Wysdom Radio™

This episode breaks down a randomized controlled trial from Hepatology exploring whether prophylactic embolization of large spontaneous portosystemic shunts (SPSS) during TIPS can prevent post-procedural hepatic encephalopathy (HE).The Core Problem: Even successful TIPS can trigger HE by shunting toxins away from the liver, especially in patients with large preexisting SPSS. The Key Strategy: Embolizing SPSS before stent deployment improves visualization and avoids catastrophic coil migration after portal decompression. A High-Impact Result: Overt HE was cut nearly in half (21% vs. 48%), with a remarkable number needed to treat (NNT) of just 4. No Increased Bleeding Risk: Closing these shunts did not increase variceal rebleeding or compromise TIPS function. The Trade-Off: The procedure adds time and briefly increases portal pressure, requiring operator confidence and careful execution. The Bottom Line: In a highly selected subset of patients, combining TIPS with SPSS embolization is a powerful, anatomy-driven approach to reduce HE risk.Tune in to learn when this added step is worth it!

This episode breaks down the landmark HI-PEITHO trial (NEJM, March 2026), a multicenter randomized controlled trial of 544 patients that finally brings clarity to the category of intermediate-risk PE.The Inclusion Criteria: HI-PEITHO mandated a strict "intermediate-high" entry bar: RV:LV ratio > 1.0 plus dual objective signs of distress (e.g., HR > 100, BP < 110). It isolates the cohort most likely to crash.The 7-Hour Rapid Protocol: We discuss the operational shift away from the legacy 24-hour ICU drip. The trial utilized a concentrated, bilateral 7-hour infusion of ~17mg Alteplase via the EkoSonic system.61% Risk Reduction: The headline result: US-CDT achieved a massive relative risk reduction in the primary composite endpoint (cardio-respiratory collapse or decompensation), with an event rate of 4.0% vs. 10.3% in the heparin-only arm.The Safety Holy Grail: In a major win for the "local low-dose" strategy, there were 0% intracranial hemorrhages (ICH) in both groups. Major bleeding rates were statistically insignificant (P = 0.64), validating the safety of this sub-20mg protocol.Mechanical Thrombectomy Question: While HI-PEITHO establishes a modern benchmark for lytics, it does not address the rise of large-bore mechanical thrombectomy. It sets the safety and stabilization bar that future MT trials must now cross.Tune in to learn about the March 2026 data!

This brief covers a massive 950-patient study identifying how to predict Post-TIPS Liver Failure (PTLF), which occurs in approximately 18% of cases.The 18% Problem: With nearly 1 in 5 patients failing after TIPS, this study provides a vital roadmap for identifying high-risk candidates before they hit the table.Baseline Red Flags: Older age, a history of Hepatic Encephalopathy (HE), and celiac stenosis were found to be independent predictors of PTLF during pre-procedural workup.The Real Signals: Forget static numbers; the focus post-op must be on the peak MELD score and the percent change in INR. These are the dynamic predictors that actually matter.The AST/ALT: This study debunks "enzyme panic." While startling, AST and ALT spikes are like loud car alarms—scary, but they do not independently predict whether the liver will fail to recover.The Bottom Line: Combining clinical history with dynamic post-TIPS labs is the key to identifying candidates for early transplant evaluation before a clinical crash.Tune in to learn which post-op "alarms" are worth investigating and which you can safely ignore.

This episode highlights the MILESTONE study, a ground-breaking first-in-human trial presented at the Society of Interventional Radiology (SIR) 2026 Annual Meeting. The research explores a novel endovascular approach to "rewiring" the body's metabolic control center to treat Type 2 Diabetes Mellitus (T2DM).A Safe Metabolic Rewire: Using a novel six-electrode catheter system, researchers performed endovascular denervation of the celiac artery and nearby aorta. The study achieved a 100% technical success rate with zero severe treatment-related adverse events, proving the safety of targeting the splanchnic sympathetic nerves.Dramatic Glycemic Control: The six-month data showed a significant metabolic shift, with average HbA1c levels dropping from 9.9% to 8.0%. Additionally, fasting plasma glucose and insulin resistance (HOMA-IR) plummeted, marking a major clinical improvement without lifestyle changes.Reduced Insulin Dependency: Patients saw objective improvements in liver and beta-cell function. Most notably, daily insulin requirements were reduced from an average of 24 units down to 19 units, suggesting a future where IR interventions could minimize or replace heavy pharmacological regimens.The New Frontier: This Abstract of the Year signals the potential for Interventional Radiology to move beyond traditional vascular work and into the primary management of chronic metabolic diseases.Tune in to learn how interventional radiology is positioning itself at the center of the diabetes care team.

