What’s in My Bag: A candid discussion with some of the nation’s greatest peripheral interventionalists—including equipment preferences, technical tips, and insights into the future of peripheral intervention.
This week in “What’s in My Bag”: A sit-down with Dr. Michael Bacharach
Medical School: University of Wisconsin
Internal Medicine: Mayo Clinic with emphasis in Vascular Medicine
Cardiology: Mayo Clinic, Rochester Minnesota
Interventional training: Mayo Clinic, Rochester Minnesota
Peripheral Intervention Training: Cleveland Clinic
Hobbies: Hunting and Fishing
Who or what was your inspiration for a career in vascular medicine?
Dr. Bacharach: Ernst Schneider, a Swiss-German angiologist, gave a lecture at the Mayo Clinic in 1986. He demonstrated all kinds of novel therapies including clot extraction and catheter-based lytic therapy—things nobody was doing and the time. I was enthralled. I thought, “that is what I want to do”. I met with the head of the Mayo Clinic at the time and ultimately designed a new curriculum for myself which included Interventional Radiology and Vascular Surgery. This then allowed me to do a full year of dedicated vascular intervention training at the Cleveland Clinic.
How did you find Sioux Falls?
Dr. Bacharach: I had friends in Sioux Falls, South Dakota: I gave a talk out there while I was still working in Cleveland. It was an integrated group that included cardiac surgeons who performed most of the vascular work. Initially I declined when they asked if I was interested. After a few years in the Cleveland Clinic, it became clear that I needed to find a new home. I called them and I have been there for 20 years.
Describe clinical practice in Sioux Falls? How would you describe the pace?
Dr. Bacharach: Last year we did 760 vascular cases. This is one of the benefits of living in a geographically isolated region with a large catchment area.
Do you still practice coronary intervention?
Dr. Bacharach: I consider myself a vascular medicine guy who trained in cardiology. I rarely perform coronary intervention, though I am current developing a TAVR program and perform 4-5 TAVRs a month.
What is your favorite vascular intervention? How many do you do a year and what devices do like to use?
Dr. Bacharach: Aortic endografting. I performed 90 endografts last year. When I was at Cleveland I saw the initial endograft devices being developed. I worked very hard to bring that technology to Sioux Falls and was one of the first interventional cardiologists to really take an interest in it. I have used all of the current modular devices (Cook , Medtronic, and Gore) and unibody devices, they all work very well.
Do you preferentially use any of them?
Dr. Bacharach: My father drove a Ford. He liked Fords. Our neighbor liked Chevrolets. I can’t tell you that any of them shines above and beyond. There are some nuance differences, such as supra-renal fixation, which the Cook and Medtronic devices have and the Gore device does not. I don’t really see that as a drawback. We currently do about 80% of our volume with the Gore device.
What about newer devices such as AFX Endovascular AAA system® (Endologix, Irvine California) and Ovation® (Trivascular, Santa Rosa, California) device?
Dr. Bacharach: The AFX Endovascular AAA system® (Endologix, Irvine California) is a useful unibody device. When we employ snorkeling techniques to salvage the internal iliac arteries, we will often use this. Gore has some new branch preserving devices that we are currently involved with in trials. Ovation Prime™ (Trivascular, Santa Rosa, California) is interesting. We don’t use it in the acute setting (rupture) but for short necks and other scenarios it is appealing.
Do the caliber of the devices affect how you think about them and use them?
Dr. Bacharach: Both the AFx™ Endovascular system and Ovation Prime™ are smaller and lend themselves to percutaneous strategies. However, I have used preclose technique for all of my endografts. Whether I go percutaneous is dictated more by common femoral artery anatomy. If you are careful and use good technique you can use percutaneous techniques with all of them.
Moving on to lower extremity interventions, give us some insight into how you approach femoropopliteal occlusive disease?
Dr. Bacharach: If I can access antegrade I will. I use a 6 French sheath and either an angled glidewire or an Terumo Advantage™ (Terumo® Medical Corporation). If I have gone extraluminal, I will reenter with 0.014 CTO wires or a V18. I am “old-school” and really never use crossing devices. Perhaps this is because I am cost-conscious. I very rarely require a reentry tool, but I use the Outback when necessary.
Do you believe in atherectomy?
Dr. Bacharach: Not really. I think of it like a niche device. I found that with atherectomy I was getting similar restenosis as I did with stenting, but I could place a stent in a fraction of the time. So, I rarely use atherectomy devices. I reserve its use for specific anatomical locations. Isolated short popliteal artery segments that I am trying to avoid stenting, or ostial profunda lesions in a patient with prior common femoral endarterectomy and profundaplasty.
