iMRI new procedures
Joshua Krieger
Riad Salem, MD, MBA
Joshua Krieger talks with Drs. Desai and Salem about their experiences with interventional MRI, early skepticism and challenges, Cook’s “iMRI cath lab,” expanded imaging opportunities, and procedural possibilities.
Episode Transcript
So, thanks so much for being here today. Today we’re going to have a conversation around interventional MRI and some of our experience here recently. [Let’s] do some quick introductions. My name is Joshua Krieger, and I’m a part of the Cook Advanced Technologies Group, which is a part of our R&D infrastructure. We coordinate with both our Vascular and Med Surg divisions and are often looking at things that span specialties., and I head up our work on augmented therapies, and I’m a part of the leadership of the iMRI group.
My name is Riad Salem. I am Chief of Interventional Radiology and Vice Chair of Imaging Guided Therapy at Northwestern. My areas of interests over the last 20, 25 years have had to do with a broad scope of interventional radiology techniques, interventional oncology, portal vein work, prostate oncology, et cetera. And I’m excited to be here today.
My name’s Kush Desai. I’m an interventional radiologist working with Dr. Salem at Northwestern University in Chicago. I am the medical director of supply chain for Northwestern Memorial Healthcare Corporation for our entire system, as well as the director of deep venous interventions within Interventional Radiology. I would say that my primary interests started with inferior vena cava filters and really has expanded to deep venous obstruction of venous thromboembolic disease. And the whole spectrum of venous disease is now my primary clinical and research focus.
Fantastic. Thanks so much. Real quick, a disclaimer and then disclosures. Today we’re going to talk about a number of products that are purely prototype. We’re not talking about any commercial products. And we are going to talk about some studies, none of these were human cases. As far as disclosures go, mine’s pretty straightforward: I’m a full-time employee of Cook.
I’m a consultant for Cook.
I’m a consultant for Cook as well.
Fantastic. So, today we want to talk about iMRI, which might be surprising to some, but we’ve seen some really exciting things in this space, but I’m sure a couple people are skeptical out there. You know, this is not a topic in primetime. So let’s maybe start with some of the previous experience that the two of you have had with iMRI, or interventions around MRI.
So I came to Northwestern in 2003, and at the time we had an IRMR unit, one of the first in the country, and one of the very few on the planet. And I guess I would have to say that my observation back then basically identified that the technology and the technique itself at the time was significantly challenged by availability of devices, product versatility, user friendliness, imaging. In some ways it was, you know, before its time.
Yeah.
And we never really had an opportunity to really study it because, again, of the limited equipment that we could use. So effectively, that room became separate. We separated it into an MR unit, and we separated into an angio unit, and it never really developed, and so that’s my early experience–and really without much more advancement for 20 years, until now we’re working on MRI, and sometimes I just feel like some ideas, you know, are too early. They predate their optimal time. And that’s why it’s sort of exciting now to be working with you and Kush on something that maybe now it is its time. We have–potentially have the tools and the technologies to move this thing forward because, you know, it might in fact address an unmet need.
Yeah. It really felt like a leap too far from our normal current workflow at the time, right? It was very difficult to imagine translating what we do daily in an angiographic suite into the MRI, not only because of the devices, but because the lack of a fully integrated solution.
Mm-hmm.
You know, how is–how are we going to communicate with each other? How are we going to look at what we’re doing? So there was so much more that needed to be done, and it just probably wasn’t ready, as Riad said, for evaluation and eventually innovation.
Fantastic. Yeah. So that integration, the device availability, the availability of peripherals–just out of curiosity, what was–how, within the department–you know, I’m sure that was not a cheap room at the time. Snd as you think about scanners in radiology and interventional radiology, I wonder kind of how that fits into the picture as well.
Well, from that aspect, you could potentially equate one of those rooms with maybe two angio rooms.
Mm-hmm.
And maybe almost two magnets. So you have to–so if you sort of try to normalize that to something we can relate to, is there a lost opportunity if these are expenses that we’re incurring for such a room and it’s not being optimized from that aspect? And so, yes, it was not expensive, it was an investment. But I think, again, it sort of predated its opportunity back then. And the peripherals, as you referred to them, were really not optimized. I personally remember, I believe, doing two cases with needles that I had to wait for and order and make sure they were compatible to perform some complicated biopsies. But by no means was it an easy undertaking.
