we do already, better. So we have that data already. We know that prostate cryo is safe. We know that needle gun. When you do that and you say, “I can do this kind of better and faster and safer for you,” which is sort of what we do in IR, it draws patients in from around the country and sometimes around the world. We draw people in anyway for vascular malformations. When they hear we’re doing them under MRI, the number goes up.

And when our nerve ablation program is up and running at full speed, people are now coming in from all over because surgeons from other institutions understand the need to find the very specific branch that’s causing pain to do their procedure in the long run, and eventually for us instead to cryoablate it and do our procedure when they don’t want to do a surgical procedure. So there’s no question that when you build something novel, safe, and effective—and we have the safe and effective now; this is just safer and more effective—it draws people in from all over. And a lot of self-referral as well. And I tell any group that’s starting, do your first view internally with your own comfortable providers who you can collaborate with so that everyone’s comfortable, and then once you’ve gotten some success, start ramping up the PR campaign. And it doesn’t take much to bring everybody in.

I think you’ve both mentioned collaboration here just in the last couple minutes. I wonder—IR is intrinsically quite a collaborative group, but I wonder if you could speak to how iMRI has affected collaborations with other specialties within the hospital.

Yeah, I mean, for us, it starts with, honestly, collaboration with a whole new set of staff. This is no longer just your IR tech and you and your nursing team; this is now often an IR tech, an MR tech who has to learn your language and learn the way that you communicate, and an IR tech who might have to learn how to run an MR, so that you’re very dependent on your team in interventional MR, right? You have to be able to communicate with the folks running the system. Even if you’re running it yourself, you can’t run everything from bedside. And so that whole communication sets a whole new level of collaboration, and at least we found that when we start building our teams, those teams don’t want to break up. Even when a system might shut down, they stay as a diagnostic team at the end because we really build a way of speaking to each other and a way of communicating.

But then once you start bringing patients in, this shouldn’t be seen as a threat to another specialty. This potentiates us as much as it potentiates them. The concept of “a patient’s going to come in for a prostate cryo; what they really need is a TURP, or they really need a prostatectomy or a radiation,” that’s a very good example of bringing in a whole host of patients, only 10 or 20% who may make it to your magnet, and the rest need other things. And I think when you see that—it was a theme at the foundation there last night, is a rising tide raises all boats, that’s really the concept. We’re bringing a new modality, a new concept into imaging and imaging-guided interventions, and done properly, it brings in patients for everybody, and a health system should, under the modern system, want that.

And nowadays, there are very few areas of medicine that IR doesn’t touch, so inherently, we are the greatest collaborators, in my opinion, because we do work with so many different groups. In my program, we have two urologists that I partner with. We all see the patient ahead of time. We all talk about the patients at a multidisciplinary conference. We evaluate them for candidacy. They come at the procedure; they will come help place a Foley warming catheter. We’ll look at the treatment zone. It’s a real collaborative approach.

And then afterwards, we’re partners in the follow-up. So, they see them at three months, I see them at six months. They see them at 12 months, and we kind of go back and forth. So it’s really a group effort. And it’s, I think, good, because there’s a lot of resources that go into treating these patients, so if you can build on multiple teams to get the work done, I think that’s for the better. And even for our vascular malformations, we have a birthmarks and vascular anomalies clinic, and we all work together, multiple specialties—dermatology, surgery, plastics, ortho, radiology, IR—to really find the right treatment for patients because, it’s exactly right, this isn’t going to be the right treatment for everybody, but it’s good to be at the table, so for those patients it is, we can present that option to them.

And let’s also be fair. In most referral cases, they don’t really know what an interventionalist does in minutia. They want their patients to get better. And so I don’t mean to say they don’t care. They don’t really care if you do it under MR, CT, or you use voodoo. They want you to make their patient better in a scientific and real way. And so once you can prove this is the modality, it may bring patients into that modality, but if you feel like that patient really belongs in ultrasound, no one’s going to fight you. They just want the patient treated properly.

