www.interventionalnews.com
15 April 2022 | Issue 85
Tze Min Wah Renal ablation
Profile: Karim Valji page 18
Profligacy and dangerous misconceptions in dialysis access Scott Trerotola (University of Pennsylvania, Philadelphia, USA), who will be awarded a Society of Interventional Radiology (SIR) Gold Medal in June 2022, raises some issues with the 2019 Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines and interrogates some dubious dialysis access interventions. Trerotola, who is the Stanley Baum professor of Radiology and associate chair and chief, Interventional Radiology, sat down with Interventional News to share his views on the current vascular access landscape.
A first word on the guidelines
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It just makes no sense whatsoever and opens the doors for a variety of complications that we literally have not seen (and for good reason) in 30 years. So, if we now allow interventionists to start putting catheters in the subclavian, the harm that is going to come to this patient population is really significant. Another important element is that they raised transfemoral above translumbar access to the inferior vena cava. Both of these access types have been studied independently and the infection rate is three times higher for transfemoral; it takes a viable access site and/or potential transplant site and, at least a quarter of the time, destroys it by virtue of venous thrombosis. It is also much more of an issue when somebody develops catheter-related venous thrombosis in a femoral vein. All this just does not happen with translumbar access. Of course, not everyone is suitable for translumbar, but for those who are, it is a much better access route. Now, is this supported by randomised data? No—and it never will be. But, it is supported by level Good medicine struck down by lack two evidence that the evidence team just seems to of evidence have ignored. They essentially seem to have Guidelines by their very nature become refused to consider lower-level evidence. a research workbook for the next What we (prior KDOQI teams) did generation. There is a fundamental in the past, repeatedly, was to then problem associated with any apply expert opinion, especially guideline formation. The fact of when we saw something we felt the matter is that committees are was good medicine being struck a victim of the evidence team, down by lack of evidence. which changes, and looks at Charmaine Lok (University of the exact same evidence with a Toronto, Toronto, Canada) and different eye. team did that here as well such A lot of evidence had as in surveillance of dialysis changed by the time the KDOQI access—I just wish they had done guidelines were updated in 2019, that in a few more places, but that is and it appears that the evidence my opinion. team tried to really push as hard as One of the areas that the KDOQI they could, even when there was not all guidelines did not go strongly enough on that much evidence. In doing so, they backed off on a lot of existing beneficial guidelines. I am Scott Trerotola (in fact, backed off on compared to 2006) was promoting and preserving the concept of overnot sure that was the right thing to do. One of the the-wire exchange for infection. We have toed this line most significant examples of this is in the vessel of choice for all of the 20-plus years I have been here at Penn and for dialysis catheters and the order in which they should we simply do not see people who are crippled by a lack be used. Previously, the guidelines essentially said internal of vascular access options such that all of their upper jugular first, then external jugular, and we can all agree extremity and lower extremity access has been used up on that. But, the subclavian vein was listed as being the absolute last choice and it was made clear that it should not and they are on dialysis with a transhepatic catheter. We see very few people in whom all of their upper extremity be used except in extreme situations. In the latest update, it veins are gone. And, when we do, they are from outside of was actually moved to the third position, on the basis that the health system. Why? Because we are so careful about there was no high-level evidence precluding this, which is insanity as there will never be a randomised controlled trial of subclavian versus other tunneled dialysis catheter sites. Continued on page 5
nterventionalists need to read the guidelines. Whilst there will soon be several different tools out there that will be easy to digest, such as a YouTube video or a podcast, there is no substitute for reading the guidelines. They are the result of a 25-year process of refinement, iteration, research and opinion, so they are the best thing we have got right now. I love the way that the most recent KDOQI update looks at access as a ‘life plan’—because you cannot take a 99-year-old patient, and compare them to a 25-year-old patient who is going to be on dialysis for many years until they eventually, hopefully, get a transplant. And, if you are practising dialysis access interventions, it behooves you and your patient to read those guidelines. Not doing so really means that you are not practising evidence-based medicine—and you should be.
Alik Farber: Industry relationships page 25
SIO 2022: ‘Controversies’ in current cancer treatment One of the sessions at this year’s Society of Interventional Oncology (SIO) meeting (24–28 March, San Francisco, USA) comprised four debates moderated by David Breen (University Hospital Southampton, Southampton, UK) and William Rilling (Medical College of Wisconsin, Milwaukee, USA). One of the key takeaways from the session was that radiation oncology has seen much innovation, and that this must continue in order to provide the best outcomes for patients into the future. Another was that “response assessment [can be] challenging”.
Peripheral colorectal lung metastases: SBRT vs. ablation
Abraham Wu (Memorial Sloan Kettering Cancer Center, New York, USA) and Thierry de Baere (Institut Gustav Roussy, Villejuif, France) took to the podium in turn—Wu as a proponent of stereotactic body radiation therapy (SBRT), and de Baere of thermal ablation, as a means of treating peripheral colorectal lung metastases. “SBRT has really ushered in a revolution in radiation oncology.” Wu began his side of the argument by dubbing SBRT a “new standard for early-stage inoperable lung cancer”, citing the therapy as particularly successful in metastatic tumours. Wu proceeded to highlight the non-invasive benefit of SBRT—there is “no cutting, needles, pain, nor a need for anaesthesia.” Furthermore, there are no medical contraindications, with patients free to continue on anticoagulant drugs alongside receiving SBRT. The toxicity profile, Wu assured, is also “favourable”, with “essentially no mortality risk” associated with using the therapy to treat peripheral lesions, including when treating multiple lesions, and retreating the same one. It is also easily adaptable to large tumour sizes, and complicated tumour shapes and locations, Wu emphasised. The convenience of the therapy is also a draw when it comes to SBRT, now that it is available relatively widely in “most modern radiation facilities”. Wu’s bottom line is that “high-level control is achievable with a sufficient dose”, which is Continued on page 7