Yeah. And as far as speed goes, you know, what was the kinds of images that you were getting out of the machine at that time? You know, was it real time? Were you waiting for things? What was that workflow in the magnet like?
Yeah, Kush mentioned that, right? The workflow was not that good. There was a lag for image acquisition, a lag for image presentation and display, a lag in motion response. So as I’m working, I have to wait 5, 6, 7 seconds for that response. The sharpness, the contrast, is not there. You have to triangulate many things in your head when effectively the machine is supposed to do that for you, if you’re going to socialize something like that. So it was challenging By no means were things simple simple at the time. And so from a workflow standpoint, there were hurdles at every step of the way, from the work working, the procedure component, the imaging component, the interpretation component. They were all big challenges.
Yeah. And I have to say, I came more from a fluoro ultrasound side, you know, within Cook, and when I heard about iMRI at first, it was, you know, this is typically expensive, this is slow, we don’t have a lot of devices. And so I think, you know, maybe for a little context to what’s happened over the last year, over the last eight months, with our conversation, I’d like to give a little context to everybody on kind of how we got into this. We’ve been talking about this for a couple of years internally, but you know, Cook first came to the iMRI space with needles in ’96. I think, again, a little ahead of its time at that point. There was that lack of integration. And history since then has shown that multiple groups, you know, be it physicians, device companies, scanner manufacturers, have tried to push iMRI forward, and we really felt like to make an impact we wanted to be a part of a collaborative group and a group that really focused on integration of all of those elements together.
And we were really fortunate to be introduced to Siemens, who it turns out felt the same way, and so we’ve been able to partner with them. And in order to drive innovation, we actually purchased one of their Free.Max systems and have it installed in one of our facilities which is just, you know, 50 feet from our core iMRI engineer group. And we’ve turned into–and are continuing to evolve it into–basically an iMRI cath lab, trying to make a state-of-the-art space for procedures and for collaboration. And I have to say, Siemens has been just a phenomenal partner, both with the Free.Max opening up just a tremendous number of possibilities, but also just the team in general has just been a joy to work with and a lot of fun to work with.
So as we said earlier, it’s a multi-part collaboration. We’ve got that hardware software pieces, we’ve got devices and disposables, and then we have the healthcare provider and physician, and iMRI tech piece. So I’d love to segue into some of your experience in the new magnet. I do really quick though, want to say, you know, across the last 20 years, there’s been an absolutely dedicated group of people that have continued to work in this space, and I just want to acknowledge them. Cook is coming into this, but there has been a group that has always been in here and their work has continued to put forward pressure on this and push this forward and evolve technologies. And we really owe them a debt of gratitude as we have this conversation. So over the last eight months or so, we’ve had three procedures in the machine. And I think the story of those, and your experience of those, is illustrative of how we’re starting to interact with these technologies and might inform how we think about the clinical future of these technologies. So maybe let’s walk through those.
Yeah. So, you know, you were very forthright about what to expect. You’re coming in, as you said, you’re going to kick the tires–
Mm-hmm.
–and we’re going to find all the pain points. And it’s not just a needle, a wire, a catheter, a stent, it’s–I can’t hear you while the machine is going. I can’t see what’s going on, because we need to make sure that the monitor’s closer. We need to change the sequences. And so in the first one, and I’ll let Riad speak to the second visit, but in the first visit, we just spent hours trying to find the wire.
Yep.
And that’s okay, because we learned a ton from it. I know I did, and he did, and the Cook folks did. And it’s clear that the Siemens folks learned a ton just being on the call and thinking on the fly, all right, for the next time, how can we improve this? And we did get quite a bit done in that first visit. Beyond the wire, we did some implants as well. But then I’ll let–I’ll transition to Riad, and when he talks about the second visit, it’s night and day. The wire was found within approximately 30 seconds on the second visit. And that’s eight hours apart. And not–and of course, clearly highlighting all the work that you, and Siemens, and the group, and the team did in between.
