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Navigating comprehensive PAD care in the current climate

Navigating comprehensive PAD care in the current climate

Dr. Kumar Madassery
Dr. Parag Patel

Drs. Kumar Madassery and Parag Patel talk about the recent media storm around PAD treatment, BEST-CLI and BASIL-2 results, the referral network, tips for new IRs, and more.

Episode Transcript

Introduction (00:00):

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.

Dr. Kumar Madassery (00:18):

Welcome, everyone. We’re here live at SIR within Cook’s podcast booth. My name is Kumar Madassery, and I’m honored here to be here with my esteemed guest, Dr. Parag Patel. You’re going to want to listen to this episode. We’re going to talk about how to navigate this uncertain climate in PAD and how IR is going to create a resurgence into this space, which we originally started. First off, Parag, you want to just introduce yourself and say where your role is currently in the PAD space?

Dr. Parag Patel (00:45):

Yeah, thanks, Kumar. Excited to be here with you. And, yes, as you mentioned—Parag Patel. I’m an interventional radiologist in Milwaukee, Wisconsin. I’ve had a longstanding practice there for the last 16 years or so and have been really involved in PAD education, trying to make sure we get the word out and young interventionalists feel and understand that their place in this treatment of patients with PAD is live and real, because there’s plenty of patients that need to be treated.

Dr. Kumar Madassery (01:14):

Absolutely. And so I’m in Chicago at Rush Medical Center. Been there since I was a surgery intern, a little wee intern who didn’t know anything about IR but found the passion. I would do it a hundred times over. And my primary focus is limb-salvage PAD with wound care. I think it’s very important, because I think the elephant in the room is that we’ve had a tumultuous 18 months of topics related to PAD and CLI and some articles which were scientific articles as well as some sensational news pieces about what’s going on. So let’s just dive right into it. We see a lot of uncertainty as to what to do with all this information, whether it’s talking about BEST-CLI trial, BASIL-2, and some of the ProPublica, New York Times—how do we—what do we do now as an IR community to address this, and what have you seen as an impact?

Dr. Parag Patel (02:01):

Yeah, these are great questions. I think the biggest issue that came about with some of this mixed news or information in the media was potential for distrust or inability for patients to really understand where do they go for real help? They’ve got problems with their legs, particularly vascular disease, if that’s what it’s determined to be. And then they’re hearing mixed messaging in the media about going to a vascular specialist and having treatment done or overtreatment done and not recognizing that in some of those instances, without that treatment, they would have lost their limb—and that repeated treatment and diligence and making sure that management was done and follow-up was done appropriately—they were able to actually salvage things.


Now, this is a complex disease. Once you get to the point where you have peripheral vascular disease, you have an advanced form of it, particularly when you’re symptomatic. Most patients don’t present with symptoms. They’re asymptomatic, and they’re floating around in our communities without realizing they have that problem. Once they’re diagnosed, they have a real risk of mortality and amputation just by curing that diagnosis. So these aren’t just your regular well-being patients. These are sick individuals that don’t really maybe appreciate it to the extent that they’re noticing it in their limbs once they finally present to you—particularly those advanced patients that you see with CLTI, those are the highest risk.

Dr. Kumar Madassery (03:19):

I think it’s interesting—the media storm and what we’ve seen as a fallout, it shows a couple things. There’s a lot of positioning by societies and groups and whatever, but what we all have to realize is there’s not enough of us as it is to help the number of patients out there who need this. And I think that’s part of the thing we need to dive into, how to get us as an entire IR community and specialty and membership to really reengage in the space that desperately needs it, because there’s not enough physicians of any of the specialties. So let’s talk about this in terms of—from—data. So we had BEST-CLI, which came out, and it seemed to be—everyone’s anticipating looking at it, a 10-year project looking at is bypass better or is endo better for CLTI patients? So what did you think if you just talked top pearls from that that you took away from it?

Dr. Parag Patel (04:03):

Yeah, so I think BEST-CLI—and we were actually a trial site for that, so I was one of the PIs in Milwaukee, and we enrolled a number of patients in that trial. And I didn’t actually speak too much of the background of my practice setting. It is multidisciplinary with our several interventional radiologists and vascular surgeons with some vascular medicine docs mixed in, that take care of patients at the Medical College of Wisconsin in that metropolitan area in our network. And the reason I mention that is not everyone has that sort of setup, but you can exist in that setup and be an expert leader in that setup and don’t necessarily have to defer to other colleagues or other specialists. The reason I say that background with regards to BEST-CLI is that even prior to the trial, we had a low threshold to call our surgeons if we thought that there was a need for something. Some patients need revascularization with a limited amputation.

