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The COLLISION Explained
This 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 Rusty Hoffman) is replacing the outdated "see one, do one, teach one" model.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
17 Mar 2026
AHA/ACC 2026 Guidelines for the Evaluation and Management of Acute Pulmonary Embolism
AHA/ACC 2026 Guidelines for the Evaluation and Management of Acute Pulmonary Embolism
The 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
9 Mar 2026
Stanford IR's Dr. Lynne Martin on PAVM Treatment
Stanford IR's Dr. Lynne Martin on PAVM Treatment
This episode covers the critical paradigm shift in treating Pulmonary Arteriovenous Malformations (PAVMs) as detailed by Dr. Lynne Martin from Stanford Interventional Radiology. We discuss why the old "block the pipe" method is obsolete and how to achieve durable, definitive occlusion.
The Silent Neurological Threat: We explore why intervention isn't about hypoxia—it's about preventing paradoxical emboli. With stroke risks up to 32% and a 40-50% prevalence of silent brain infarctions, the lung's broken filter puts the brain directly in the firing line.
The Odontogenic Connection: A crucial clinical pearl: routine dental cleanings can cause brain abscesses in PAVM patients because transient oral bacteria bypass the lung filter. Lifetime antibiotic prophylaxis for dental work is mandatory.
The "3mm Myth": The old rule of only treating feeding arteries >3mm is dead. Modern guidelines dictate that any measurable, safely catheterizable PAVM—even 2mm feeders—must be treated, as they still carry significant stroke and abscess risk.
Why Proximal Coiling Fails (The Jailed Nidus): Placing a coil proximally creates a low-pressure, ischemic environment that triggers massive VEGF release, recruiting tiny collateral vessels to feed the sac. This creates a "jailed nidus"—a growing AVM that is now impossible to access and treat.
The New Standard ("Pack the Bucket"): Dr. Martin advocates for complete mechanical occlusion of the nidus itself using soft, high-volume detachable coils ("liquid metal"). We discuss why vascular plugs are contraindicated inside the sac and how to hunt for the hidden systemic feeders (bronchial/intercostal arteries) that cause recurrence.
Tune in to learn why we are moving away from being "catheter plumbers" and how to definitively protect your PAVM patients.
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