Yeah. I loved that first one. I mean, we found a lot of pain points, and I have to say, I was kind of shocked, even as somebody who had worked in the building and worked with the machine. You know, we go in vivo and, where exactly are our devices? And figuring out, you know, when you’re in that AP view of the–you know, my impression of flora is you’re compressed. The vena cava is flat. Well, it turns out it’s absolutely not flat. It comes up, it dives back down. And so dealing with that planer image was just something that I did not–I didn’t expect. It was a, you know, maybe a mis-expectation on my part, but it was–it was all learning.
Yeah. Yeah. I would agree with that. I mean, the first day was, you know, very interesting because when you guys asked me to contribute to your project, at first, I was–I was excited, but I was uncertain. You know, I was–I was a little skeptical. This is normal to be–when it comes to MRI. But to me, what I remember most about the first day is, yes, we were struggling to find wires, but I also remember one, the ability to see the vessels for a long time with a contrast agent that we had used–number one. But number two, the idea that I’m used to seeing things in three planes, usually X, Y, and Z. The problem is, now you can give me more planes. You can give me any plane. You can line something up along the cava, along the hepatic vein.
These are not planes I’m used to. I’m used to taking my X, Y, Z access and correcting for it and finding the correct plane. But now you can line anything up. And so what was most interesting for me at the time was that I recognized that to move this forward, I now needed to add an extra dimension to the 3D processing. And it was becoming–it was going to become much more complicated, but doable and helpful. Because I remember you said that, Josh, you’re like, “Well, look, let me line up the cava for you.” And I’m like, “Line up the cava?” And now all of a sudden you see the entire cava in one plane, normalized and corrected for the animal that we were working on. And so that changed things. And I think that’s something we–I learned in the other labs that we did, and will become invaluable as we continue to perfect this tool.
I think the other thing that struck me particularly–you know, I am not an IR, I’m not an MD–but coming from seeing a lot of fluro is, you know, what am I used to seeing? I’m used to seeing a wire catheter and the bones behind it. And just the amount of information that we could see was really–I remember you making a comment–it was either the first or the second, when we went into a renal vein, you know–I’ve never actually seen the kidney while I cannulate the renal vein.
Right, right. It’s all secondary information. You know it’s there. My catheter’s advancing, that must be the renal vein. And then you inject contrast to confirm.
Right. Right. Imagine doing renal angiography knowing that you have to, say, embolize a lower pole tumor. Well, the wire’s going down somewhere in the lower pole, but I might not be in the right one. Now with MRI, the realization that, no, I know I’m in the right one because I see my catheter and wire going up to the tumor.
Right.
Dynamically.
Yeah. So that first day, we figured out how to deal with contrast, which is again, a different paradigm. There’s no contrast injection when you want to see the bloodstream. There’s, you know, a single injection or an injection that lasts, you know, two hours, and gives you that full vasculature. And we worked through some of that initial kind of wire and catheter work. How do you find this? How do you find home base? And you guys, I–you kicked the tires. You did exactly–you went way beyond where we were hoping to be. We found a ton of problems and were able to then kind of systematically work through those.
Mm-hmm.
And about two months later came back and I think we had a little bit of a different experience.
I’ll start. Yeah. like I said, I mean, the matter of finding the wire was like, I don’t see my wire. Oh, our technician, who, by the way, as an MR technician, I’ve never met anyone quite like him. He is–he is exceptional. One of a kind, a true gem. And he found the wire. He’s like, “Oh, I’ll find your wire.” And he found it. Okay, we just did in 30 seconds, what took four hours the first day. Okay, so now we know this is non-linear growth. Basically, it’s exponential growth from where we started. Then we can talk about real things. All right, let’s put the catheter down. Let’s select vessels. And I think the penultimate thing–I’ll let Riad talk about it because that’s his area of expertise–was, can we do something that is broadly considered amongst the most difficult IR procedures, which is transhepatic portal access? And I’ll let him talk about it.