Dr. Kumar Madassery (04:56):

Right. Right.

Dr. Parag Patel (04:56):

So some patients are better served with endovascular only. And our surgeons are very comfortable with us pushing the envelope with endovascular means, particularly the more complex CLTI interventions, and they’re more than happy to jump in and help with a bypass or a hybrid-related procedure, say a common femoral type of issue where we can maybe do something with an endarterectomy and then endovascular for the remaining portion of that. The reason I mention that is that the outcomes of BEST-CLI really didn’t change our practice. They validated what we did. If they’ve got good vein, then we may consider them for a distal bypass, or we may preserve that for future use. If it’s fem-pop and endovascular means, we’re going to go endovascular and not burn bridges, and if that’s not successful, then you can go to a surgery. If they only have synthetic options, meaning no suitable vein, it’s endo all the way, and only then, if that doesn’t work, then we go to do something a little bit more dramatic, which is using something that’s suboptimal bypass material.

Dr. Kumar Madassery (05:53):

I think it’s interesting, because we talk about these complex bypasses that can be offered and should be offered, but I think the availability may not always be there, so you have to figure out what is your multidisciplinary team, and what is available in your area? But you can build that practice to do that. But I think what’s interesting is that as IRs, you were part of it, and I think that’s great. We were initially part of it as well, but we don’t have a strong representation in trials like this. If you look at—70% of the endovascular intervention was done by vascular surgery. That’s not a fault of vascular surgery in my mind; that’s a fault of us.


We have to be more present and relevant to this to provide meaningful science and data and expertise, and I think that’s part of our mission is how do we get back into it? So people like to focus on that, saying, “Well, that’s why it’s wrong, and the data’s bad.” I disagree with that. I think that’s where we have an opportunity to get back into this and figure out how to train. So with BASIL-2 now the answer was “Hey, wait a second; endovascular’s better,” and now we’re confused. So what did you think from that one?

Dr. Parag Patel (06:51):

Well, you’re exactly right. So we had a different patient cohort—some a little bit different, but similar endpoint—I mean, looking at endpoints in complex patients with advanced disease and comparing them, endo versus otherwise, and it’s a different patient population. It was outside the US, predominantly in the UK, and we saw improvements with endovascular means. And so what does that mean? Is it operant-based? Is it knowing which patients to select? Is it knowing that some are best suited by—and what technologies are we using is the other piece of this, right? Because BEST-CLI occurred in the midst of the whole paclitaxel debate: Is this good? Is this not good? Were endovascular means being done with suboptimal tools rather than what we know are established best tools now—which still has a limited uptake, by the way. We know we have good technology for why we should use antiproliferative technologies, and guess what? We have a limited uptake or penetration in the market, and that’s a class effect. All of the antiproliferative technology’s done better, and for whatever reason, those people treating—those of us, the general US interventional population, has only had a limited uptake in its use.

Dr. Kumar Madassery (07:59):

Yeah, I think that’s very true. I think a lot of this in the CLTI and limb salvage or even PAD space requires an incredible amount of clinical management. You were heavily involved in the entire inception of IR residency and training in this. Where do you see that we need to incorporate more of this, and how do we get a tangible result from this process for trainees moving forward?

Dr. Parag Patel (08:20):

If we’ve learned anything a long time ago, we can be expert at procedures and doing things really well, but if we don’t understand the disease state, how to manage it, manage the complications and the patient thereafter, you’re only going to be able to do it for a limited time. We’ve proven that, right? We’re doing prostate embolizations, we’re doing oncology treatments, and we’re holding onto those treatments because we’re selecting those patients, managing them, and following them up appropriately. That’s the lesson we learned for vascular. And the other part of this is that there’s too much disease out there for any one specialty to own this. So it has to be treated by a cadre of folks who are focused on wanting to take care of vascular patients, not just doing the procedures. And so the beauty of the interventional radiology training pathway and evolution of the specialty was that any disease state that we treat requires you to be a clinician—and management of that disease state first, as it relates to vascular disease, 100%.