The COLLISION ExplainedThis episode breaks down the practice-changing COLLISION Trial (Lancet Oncology, 2025) and explores how the IR community must scale its skills to meet the new standard of care.The Mic Drop: For decades, surgical resection was the undisputed gold standard for Colorectal Liver Metastases (CRLM). The COLLISION trial randomized patients eligible for both surgery and thermal ablation. The trial was stopped early for benefit, proving that ablation is non-inferior for overall survival (Hazard Ratio 1.05).The Staggering Cost Difference: While survival was equal, the physical toll was not. Surgery resulted in a 46% adverse event rate and a 4-day median hospital stay. Ablation cut complications to 19%, reduced the hospital stay to just one day, and had a 0% treatment-related mortality rate.The A0 Margin Mandate: To match surgical success, IRs must achieve an A0 margin—a visible 5mm buffer of ablated tissue surrounding the tumor on post-procedure imaging. Achieving this margin ensures the absence of local progression in 95% of cases.Scaling the Skillset: We discuss how the platform Wysdom (founded by Dr. Rusty Hoffman) is replacing the outdated "see one, do one, teach one" model. Through bite-sized "Clinical Pearls" and private "Morning Rounds," Wysdom provides just-in-time digital mentorship, allowing community IRs to learn complex techniques (like hydrodissection) necessary to achieve that critical A0 margin.Tune in to hear why the default question at the tumor board is shifting from "Can we cut it out?" to "Why wouldn't we ablate this first?" Based on comments from experts, content on Wysdom, and the article cited below.Puijk RS, Ruarus AH, Vroomen LGPH, et al. Colorectal liver metastases: surgery versus thermal ablation (COLLISION) - a phase III single-blind prospective randomized controlled trial. BMC Cancer. 2018;18(1):821. Published 2018 Aug 15. doi:10.1186/s12885-018-4716-8

AHA/ACC 2026 Guidelines for the Evaluation and Management of Acute Pulmonary EmbolismThe alphabet soup of societies (AHA/ACC/ACCP/ACP) has officially released the 2026 Multi-Society PE Guidelines. These guidelines move the field away from the blunt submassive labels and into a new era of granular, physiology-driven care.Categories Classifications A–E: The 2011 AHA labels are officially retired. We now use a spectrum from Category A (Subclinical) to Category E (Cardiopulmonary Failure). Key for IR: Advanced therapies are now strictly reserved for Categories D and E, while most Category C patients (even with RV strain) remain on medical management unless they deteriorate.The "R" Modifier: A new suffix for patients whose primary threat is respiratory failure rather than hemodynamic collapse (e.g., Category C2R), allowing for a more nuanced triage during PERT activations.Reading Room Mandate: The guidelines emphasize that clot volume does not equal risk. Radiologists must now prioritize reporting RV dysfunction parameters—including RV:LV ratio, McConnell’s sign, and TAPSE—as these are the data points that actually drive the A–E categorization.IVC Filter Pullback: In a major shift, routine IVC filter placement in anticoagulated patients is now a Class III: Harm recommendation. They are strictly limited to patients with absolute contraindications to anticoagulation or those failing therapy.The "Clot in Transit" Data Vacuum: For the 2-4% of patients with floating intracardiac thrombus, the guidelines admit a lack of randomized data, mandating a multidisciplinary PERT decision rather than a fixed surgical or interventional algorithm.Tune in to master the new rules of engagement for the IR suite and ensure your reports meet the 2026 standard. Based on comments from experts, content on Wysdom, and the guidelines cited below.Writing Committee Members*, Creager MA, Barnes GD, et al. 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. Published online February 19, 2026. doi:10.1161/CIR.0000000000001415