Yeah. So, second day, you know, we’re excited see what sort of solutions you guys–Cook and Siemens–have found in terms of the challenge we had at the first time. And lo and behold, now we can see wires faster in real time. And yeah, we were playing around as, you know, trying to, you know, confirm visibility and seeing how we were going to optimize things. And we talked about it. I remember we were talking, saying, “Hey, what should we try? What is really considered so tough and so challenging that you need other types of imaging guidance?” You know, IRs fear it, IRs punt it, and, you know–to defer to others, et cetera. And that refers to chip placement and access from the hepatic vein to the portal vein. And you know, it was maybe a little choppy to maybe identify the hepatic vein, but once the hepatic vein was well visualized with some clever solutions from Sean and his team, but also from Siemens and the team in terms of imaging display. Yeah, you know, we got into the portal vein. That’s kind of crazy that we did that. This is the second–our second day there,
And we got into it faster than a lot of people get into it under flora.
Yeah.
It wasn’t that long.
Yeah.
Just to–so you’re talking about–again, we’re all used to looking at a whole imaging volume, and we were able to precisely triangulate and find the right imaging plane–as Riad pointed out, it’s not X, Y, or Z, it’s something else in the middle–and dynamically watch puncture of the right portal main. I mean, it’s–if you take a step back and think about it, it’s pretty astounding.
And then Josh, maybe that imaging sequence that the team from Germany came up with, the three–you want to tell us a little–or you want–or you want me to say–talk about it?
Yeah, so I’ll tell you kind of what I remember.
Yeah.
And then you can speak to the actual imaging.
Sure.
We were sitting there and, you know, we’ve got, at that point, I think we were running 10 millimeter slices, and, you know, you’ve got a 10 millimeter segment. We were kind of an AP type view, and so youcould see very clearly because it was all in plane, the needle was coming down about a centimeter and half into the hepatic vein. You were able to turn that. But then we had to kind of move it up, anterior in the body, in order to track that needle up. And I remember–you know, we’ve got the room set up so that we’ve got the ability to have a Teams call, we really want this to be a global collaboration room–so one of the folks from Siemens, sitting in Germany, kind of flagged us and said, “Hey, can we just kind of huddle up for a second?” Sure. Absolutely.
Yeah. I think I met him in Germany about two weeks ago when I was there. He came out and said, “That was my idea.” I’m like, “That was a brilliant idea.” And the idea was this and–Josh–was that–you’re right, we were doing the case and we saw a coronal image and the slice of about 10 millimeters. Well, that means, if there’s anything outside of those 10 millimeters, I can’t see. And so the idea was, how about we create three simultaneous images side by side at–with that–that basically show you a different slab at 10 millimeter intervals. So now all of a sudden, with three images on one screen that are side by side, I can see 30 millimeters, right? Just so–I just got to scroll across the screens and I can now always see where my needle is going.
And so now, now you’re expanding the depth with which you are seeing, right? Because as you said, flouro–and Kush said that too–fluoro is you’re seeing the entire body, you’re going through the entire–at the same time. Here, if you’re only giving me a 10 millimeter slab, there’s a lot of tissue I can’t see. But now with this new visualization methodology, or method, to sort of assess, you know, location, you now can see 30 millimeters, which is a lot of tissue. That’s a lot of plane.
Yeah.
And and it was–it really sort of–it was a big advancement in my opinion, because now we could do a lot, comfortably, always knowing where our wires and needles were.
Yeah. I mean, I–so I could not–you know, if we’re going to look at another axial imaging modality, I could not imagine doing a TIPS under CT guidance. Right. You’ll never find–you’ll only see a point because you’ll never be exactly parallel to the long axis of what you’re doing–your needle, your sheath, your cannula–and with MR, you can do it. And the best part is once you get in, it’s not a puff of contrast. You’re through the liver, you see exactly where you exit the hepatic vein, where you entered the portal vein, and you watch your wire and you’re not guessing, “Oh, am I in a coronary vein? No, no, no. I’m in the splenic vein.” Right away. So it’s–it’s quite profound.
Yeah. I think we had fun kind of joking about it, but it turns out a hepatic vein–or a portal vein–it’s a lot easier to hit if you can see it.