I think—and what we try to prove in our training program, and I know you have one as well, is that yes, these procedures come, but they come through the clinic first, and you evaluate those patients. You manage the things that you need to do with risk-factor modification, medical management, and then take care of their intervention, and then there’s subsequent management follow-up that needs to be done thereafter. These patients will always have this disease once they’re diagnosed, there’s always going to be something to be done, and there’s way more patients out there that are not getting treated. The data’s out that this is not limited to rural areas and where there are limited physician availability, this is even occurring in large metropolitan areas where certain patients are having higher rates of amputations than other cohorts. And we’re seeing it’s not because there aren’t doctors there, they’re just not getting treated, they’re not being diagnosed, they’re not being identified, or they don’t have the access for whatever reason.

Dr. Kumar Madassery (10:02):

I think it’s totally true, and I think the beauty of a clinical program is you learn every aspect of it and you start building referral networks by—those patients need help that maybe you’re not always managing. But that’s how I think that referral arm’s kind of tentacles spread out. And I think that one of the beauties of clinical management is you learn how to say no, and I think that’s a power of understanding the true process, and—”Hey, this is not something I should jump into, because this is not the right thing.” I think we are heavily built on procedures. We’re heavily, incredibly talented at wires, catheters, opening things in the body parts to treat cancer and shut things down. But I think that longitudinal care makes a big impact, and that’s something that trainees—we really need to find a way to make that impactful to them. I think that has to be a big strong point.

Dr. Parag Patel (10:46):

100% agree. Anyone that’s invested in doing procedures, has trained in doing procedures—the true power comes in being able to tell a patient whether they’re appropriate or not for it. If someone else comes to you and says, “I want you to do this,” and you just do that, that’s very ancillary-service-like, right? The power of interventional radiology becomes—we are so skilled to do these, but we also know when it’s appropriate, when it’s not appropriate. If all the patients that come into your clinic end up getting a procedure because they’ve already been predetermined by someone else that they need a procedure, are you really adding a lot of value, or is someone else filtering that out before they get to you?


Do you have a glorified—what I call a “consent clinic” where all you’re doing is making consents all day in clinic? Is that really a clinic? Or are you actually assessing patients, determining, “Hey, right now you don’t need anything. We’ll follow you up in 3 months and see where you’re at. Maybe you’re improved, and we’ve done well with medicines which are much better now. Or do we need to progress to something a little bit higher level and bring you to the angio suite and do a procedure?”

Dr. Kumar Madassery (11:47):

I think that’s the beauty, because if you have that longitudinal care, you build referrals, and also you’ll find patients that you are knowing is better for surgery, is better for this. So I think there’s a beauty in you sending a patient to the surgeon, because now you’re acknowledging the whole comprehensive care and saying, “I’d really like to see—I’d like you to see this patient to tell me that bypass is better, because that’s what I think.” And sometimes you’d be surprised as to how that reciprocal effect develops a relationship—even things that may have been a little bit “hostile” or whatever you think it is—and sometimes that’s because that olive branch coming from you may be a better start than expecting someone to send you everything.

Dr. Parag Patel (12:23):

I think that’s a great point for young trainees. So people coming out—early-career interventionalists or those who, in training—who are about to embark on this—they might say immediately, “Well, the referral network is already established. So-and-so, whether it’s specialty A or specialty, B, already gets all the referrals.” And that’s all the referrals from that 1 or 2 docs or that source, but that’s not—don’t limit yourself to that source. There’s so many other places out there that haven’t been tapped. There are community health clinics, there are podiatrists, there are other primary care docs who probably don’t have a fixed set of referral base, particularly if you do the stewardship to manage it.


[If] you have a referral base that you follow up with, show them how well you’re taking care of their patients, and you let them know what you’re doing to make their patient population that they’re overseeing do better with regards to limb care, they’re going to continue to send you patients. And it’s the individual that wants to be hungry and take care of patients like that. It doesn’t matter what specialty you are. The other referral bases will start to move to you if you provide that type of service, whether it’s in vascular oncology or otherwise. You can’t just sit back and expect it to come to you. You’ve got to put the work in, meet the patients where they’re at, talk to the referring docs, and let them know the service you’re providing.