Would you describe yourself and a stenter or stent-minimizer?
Dr. Bacharach: I am a stenter. I am trying to get the best luminal result that I can at the initial presentation. I balloon and stent. I do not want to come back. We used to see short-segment SFA stenoses that responded well to balloon angioplasty, but I just don’t see those anymore. That’s not the patient population that I treat. The pattern of disease seems to have changed. I find myself looking after a sicker and older patient population with multi-level more extensive disease.
When you stent, what do you like to use?
Dr. Bacharach: For routine superficial femoral arteries arteries and longer lesions I have gone with mostly Medtronic nitinol self-expanding stents. In terms of DES, I tend to use Zilver® PTX® (Cook Medical, Bloomington, Indiana) in restenosis after seeing some of Zeller’s work. I rarely use Zilver PTX® as a first stent. There are a few other intriguing stents on the market. The SMART® stent (Cordis, Bridgewater, NJ) is interesting and easy to deploy. I am still waiting to see how they fare in the long-term. The Supera® (Abbot Vascular, Abbott Park, Ilinois) stent, which I have been deploying for a few years now, is very useful, though there is a bit of a learning curve with the device. There is a role for it when going across the adductor canal especially when I need to stent the above-knee popliteal artery, though I try to avoid the popliteal when at all possible.
Do you enjoy critical limb ischemia?
Dr. Bacharach: Not really. I think of critical limb ischemia something I have to do part and parcel with providing a full service to patients. Patients with critical limb are challenging patients with a high recurrence rate and are often recalcitrant to medical therapy and risk factor modification. Overall, I find critical limb to be professionally less satisfying than other areas of vascular intervention. I don’t shy away from it, but I don’t relish it either.
Do you use pedal access? When?
Dr. Bacharach: Not frequently. It is rare that I am not successful in an antegrade fashion. However, desperate measures must be taken by desperate men. In general, I am very conservative about pedal access. I will only access the pedals after an antegrade attempt has failed once or twice. Maybe this happens a handful of times a year. We used to do popliteal access, but I have largely abandoned that because sheath management can be such a problem.
I have heard that you perform catheter directed lysis, do you think the type of catheter matters?
Dr. Bacharach: No, I don’t.
What do you think CREST II will demonstrate?
Dr. Bacharach: CREST II will be difficult to recruit for. I’m also concerned about the stent arm since finding experienced operators maybe difficult, compounded by the fact that many operators have such low volumes in the absence of registries.
What is your sense of the BEST trial?
Dr. Bacharach: BEST could be a very important trial. However, it will be dependent on centers in which both surgical and endovascular skill are equivalent.
What made you successful and good at what you do?
Dr. Bacharach: I was fortunate to have had wonderful training at the Mayo and at Cleveland. I worked hard. I was available. And I was always very passionate about what I was doing. Large volume was very helpful. It is like that old joke, “how do you get good judgment? Through experience. How do you get experience? By having bad judgment”. I made a lot of sacrifices. I missed lots of soccer games.
What advice would you give to clinicians applying for positions in the field of vascular intervention?
Dr. Bacharach: Many fellows are graduating with a wealth of experiences in their respective training programs. But one has to realize that your training is never truly complete and that you are always evolving. Having the mindset that you are willing to ask for help is important. Coachability is key. We are wary of applicants who are truly overconfident and come out pounding on their chest saying “I want to do complex cases”. That is a red flag for us.
Looking at the future of vascular intervention, do you think the future is bleak or bright?
Dr. Bacharach: It depends on your mindset. I think that it is bright for practitioners who are dedicated to vascular intervention and have demonstrated true interest and/or expertise. One has to be willing to see the swollen legs, the blue digits, and the odd vasculitidies. The future might be bleaker for people/coronary interventionalists who are solely interested in expanding their interventional volumes. High-volume centers don’t really want people who dabble in vascular intervention. One has to embrace vascular medicine in a more holistic way. You have to carve out an area of expertise and be recognized by your referring practitioners as someone who takes care of people beyond the bread and butter of cardiovascular medicine. With the right mindset, the future is very bright.
This field is constantly changing and fascinating. The level of change in vascular intervention has been monumental and has outpaced the advancements within coronary intervention over the past decade. There will be challenges, especially cost. We have demonstrated that we can look after patients well but expensively. Can we do it cost-effectively? That will be a huge challenge for the interventionalists of the future. Overall, I am high on the future of vascular intervention.