Turns out, who would’ve thunk it, right?
Who would’ve thought, right?
Right, right. One of the things with that–and just to paint a–you know, this is an audio medium, so just to really paint that picture in people’s minds, you know–what we had there on the screen, right there in the room in front of you, as you stood there, kind of in a normal cath lab kind of position, was three images next to each other that were stacked coronal images. And on the left side, you could see the IVC and the hepatic vein. You had one slab up in the middle, and one slab up on that right hand side, you could actually see the entire portal vein, including the right trunk, which was our target at that point.
Correct. That’s correct.
And so, you know, watching–I have to say, that’s not a view I’d ever seen before. and so it took a second to orient, but watching the needle progress from one to the next to the next, and having that last one simply be, well, I guess we’re there now.
I mean, you can imagine the next step in that, is you acquire those three separate slabs, but now you build some sort of fusion image of those three, and now you’re literally seeing three centimeters deep, right?
Dynamically.
And so now you can see everything moves. Let the software do the work. That would be fantastic.
Yeah absolutely. So staying on that, that kind of moment, you know, I think one of the things we had said before is that, you know, oftentimes you were waiting for images. But at this point we were working in real time. I think at that point we were working four or five frames a second, no reconstruction time. And I think that was kind of a surprise as well.
Yeah. I’ll start from here. So, there’s no doubt, the young man that was sort of steering that ship, so to speak, on the the Free.Max is outstanding. He needs to be involved in future training because we need more people like him. And he was very quickly able to adjust the sequence that we need, the slab thickness, the location, to fit exactly our need. And while there’s a lot to learn, I can easily see this, you know, once you have the right technology and the right people in place, to be able to democratize this sort of process. Because that’s–at the end of the day, we want this to be able to be used by many people. But there was no doubt that that was an important component when we saw that.
Yeah. And I think that realtime capability, a real shout out to the Siemens folks. I mean, we did not come up with those sequences, the machine came with that. And the ability to, you know, turn the dials to adjust contrast, spatial, temporal resolution. And you know, we’ve run the machine at 10 frames a second real-time and we can back it off and get high res. And I think maybe I’d like to take a moment on that one because it’s, again, kind of a different paradigm. That ability to change those three elements–contrast, temporal, and spatial–to get the imaging that you need in that moment–I know that as we go to the third procedure, we redid TIPS with some improvements and, you know, we had that ability to move fast and then to verify where we are. I wonder if you could speak to that a little bit.
Yeah, I mean, it just became more about recognizing that the way we’ve been working our entire careers is based on just spatial relationships, right? It is, “Oh, the wire’s on the right side of the spine, therefore I’m not in the aorta.”
And you can, and you can imagine, you know, as we figure this stuff out, that there’ll be like a series of sequences, crossing the heart sequences, you know, working on a cava, working, you know, below the pelvis. Arterial–I mean, so that it’s cookbook and programmable. These are the optimal images. And so, I mean, that to me is where this heads, you know, because people need guidance, and the experience we’re gathering here is really going to going to shape how people implement this, for sure.
Yeah. And I know that’s a conversation we’ve all continued to have, you know, from the very beginning. And that’s, you know, the world–the interventional tools we have were really built for fluoro and ultrasound, and so we know how to do that well. And I can hand you a device and if it’s radiopaque, most of the time I don’t have to say a word, right?
Mm-hmm.
You know how that works. And because there is a really–there’s a little bit of a paradigm shift here. I think in IR you’re used to seeing those sectional images, the MRI work. But it’s a different paradigm to run intervention under that. You know, we’ve really got to be attuned to building out fully integrated procedures. it’s not just handing over a device and saying good luck. It’s working, you know, with Siemens to make sure we’ve got the hardware in place with auxiliary device manufacturers, to make sure we’ve got screens and communication, you know, integrating devices into that to really come up with, as you said, a workflow that can be more widely deployed and trained.