Dr. Kumar Madassery (13:40):

So I think that’s critically important. We’re here at the SRI Annual Meeting. This is where we all get together as a family and we see the thing. I think I’ve been really impressed by the young trainees, med students, young residents who are just showing up, asking questions, asking about how to do this, how to build a clinical value. How do we guide them as to—this is opportunities for you to build upon this PAD outside of just where they’re training. What do you think are some opportunities and avenues that are very valuable for them at a high-yield level or giving them exposure?

Dr. Parag Patel (14:11):

The annual meeting’s a great place for networking, obviously seeing the latest devices, learning about new techniques and even the basics. But I would say is that—2 comments: First of all, the talent pool coming into interventional radiology is phenomenal. Over the last decade since we started this residency, we’ve literally got the best and brightest in medicine coming in. It’s one of the most competitive specialties. So you know you’re capable, because you’re of that cadre of individuals that could basically go into any specialty, and you’ve chosen IR. That’s how competitive it is. There’s nothing that differentiates you at that starting point of a residency than any other surgical specialist or medicine specialist. Now you come through your IR residency training, and you have an interest in learning more about PAD, and you’ve learned the basics maybe through training, but you want to go out in your new community separate from the umbrella that you have in your residency training program, and you want to build it out.


Well, our networks are strong. I think the IR community loves to help each other out. These meetings, standalone meetings like the SIR Edge meeting, which is going to focus on PAD, and resources that we provide, are really wonderful tools for problem solving and difficult-patients management issues and even technical things. I would say you got to go out there, you got to talk to physicians, and you got to realize it’s not going to be the first 3 months, 6 months, and maybe the first year where you see a regular occurrence of patients in your clinic with PAD. But the moment it starts to come and you get that opportunity to show that stewardship to that patient and call that—every time I see a patient in clinic for a referral from a new doc, I send a note or even a phone call or a text to that provider, saying, “Hey, saw so-and-so, doing well, I’m going to start them on this,” and just let them know that 1) I acknowledge the consult, and that 2) that I’ve taken care of it.


And if I’ve done a revasc, I let them know every time. Every clinic follow-up visit for that same patient is an opportunity for me to remind that referring doctor that I’m taking care of their patient with regards to their legs. They don’t have to worry about. If they have any questions, give me a call. So that’s free advertisement, if you want to call it advertisement. These dirty words about marketing—it feels—and business of medicine—feels like, “Well, that’s not why we went into medicine, for the business side of it.” That’s not the point. The point is those docs don’t know that you are available to them, and what you’re doing is you’re making that awareness to them by doing that.

Dr. Kumar Madassery (16:23):

Yeah, I think it’s like identifying yourself. I mean, to be fair, I think we have to remember that every physician—we have to remember—wants what’s best for patients—whatever happens in the stresses of hospital systems, societies, whatever. There’s a lot of pressures that come at you when you’re working and you’re growing, but I think at the end of the day, everyone does still want what’s best. I don’t think people nefariously out there are like, “No, I want this patient to suffer.” It’s just a pressure. I think it’s about navigating those and finding a way to make yourself comfortable and not have to worry about those kind of things. I get this question a lot. I’m curious how you—I’m sure you do as well—but I get young IRs who are out there, and they’re like, “Hey, I want to build this practice,” and they have a basic question: “How do I go convince somebody to send me a patient when I haven’t built the volume yet in PAD?” How do you think you would recommend somebody to work on that?

Dr. Parag Patel (17:11):

Well, first of all, you want to make sure that you’re knowledgeable and—just the basics, taking care of these patients. I presume coming out of residency, you know the basics in differentiating leg pain for vascular pain versus neurogenic versus venous claudication—initial management of that. And then you want to educate. You might do community education to patients, and so it could be drug to consumer, if you will. It might be viewed that way, but you can go to local community centers, churches—go to the local pastor in a parish, or do screening. We’ve done leg screenings on a Saturday to assess for screening ABIs. These are ways that you can identify patients and then send notes to their primary care provider that you’re—hey, you’re a vascular specialist in the area looking to do this. Alternatively, you can go to primary care providers. What’s challenging now, I think with consolidated health networks, is this feeling like you have to consult or you have to refer within your network.