I think that speaks to it being an additional tool. Now, I wonder if there’s a—We’ve talked about just a whole number of facets of this. I wonder if each of you have an example of a patient where all of this combines to a visualization, a treatment that couldn’t have happened otherwise. What is a great example of the effects of iMRI broadly on the patients that you serve? I wonder, Erica, maybe start with you.

Sure. One patient comes to mind I treated about nine months ago, a middle-aged gentleman with gluteal vascular malformation, a lot of discomfort, unable to sit, unable to play hockey, which he liked to do. He came in, he had had sclerotherapy treatments before, which had not encompassed all of his symptoms. It’s amazing even on the diagnostic MR, you didn’t quite get the feel for it because he was supine. We put him prone in the scanner, and I said, “Oh my gosh, look at how big this vascular malformation is.” So we were able to go in, do a really nice ablation from him. I think it was a very large area close to the skin, so we probably covered about 90% of the area. Just saw him in follow-up, and he was like, “My life has changed. I can sit. I can play hockey.” He was kind of a more curmudgeonly guy beforehand, and his whole mood affect was changed because he was not in chronic pain. And I think we couldn’t have done that in anything else. I looked at his CT scans, I looked at his ultrasounds. There was no way you were going to be able to tell the extent of that malformation from those imaging modalities, but once you got him on the MR, it was clear as day.

That’s an amazing example.

So not to use a similar example. I run a very large vascular anomaly center; I have for years. I will just speak to the vascular anomalies in general under MR. We talk about MRI being our gold standard workhorse. And you and I have spoken in the past about MRI not being taking pictures, but a conversation between the machine and the operator and the patient. You literally—an MRI, a CT or an x-ray, angio, and ultrasound to some effect—it’s really about taking pictures, right? In ultrasound, you can ask some questions about flow. MRI is really asking questions and getting answers back. If you ask the wrong questions, get the wrong answers or not the answers at all.

So we use MRI as our gold standard for all vascular malformations, and then we go and treat them under ultrasound and fluoro. And arguably, I think most of us do a really good job most of the time, but you can never tell the full extent of coverage when you’re doing a vascular malformation, particularly a venous malformation, under those modalities. Under MRI—and this is one of the things that got me originally—John Lewin, back in the earlier nineties than me, so my mentor’s mentor, was marching his needle through in real time and filling the lesion with—You know, he’d push it in, fill it with Sotradecol, pull it out, put it in the next part, and he would march through the lesion on MR and cover 100% of the lesion in one treatment. Blew my mind.

For me, I use it a lot now as a problem-solving tool for people who have kind of burned-out malformations where it’s mostly scar tissue, there’s not a lot of vascular space left, and so I now use MRI to get to lesions I—no way I could get to any other way, like on the edge or behind the scapula where I can’t really see it, where there aren’t phleboliths so I can’t really see it on CT.

And I had patients come in with those lesions where you treat a 2 cm lesion behind the scapula everyone else pooh-poohs, and all of a sudden they can reach up and grab their groceries off the shelf and wash their hair and reach their hands above their head. And I also use it for treating malformations that we’ve been treating well for years and there’s just no more I can do with standard modalities. And now I can see it under MRI and cryoablate it, and all of a sudden, the patient feels better. So for me, that’s that.

But I think the other concept that we’ve both experienced is, nothing sucks more for the patient than coming in for a biopsy for something they’re terrified of and we are in the middle of it and get a nondiagnostic sample because we can’t tell on CT if that’s the active component or the non-active component. Being able to see that on MRI and know that your diagnostic accuracy can be higher and that a patient won’t have to come back again is something that really blows patients away, even more than, I think, what we do for malformations. Patients coming in having failed biopsy, failed biopsy, and all of a sudden, boom, within 15 minutes, Erica’s able to take a sample, I’m able to take a sample, and we’re right, and it’s done, and the patient’s biopsied and diagnosed, changes care in a very meaningful way. So for a procedure we consider fairly minor, it vastly alters the patient’s care pathway.