And, you know, specifically to the comment on workflow, it’s probably going to be rethinking workflow. Right now you do non-invasive imaging to make your diagnosis. You do your intervention to treat the disease. And then you do your follow-up imaging or whatever it may be to follow up that patient. And now I would argue that the possibility of a fully complete solution where diagnosis, intervention, and immediate follow-up is possible all in one care setting. And I mean, the implications for that are huge, right? Because of access to care and time and cost to society and all those things. But like everything else, we’re going to have to rethink that.
Yeah. Like we use we use indirect surrogates now, as you know, for efficacy. Pressure gradients and measurements, et cetera. But now if we can evolve into true physiology and functionality immediately post procedure like Kush is talking about–say you place a stent, now look at this flow. As opposed to, gradient, no gradient, that is prone to artifact. Now look at this flow. This flow is augmented 600%. That’s a big–that’s much more helpful information than gradient dropped from, you know, 10 to eight.
Well, and you’re so–and it actually even brings up another point. Right now we have to use multiple different modalities to get different information. Flouro gives an atomic and spatial information. Contrast phonography gives–or contrast angiography, venography, whatever it may be–gives dynamic information, but it’s still subjective. It’s not objective information. You might do intravascular ultrasound–and we’re looking at something that, for example with an MRI, not only do you–can you see the relationship of an implant to the adjacent structures, you can actually image the implant itself and not only get a subjective idea of how it’s doing, but with 4D flow techniques and all sorts of things, you can really, you know, “What is the flow now?” Exactly to what Riyad said. So it’s going to be rethinking all elements of a procedure.
And I think we’re just at the beginning of kind of playing with that. I know that, you know, one of the things we did in the third procedure we did together was deploy a venous stent, a pair of venous stents, in the–would it be the–external iliacs of the animal, and then come back and say, “Okay, you know, what’s the flow through these?”
Right.
Any thoughts on that one or–?
No, I mean, it’s exactly right. So I mean, now I would just inject a catheter and see the contrast go and it’s like, okay, that looks reasonable. And, you know, I might put an IVUS through it and say, “Okay, the stent is opposed and that looks reasonable,” and all that kind of stuff. But I’m not going to get the followup that, when a patient comes back for a CT scan at one month, you see the spatial relationships and you know the presence–the lack of a filling defect says that it’s patent, but I don’t have any idea of how patent. What does that mean dynamically, physiologically? You can get all that right at the end of the procedure, in an MRI. It’s right there.
I was pretty amazed by the visibility of the stents, frankly. They were obviously very easy to deploy, but the post flow imaging was outstanding, but the visibility of the stents themselves was pretty amazing. And you could see the contrast. I mean, the fact that there was contrast in them as well. So it was pretty impressive. The imaging, certainly for just a 0.55 T, it’s pretty impressive.
Yeah, I mean that Free.Max has just been an amazing machine to work in. Credit to Siemens there. You know, the one other thing I wanted to make sure we hit on is–and it’s something that was just right at the end–was we set up– we’ve been working on, on you know, looking at vascular a little bit more, but we set up one of our biopsy simulators at the end there and just kind of wanted you guys to have feedback. I know that you both, you know–biopsy is a regular part of your weeks–and provide feedback on, you know, hitting what was at that point about a five or six millimeter target, freehand in the machine.
Yeah, that was outstanding. The reality is now we live in a world where frequent repeat, specific, biopsying is being requested–so specific lesions–and we need tissue for NGS and for other testing. So the idea that we were very quickly, simply able to use what I think you guys called as a guidance gun that allows you to line up into the plane and advance that needle into a five millimeter structure that was very easy to visualize, is not something that we can do easily under–currently under ultrasound or CT. It’s live, it’s easy, it’s simple. That’s a game changer from that aspect.
Yeah, and it’s dynamic, right? So you get all the benefits of dynamic imaging from an ultrasound guided biopsy, but then you get the 3D spatial relationships of CT, now without the radiation that comes with CT fluoroscopy, right? And again, you–all you have to do is find, oh, this is how I’m going to advance the needle into it. Somebody punches a button, all of a sudden your plane shows, exactly–and you’ll watch the needle real-time going in to hit a very, very small lesion. And it’s not a matter of you using your left hand with an ultrasound or right hand with ultrasound to hold the ultrasound transducer in plane so that you can watch it. You take that whole element out, which reduces the error, and then opens up the possibility of hitting lesions right now that frankly we don’t say yes to, because the risk of sampling error is too high.