Dr. Kumar Madassery (18:03):


Dr. Parag Patel (18:04):

But you probably have providers within your own network as well, and there’s so many of them. So I think there’s a number of different ways to go about that, and it’s never always the same thing at every location, so you have to explore it, and as you do that, you’ll start to see that it starts to come back. You’ll start to see that that doc sees the next patient, or you try to make it simple for them. I’ve always told my trainees, when we do venous, we do arterial, and we even do some pain procedures, that you could probably send the referring doc—”Any patient with leg pain, send my way. I’ll work it up. I’ll figure it out, which way it is.” It doesn’t matter. Don’t make it hard for them. Don’t have them do the screening. You’ll figure it out—if it’s venous, if it’s arterial or otherwise—and then you’ll determine what needs to be done. Most times you’re going to be able to manage it.

Dr. Kumar Madassery (18:48):

I think that’s an excellent point right there. Our physicians, especially primary care, even podiatry, they’re actually overburdened with patients. And the efficiency that they have to operate under, which is pretty much on a computer now, that’s pretty much your medical system—it’s nonstop. Everything’s tracked. They have to get to the next patient they have. I think what’s easy is when you find a physician, you say, “Hey”—just like you said—”let me take care of everything. You just let me know, and I can evaluate if it’s needed, not needed. Even if they need other things, ancillary referrals, I can address that for you too.”


If you take that burden off them, they’re going to find you as a valuable resource and a partner in patient care, because—I see primary cares all the time. They’re just like, “I don’t know where to go. I don’t know who to send it to.” And then people are asking them to order a limited ABI—”No, no, no. I wanted physiological segment tools.” Or, “No, what is this? What is this?” Then they get called by the imaging center for insurance problems. It’s like, if you just realize that your goal is to help them do their job better and then in return you get to manage patients, I think that’s a very valuable point to this.

Dr. Parag Patel (19:49):

But that’s the stuff that trainees in any specialty never really see: all the inner workings that makes a thriving practice work, right? What makes the clinic work is not just having a room in a space and perhaps a nurse or an MA to room them, but it’s all the coordination that occurs: the pre-authorization, the phone calls, the phone calls by us to insurance companies for justification for therapies if that’s needed, clarification to imaging centers, and so on, whether it’s noninvasive, a fast imaging study, or clarification on a cross-sectional imaging study—what exactly you need. That’s all in your purview, and frankly, your responsibility in the management of that patient, because you’re ordering it in relation to the things you’re trying to assess, right? And we’re specialists, and we should continue to be specialists, but we should be taking some of that burden off of our referring docs if we think we want to take care of those patients. That’s how you get more of these patients.

Dr. Kumar Madassery (20:40):

I see it all the time by podiatrists, surgeons, and other people who send me these complex patients. They feel so happy when I told them, “Hey, I saw this. I don’t think I need to do something, but I’m going to send them to PM&R, because they can do some spinal injections and stuff. I am getting an MRI for this and this,” and I just give them an update. I think it’s amazing, the sense of relief they feel, that they can just focus on something else, and you’ll update them. And I think it’s important for young physicians starting off to remember, you don’t need to have 17 referrers sending you patients in year 1.


I think it’s important–at least I’d love to hear what you think: Find 1, maybe 2; try to get 1 patient. Do a phenomenal job of taking care of them, giving a brief update to them. And what I do is—I’m still primitive: I take photos on my phone, I circle things on the phone, I send them a picture, say, “I know you may not know what you’re seeing here, but I did this. I’m going to keep an eye on this. I’m going to follow this up, just so you know.” And you’re not telling them to do anything. You’re including them in the conversation that no one includes them in.

Dr. Parag Patel (21:37):


Dr. Kumar Madassery (21:38):

Is that something you’ve seen?

Dr. Parag Patel (21:39):

Totally agree. I think that’s one of the ways to build a practice. This false sense that every single primary care doctor in the health system has to refer to me, otherwise you’ve failed. It’s not like that at all. We just got done saying, I think—and hopefully made it clear to everyone that’s listening—there’s way too many patients out there to be treated by the existing number of vascular interventionalists or vascular specialists out there, of all specialties, frankly.


So you trying to take up some more patients and identify them is not taking away from anyone else. You’re actually helping bridge the gap of burden that we’re getting right now. So I think that’s an important point. Start with 1 primary care physician, 1 family practice doctor, 1 podiatrist. If you get 1 of each of those, say 3 docs in 3 different specialties, right? And you get their book of patients that may potentially have leg pain or PAD, if they’ve identified clearly that that’s what it is, you’re going to have a large number of patients at the end of that first year that you’re going to be seeing, screening for management of disease, and taking care of.