I mean, it seems that moving from uncertainty to certainty and a potential pathway back to health, I mean, those are wildly different places. As we talk about this, I wonder if we could maybe end with a little bit of advice to anybody listening whose interest is piqued. I wonder, Erica, I might ask you, if you’ve got another attending that is maybe interested in this but saw things 10 years ago and was a little bit skeptical, what would you say to them about where this space is today and where it’s going and the value it may have to their practice?

Yeah. I think what’s been most effective for me is “seeing is believing,” so I’ve encouraged several partners, “If you want to do cases in the MR, I’m happy to do them with you because it’s a little bit of a different setup. Happy to do it with you, happy to guide you through it.” And then when they get in the scanner and they start seeing the images, they’re like, “Oh my gosh, why haven’t we been using this forever?” He’s like, “I feel so comfortable knowing where my margins are. We’re doing cryo and superficial lesions. We’re close to the skin. We can grow the ice ball very precisely and not get into the skin or adjacent nerves, things that we want to avoid.” So I think if you’re interested, and maybe even if you’re not interested, it’s good to go see a case, come to the booth at SIR here, check out some videos, some demos, because it really will open your eyes.

Fantastic.

I have very little different advice. Just come try it. All the interventional MR folks in the world have had their doors open, honestly, since the early ’90s. We just love people to come. We train each other. We learn from each other. There’s a whole history in this field. Call up a center that’s doing it. Call up Erica. Call up David. Call up me, someone who’s doing it, and come try for a day, or come out to one of the research facilities that you guys run or that the imaging vendors run, and go try it. And I will tell you, you won’t go back. It’s very, very hard to see everything and to feel like you have real-time control and do it in an environment that now feels natural and not want to do it.

The other thing I would say is, if you’re going to start a program, start easy. Like we would any other junior faculty coming out into practice, do the stuff you know you’re going to succeed at right away, and start to stretch after you have a few successes under your belt, and also be patient. I mean, in the old days, it was be really patient because you had to build the room from scratch, but you’re learning a new environment, new system; you’re going to get trained. Be patient, because even when we open a new angio room, it takes a month for everyone to get comfortable in that room. You’re not going to walk in, necessarily, and feel like you’re home. Many of us did, but that may not be you. But once you see it, you can’t go back. You just can’t.

I might ask an additional question of you, Cliff.

Yeah.

And that is, I know you work an incredible amount and have with residents, with fellows, with trainees. If you’re at the beginning of your career, if you know that IR is something you want to do and you’re just hearing about this for the first time, what’s the advice you would give that person as they begin—

Don’t do interventional MR, because once you try it, you’re going to want to do it and you’re going to drive everyone in your practice crazy, begging for the scanner. No, I’m kidding. If you’re interested, right, and you may really love, currently, endovascular and just never want to touch a needle. And right now we are talking needles, but we will be talking catheters and endovascular in the future, but that is a heavier lift. We know that in our world as well.

But if you have the inkling of interest, read a little bit, listen to some of these podcasts, and go try it. Really. Because I think we’re going to be champions, but at a certain point, you need people to just come and do it, and that is going to end up being the newer folks coming out. They’re a lot less scared of technology than the people who are senior to us, the people who are so comfortable in angio and CT that they’re like, “We don’t need this at all.” And I think that’s where we’re going to drive it. I mean, I’ve never shown a trainee interventional MR systems and not have them say, “I need this at my facility.” But I’m telling you, if you try it, it’s a pretty high bar right now you’re asking for whatever practice you’re going to join, but I think we would like to have that problem.

Absolutely. Thank you so much. I’ve so appreciated being able to have this conversation today. Appreciate your time and your joining and being collaborators in this space and, quite frankly, the people who have come before and the shoulders that this is really built on. So thank you so much for all that you’re doing in the space and for joining today. If you are listening to this and you’re still at SIR, by all means come by. We’d love to chat with you and show you what we’re doing here on the show floor and see if that’s of interest to your practice. And thank you so much for listening.

Thank you. Thanks for having us.

Thanks for having us.