And right now, challenging cases where we have to use, you know, needles and fluoro or whatever, you know, you’re technically radiating yourself if you’re too close. And we try to avoid it, and we use, you know, other hemostats or something else to get out of the radiation field. But this technique allows you to use your best tool, which is your hand.
Yeah.
It’s your most stable and direct tool, your hand. You don’t have to worry about radiate–you can take your time, line up properly, and advance right into that area. It was less than a minute. That’s big because it allows you to optimize all of the tools that you have that are going to make you successful. And ultimately the best tool you have is the hand–is your hand.
Yeah. And I think you’ve touched on something there, which is, you know, at the end of those days, I–you know, I know how I felt, it was really nice not to take off lead to, to be in that environment where you’re not worrying about ionizing radiation while in that procedure space, for you, for the patient, for the people around you.
Certainly something that we have to be careful of now, certainly something that we are wary of, certainly something that we monitor in ourselves, but, you know, the lead does get old. It’s tiring. We have to be careful, and so the fact that that’s not necessary in this kind of thing, you know, I’ll sign up for the IRMR days personally on when it’s on rotation. I’ll rotate through that five days a week.
Yeah.
These are hours and hours and hours. And then, you know, the–years down the line, the additive effects of procedural radiation–well, we do the best we can to protect ourselves, but there’s no such thing as a hundred percent protection.
Yeah. So I think that’s a good segue. I’d love to take a couple minutes and just, you know–we’ve talked about this as, you know, a medium that allows for real-time imaging, high tissue contrast, the ability to operate in 3D, you know, radiation-free, and tuning the the imaging for the needs of the procedure at that moment. I’d love to understand, you know, as you look maybe in the near to medium term as this, you know, five to ten year range, you know, becomes a greater reality. What are the kinds of procedures in your practice that you see this impacting first, or providing the highest impact on patient care or your workflow as a physician in a busy hospital?
Well, say, percutaneous interventions are the low hanging fruit, right? Biopsy, ablation, especially ablation where you’re talking about seeing margins that are very clear of what you’re doing with the tissue sensitivity that you get with MRI that you simply don’t get with other imaging modalities. That’s the low hanging fruit. And then I would say endovascular interventions, embolizations, has quite a bit of potential, right? Because you can actually see–sure, right now on fluoro with angiography, you can see that the blood flow has stopped. But especially in what he does, where you’re talking about liver tumors that may be pulling flow from multiple different locations, right? Let’s say it’s up high in the dome and you have parasitized supply from a phrenic artery. When MRI’s going to tell you that without you having to catheterize it, so you do your primary treatment and then you were like, it’s all gone, you might feel good about it. Or if you’re missing a part of it and it’s watershed territory or getting extra hepatic flow, okay, no, I need to go and interrogate that vessel. So it opens up all sorts of possibilities.
Yeah, I would agree. I think if we’re able to augment the information that this tool can give us, that now has to do with things like physiology and temperature and flow, then that may be a real-time surrogate of procedure completeness, procedure incompleteness, needing to widen the margin. That’s all essential information because of what it now allows you to do is to really think about R-zero procedures, complete ablations, no matter where it is, because I now have information on temperature and flow, et cetera, that you can’t get from purely anatomic devices like ultrasound or CT. This now adds function and physiology–
Mm-hmm.
–which now will help us better identify when the procedure is complete. And that will be a big advancement because recurrence is a problem, repeat treatment is a problem, and complete initial treatments is a problem. So that, that’s big. We’re adding a functional component to things, and that’ll be up to everyone to figure this out, this component out, in terms of the software that can generate that. But once you start doing that, you’re going to have to change the ballgame yet again on–certainly in the oncology space.
Yeah. So I mean, take enhancement for example. He did all the work on correlating imaging followup of hepatocellular carcinoma to actual pathologic outcomes in terms of partial necrosis, complete necrosis. With an MR you can get that on the table right there.
Yep. I don’t have to wait for the tissue to prove it. I’ve got the imaging surrogate that proves that we did it.