Dr. Kumar Madassery (22:42):

I think it’s interesting. We always talk about—it’s important to have a collaborative team, a limb-salvage team. What’s interesting is that a lot of places don’t have any such thing. We’ve talked about it. So the beauty is if you’re truly interested and invested in this, you can start your own. You can reach out to the podiatrist, to infectious disease, to endocrine, and say, “Hey, are you guys cool if we just talk about some cases that I may want to see or if you see some and just see how can we as a system do better?” And I think—I’ve seen some people try that out, and you’d be surprised. Every now and then you become suddenly now in charge of this, and you’re bringing in other specialists. And the hospital sometimes will support it when they see decreased readmissions, when they see less hospital stays because you’ve helped streamline the process. These are all things that it’s incredibly in our wheelhouse. We just have to be willing to take that on. Is that something you’ve been seeing anywhere?

Dr. Parag Patel (23:28):

Well, certainly I think IRs that are—become savvy in talking to hospital administrators or understanding the economic cycle or revenue cycle within medicine are better apt to get the resources they need and understand the value that they—understand—having hospital administrators understand the value they provide to the health system. That brings resources, that brings you space and time for clinic, that brings you perhaps an MA- or an APP-level support. We’ve seen this in private practices; we’ve seen this in academic centers. You have to still know how the economics work to get those resources. I think to your point, when we see—we do a lot of things besides PAD. We treat dialysis access, we see cancer patients, we see patients with pain. And sometimes some of the issues they’re dealing with that they’re seeing you for may not be the only thing they’re having issue with, and they may have a vascular-related issue, and you can manage that.


And we’ve certainly seen patients that have crossed over from dialysis access stuff to peripheral vascular disease and certainly with oncologic diagnosis that actually have concomitant vascular disease as well. Is there other ways to remind the primary care doctor? Yes, you have these patients–happens to have a cancer diagnosis, but guess what? They also have an iliac stenosis that’s causing them leg pain. It’s probably going to be an issue for them. “I can help treat this. I’ll share with you what we’re doing.” And let them know, and make them more aware about the things that you can offer.


You got to be diligent. You can’t just sit back and wait for things to come to you. And that’s everything in medicine these days. And the last thing I’ll say is I think—what I’ve noticed over the last 5 to 10 years is—in general, our trainees—and we see trainees of all specialties through our program—more willingness to partner and work together. They don’t need to be in a silo anymore. They used to be, and I think that’s an old-school model, and that still exists, don’t get me wrong. I think the hierarchy in some specialties still exists in that way: “We own it all. We’re the place to do it.”

Dr. Kumar Madassery (25:24):


Dr. Parag Patel (25:25):

But I see young specialists in all the specialties that I interact with, that I think you interact with, that I’ve become friends with, that understand my disease state and space much better than some of their colleagues do and some of my own colleagues do and are willing to partner and demonstrate that same respect and say, “Hey, we’re doing good work to take care of patients that need it, and if we’re not doing it, we’re going to continue to have more and more patients not identified soon enough before they have an amputation.”

Dr. Kumar Madassery (25:51):

Absolutely. I think several of those points—I mean, I tell our trainees, whether it works or not, every patient that we do dialysis eval on, check their legs. PAD’s a silent killer. That’s why I call it arterial cancer, just to make patients public-aware. But if you just check their legs—it’s being ignored because everyone’s focusing on their dialysis, their lungs are fluid overload and all their other multitude—but half the time no one’s ever checked the fact that they have terrible pulses. No one’s helping risk-stratify that part of it, which may eventually be one of the reasons that takes their life away in the future. That is one avenue to consider when you’re trying to help patients and detect earlier and also a PICC line for osteomyelitis. IRs, we do PICC lines, we have services to do PICC lines. You forget that—why are they getting—where is the osteomyelitis? Has somebody evaluated? Do they have enough blood flow for this antibiotic to work?

Dr. Parag Patel (26:39):


Dr. Kumar Madassery (26:39):

It’s funny how you’ll have an eager intern who catches that, or a resident. You’re like, “This is amazing. This is like a shining moment for me that you did the extra step, and now you can help this patient move on, and now you just found yourself a patient to help.” I think it’s beautiful when you see those kind of things. I think what’s important in this—and you’ve had several decades of experience in this space—so I think, what’s your value, and how do you think people should work on mentorship? Because I think that’s a critical component.

Dr. Parag Patel (27:06):

I believe strongly in mentorship probably because I’ve benefited from it, and I’ve tried to pay it back and then pay it forward. And I think to me, it’s the greatest reward as an educator. I’m involved in this as a program director, at a training program, for a while now, and seeing others go out there in their local communities outside of my own, or even in my own, being able to take care of patients. It’s the multiplier effect. I think the reason we went into healthcare or medicine is to take care of people, get them out of pain, or cure them of their disease, or make them more aware. It’s pretty scary if you’ve had any family members with any type of medical problems, you know how that can be, and the ability to have that privilege to do so, but then also train others to do that only makes that effect that you have that much stronger.


So for me, mentorship’s a big part of my professional identity. Again, I benefited from it early on, and because of that recognition, I said, “Let’s keep doing this.” And I think it’s places like SIR where these young people around the country get together—young and old, I guess—and you’ve worked on things together, and you come to practice and learn from each other. I see this all the time at every session I’m at, and I’m talking to colleagues that are 10 years older and 10 years younger than me, and I’m learning from each of them, and they’re learning from me, and it’s this exchange that’s very organic, but I’m coming to appreciating that some of that is viewed as mentorship. Even if I’m learning from a younger operator, and frankly they’re telling me something, and they’re thankful for the time I’m providing them—I don’t know—I think I’m the one benefiting from it in the end.

Dr. Kumar Madassery (28:47):

We’ve been such an innovative field that when you get stuck in your ways of how you do things, you’d be surprised when someone else starts doing something, they find something. Sharing that knowledge comes from any age level, because as IRs, that’s kind of been our whole—what is it?—trick in a bag is that we just come up with new things on the fly, and sharing that. I think mentorship now has changed where it historically had to be wherever you trained, this is your connection. But I think we’re in a virtual world, we have so much access to communicate, good and bad. But I think the good is that you can network with any one of our members. You can find all these sessions, you can find all these courses. Cook puts on a lot of PAD courses. They can attend those courses. They can see the IR physicians or even other physicians that are always in it to help patients get better care.


And I think even for young trainees or young physicians, just reach out, connect with your community, and you’ll be surprised at that mentorship. We can do virtual discussions and do a FaceTime call if you need help. I mean, you should probably not take on crazy cases—you have no one—a little bit more experience as backup, but I think you can do all these things. I get called from fellows or even other people, like, “Hey, what do you think about this case? I’m about to do it,” or “What do you think of this?” And I think that’s the beauty of incorporating technology into what we have. Do you see that as a positive opportunity, and how do we make sure that’s done in a safe way?

Dr. Parag Patel (30:01):

Well, you certainly want to make sure appropriate patients are being treated. Not everyone with a blockage needs a treatment.

Dr. Kumar Madassery (30:05):


Dr. Parag Patel (30:05):

And not everyone with a small stenosis has a reason to have an intervention or a stent placed. So it’s critical that we continue that education. I think your point earlier about IRs being best suited for some of this—PICC line for osteomyelitis or dialysis patient, checking pulses—is an important one, because IRs can do so many different things, and service the hospital for dialysis access needs for perhaps faster access, but maybe more importantly, pain management, oncologic needs, and vascular needs.


So if you’re in a rural or an area—community or an area that doesn’t have access to all the specialists like the large, big teaching hospital or tertiary-care hospital in a larger metropolitan area, a single IR can manage a lot of different disease states, and it doesn’t always have to be the most complex disease that you’re managing, right? If we’re identifying patients at an early stage, you can be the one that helps medical management. You can be the one that gets them to the place where they need maybe an iliac stent for management of claudication.

Dr. Kumar Madassery (31:06):


Dr. Parag Patel (31:07):

You don’t have to go the tour de force your first cases through for patients when they’re in the most advanced state, but you’re best suited as an IR to identify this and actually treat many different types of patients as a single operator in a medium-sized or small-sized hospital.

Dr. Kumar Madassery (31:22):

Totally. If you think about limb salvage, wound care is actually predominantly venous patients, but they have mixed disease. So you’re well suited when you get comfortable to find a venous problem that was causing the recurrent ulcer or treating the arterial so that we can address the venous component. We do wound care. So that’s a critical component, to address both, and I think you’re well suited. It’s about building that comfort level, that knowledge base, that referral pattern. What do you think? This is the 30,000-foot view, right? We have the residency, we have SIR, we have Edge. What do you see in the next 5 to 10 years as the future of where IRs are going to be in the PAD space in a realistic approach, I think?