Yep.
I think it’s just amazing, kind of the possibilities that are here. And you know, one thing I will say on that, it’s been really fascinating to talk to, you know, people globally about this. And it is interesting that, you know, there are some similar things that come up, but everybody in their own context, in the context of their practice, comes back with a couple different procedures that they think would be most impactful. And I think it speaks to the breadth of applicability for something like this. You know, if intervention is the combination of seeing through imaging and interacting with devices, you know, this is a new way to see.
The other part I would add that is still–sort of eludes us a little bit, I think, in IR as a group, as society, is prostate cancer intervention.
Mm-hmm.
There are a lot of–those numbers are there. And you know, there are few centers now that do have interventional MRs where they perform treatments, but now again, talk about socializing or democratizing these types of things, now you can ablate, cryoablate, whatever it is, prosthetic tissue using MR guidance rather than anything else. That is also a game changer.
Yeah.
And for a procedure that’s traditionally treated with a pretty morbid operation–I mean, there is significant morbidity associated with–from a quality of life standpoint. So I mean, like–just like what Dotter brought out to try and heal disease and improve quality of life without inter–I mean, this is the next iteration of it.
I love that. Any final thoughts or anything else that you’d want, you know, somebody who started the day skeptical, but said, you know, I’m kind of interested in what they’ve got to say?
Well, all I would say is, I was that–I was you. I felt like you, so I hear you, and I feel you, if you’re skeptical, but give it a chance. Open your mind and see what this can do, especially now with a new iterations, with a wider bore, more ability to get into this, something that’s a bit more ergonomically practical for the interventionalist. You know, I think you’ll be very pleasantly surprised and you’ll see, you know, in the next few years how this impacts your practice.
You know, I think one of the things I enjoy being a part of–why I particularly enjoy being a part of this, apart from working with dear friends, is the fact that we’re at the bottom level. There’s nowhere to go but up. And to see how far we’ve gone in eight months, I–t’s going to be a ride. I’m just overjoyed to be a part of it.
It’s so much fun. It’s such a privilege. You know, just on a personal note, kind of some final thoughts, I’m a part of a team, I mean, just a fantastic team, looking at iMRI that’s focused on early-stage research. And so we’re always looking, you know, how can we form the future? But in this place with, you know, 60 years of Cook this year and nearly 50 years of SIR, you know, it–I can’t help but think a little bit about that legacy that comes before as well. I think, Kush, you kind of touched on that. And we’ve all seen that photo, you know, it’s 1963 and Bill Cook is standing there in his skinny tie, in his dark suit, across from Charles Dotter with his bow tie and his his razor sharp eyes–
What an incredible friendship, what an impact on the world, the two of them had. I mean, millions of lives since then have been impacted by interventional medicine, forged by the people here at this conference, and your predecessors. And at Cook, as you said, we’re early on in this iMRI journey. And if you’re skeptical right now, you know, good, we were too. We invite that. But just know we’re always looking for partners. So as you go through your day, if you’re–if you’ve got that mixture of commitment and discontent, the love of what you do, but the desire to form a better way, you know, get in touch with us because we feel that too. And we know that creating the space isn’t going to be easy, but that’s a part of what makes it really fun and worthwhile.
So with, you know, 60 years of Cook and almost 50 years of SIR, you know, over that time we’ve worked together to, I think, build a better world with needles and wires and sheaths and catheters. And I’d love to see it–us do it again with familiar tools, with a new way to see, and with an eye towards the next 50 years of IR and SIR. So with that, I–you know, it’s such a pleasure and a privilege to be able to work with the two of you on this.Thank you. And thank you for making time today.
I’m honored to work with you two.
Yeah, absolutely honored.
And thank you for listening today. If if you’re out there and you’re interested in learning more, my name’s Joshua Krieger. My colleague Sean Chambers and I will be here at SIR at the Cook booth for the rest of the conference. And if you want to find us after that, if you’re listening later down the road, you know, get in touch with your Cook rep and they’ll be able to find us. We’d love to talk to you.
Thank you.
Thank you so much.
Thank you.