Dr. Parag Patel (32:02):

Sure. Well, I think we have an aging population. We’ve got chronic obesity and diabetes, renal failure continue to grow, and, as I mentioned, the Baby Boomer generation continue to age, so that the number of patients that are going to need to be treated in the next decade or decades to come is only growing. So the need’s going to continue to be there. I also think that the evolution of IR as a primary specialty and focusing on taking care of patients, knowing the disease state, is going to suit them—or have them best suited to be a major player in this.


I think we started the endovascular revolution. I think we’re going to continue to be squarely a part of this, and I think we’re going to see increased market share in the work that we do, because the people coming out now in the last 5 years and the next decades to come are going to be treating patients in their training programs clinically based at the onset. So when they go out and practice, they’re looking for the same type of concepts and ability to do the same, and they’re going to see that there’s a lot more vascular patients to treat than there are oncologic patients to treat in their community hospitals.

Dr. Kumar Madassery (33:04):

I think you’re 100% right. I think what’s interesting is that you always hear, “We started this, we should take it back.” And in my mind, the way I look at it is we should be an equal partner. I think our goal is that—personally, I hope we’re at least a 33% partner in this, because then together you have a better shot at it. If you try full steam ahead, take everything back, I think, personally, that’s a wrong approach. You’re trying to build, contribute, grow, and be relevant in the space. I think that red-ocean, blue-ocean model in business is very important. You’re fighting for the 5 patients in the hospital, but then there’s a hundred patients in that zip code that no one’s helping. So I think what you talked about earlier with screening and talking and reaching out and getting a few, I think that’s where that growth begins. And I think as a society and as a mentorship community, that we’re trying to bring back this focus on clinical PAD management, limb salvage, which we’re well suited for. I think that’s where my personal hope is the goal for this.

Dr. Parag Patel (33:57):

Absolutely. We keep focusing on the pie that’s been identified that exists of patients, but what we are realizing is that we’re not trying to get a bigger piece of the existing pie, we’re just trying to realize the entire pie that we haven’t identified. It’s a much larger volume of patients, and we just need to get at those patients, and we’ll end up doing our part—and, in fact, probably growing market share well beyond what we’ve realized in the last 2 decades.

Dr. Kumar Madassery (34:18):

I mean all the data projections say that in 2030 and 2050, it’s going to be even worse in terms of number of patients with PAD, with potential amputations and all these things. So I think this is actually even a bigger task, because we won’t even be able to keep up now. We have no chance in the future if we don’t all develop this whole process within ourselves. So since we’re running out of time here, tell me your one call to action for our future of our IR specialty and our trainees and our young physicians to really bite into this.

Dr. Parag Patel (34:48):

Call to action for PAD: It still is, as basic as it sounds, be a clinician, be a doctor for these patients. If you start there, regardless of if it’s vascular disease, oncologic, or pain interventions, you be their doctor. You’re going to have patients to come. The moment we become just the interventionalist who does the procedure and the itinerant doctor who shows up, does the procedure, and walks away, and then waits for the next thing, we’re going to lose everything. And we’ve learned that already. Be the doctor you’ve been training to be in your integrated—your IR residency training programs—you’re going to do great. The field is awesome, and the opportunities for us to make a difference in healthcare continues to grow.

Dr. Kumar Madassery (35:26):

Yeah, I keep saying the future is bright. I’m fully invested in that. I see the energy. I think we’ve got to run with this. I think everyone should be going to courses, attending Edge, going outside, going to other society meetings—be relevant, go to hands-on training. I did one with trainees this weekend here, and it was phenomenal when they were sticking wires in the cadavers’ arteries—and the sense of elation in their face when they finally got to get the tactile—go get those opportunities, seek out mentors, and I think we have a lot to do with this.


Thank you so much for everybody listening out there. You can listen to these podcasts on the Cook QR code®, which is on your hotel key, and also in the future on the website. But Parag, thank you so much. Your years of wisdom come across as really helpful for these kind of things, and thank you so much for your time.

Dr. Parag Patel (36:06):

Thanks, Kumar. It’s been a blast.

Dr. Kumar Madassery (36:07):



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