Q&A: How to be safer and more cost effective when planning procedures with Dr. McKinsey.

Dr. James McKinsey is a Vascular Surgeon, Professor, and Vice Chair at Mount Sinai Hospital system. He also serves as Assistant Chief for Complex Aortic Intervention and the Surgical Director of their Jacobson Aortic Center. Dr. McKinsey has been practicing vascular surgery for about 25 years and was an early adopter of EVAR. He recently sat down with the TeraRecon team to share how he uses our Intuition suite for surgical planning and patient, fellow, and resident education. He also discussed how TeraRecon has helped Mount Sinai Hospital grow and what he sees changing in the industry. The full conversation can be read below:

WHAT SOLUTIONS ARE YOU CURRENTLY USING FROM TERARECON AT MOUNT SINAI HOSPITAL AND WHAT DEPARTMENTS USE THE TERARECON SOLUTIONS?

Currently, we have a free-standing server that we use to network with other people within the vascular surgery group. We have multiple site licenses and it works nicely, because if someone has a complex aneurysm, they want me to look at it. They will load it onto the server and I will be able to look at it and give them immediate feedback even though they may not be onsite at this institution.

WHAT PROMPTED YOU TO SEEK A SOLUTION FROM TERARECON?

My practice is geared toward complex aortic intervention and the ability to calculate the orientation of visceral and renal vessels is very important as I am planning the repair of suprarenal aneurysms and thoracoabdominal aneurysms. Being able to center line flow and calculate the path for where the aortic grafts are going to lie is critical as I manage patients with very complicated aortic anatomy.

WHAT MADE YOU BELIEVE THAT TERARECON WAS THE BEST FIT FOR MOUNT SINAI HOSPITAL AND DID IT ACHIEVE THE DESIRED RESULT YOU WERE LOOKING FOR?

It has been a very interesting path for us because originally, I started out with taking plain old X-rays and making measurements and trying to create fenestrated grafts from that. At a previous institution, we were able to purchase TeraRecon and I became spoiled by using it. It really facilitated me doing fenestrated grafts, back table modified grafts, and urgent grafts. It really was a very enabling technology. Years ago, I moved to a different institution which did not have TeraRecon, they had another 3D reconstructive program, which I found far inferior. Through multiple attempts to try and make it work, we never could, and we went back to TeraRecon and purchased the free-standing server that we use now. I can now work with other people throughout the division of vascular surgery from multiple different sites, calculating and figuring out how to do complex aortic work.

HOW HAVE YOU BENEFITED FROM WORKING WITH TERARECON?

The main benefit we have found is that it really enables us to do many more complex aneurysms and to do them safely. We have excellent outcomes from our aortic program, and it is really because of the calculations I can do prior to going in the operating room and fixing these aneurysms. I'm quoted as saying, "80% of the case is done before we actually go into the operating room" and that's because we have the ability to use TeraRecon to really plan, look in three dimensions, imagine in our minds where the aortic graft will actually lie, move the center line to accommodate that, and then see exactly see how things are going to align. It almost gives us a dry run to see how we are going to repair these aneurysms and what grafts we will need.

WHAT ARE THE MOST SIGNIFICANT IMPROVEMENTS THAT HAVE RESULTED FROM IMPLEMENTING TERARECON AT MOUNT SINAI HOSPITAL?

I think it is patient safety. We are very accurately able to predict where the grafts need to be placed to avoid blocking branches and allow for fenestrations to manage these complex aneurysms. As well as really looking and saying, "Look at the iliacs. Are they going to be large enough to accommodate the passage of the sheathes? What's going to be the orientation of the renals to a very tortuous aortoiliac segment?"

TeraRecon allows us to perform these procedures quickly and safely. If you spend five, six, eight hours doing a complex aneurysm, patients do not do as well. We can do them quickly because of the advance knowledge we have from TeraRecon and are able to plan the case well in advance. As a result, the patients have better outcomes.

YOU HAVE BEEN USING TERARECON SOLUTIONS FOR ABOUT EIGHT YEARS. WHAT IS THE MOST IMPRESSIVE THING ABOUT THE SOLUTION, OR EVEN THE TEAM, THAT HAS MADE YOU STICK WITH US?

I think one of the biggest advantages of TeraRecon is reproducibility. It is a program where I know I can come in, sit down, measure out a case, come back and feel very confident that it is how it is going to be when I go in to do the case live. I am very confident that when I make calculations using TeraRecon they are going to be reproducible and safe for the patient.

We have certainly seen cases where partners and referral doctors have used other systems and they get very different calculations regarding where the renal vessels are located. When we look the case using TeraRecon, I say, "No, you're wrong, we need to use these measurements". And case after case, we have found that I have been right. I really trust TeraRecon to let me create accurate measurements so I can treat these patients with complex aneurysms.

FROM YOUR EXPERIENCE AS A VASCULAR SURGEON, CAN YOU SPEAK TO THE VERSATILITY AND SCALABILITY OF TERARECON AS YOU HAVE GROWN?

When I look at TeraRecon, I have used it both as part of a PACS system at my previous place of employment, and now I have a single, dedicated server. We have multiple site licenses where people can connect remotely, so if I'm traveling, I can still use the system to thoroughly look at aneurysms. No matter where I am, as long as I've got internet, I can actually review the scans and give an opinion on what the options are for treatment. I have found that the system has been very flexible as I am trying to manage patients here, as well as collaborating with physicians at other sites, and even when I am traveling.

I also work with people that are not vascular surgeons. I have been working with thoracic surgeons who are looking at doing 3D modeling for tracheal prosthesis. They are using TeraRecon now to help their calculations and to try and figure out pulmonary anatomy. It is a very versatile program, not only for the vascular space, but also for other specialties such as colorectal and thoracic imaging.

AS AN INSTRUCTOR, CAN YOU TELL ME ABOUT HOW TERARECON HAS BETTER ENABLED YOU TO TEACH CASES?

I use TeraRecon for interacting with patients, medical students, residents, and fellows. All are at different levels, even within each group. When I bring a patient in, I will do a 3D reconstruction using TeraRecon, project it on the screen, show the patient what their aneurysm looks like, and discuss how we are planning to repair it. That is very impactful for the patient, because now they suddenly realize that we are personalizing a therapy for them and that we have spent a lot of time looking at their aneurysm, trying to get the best therapy for them.

For medical students we use it for general anatomy, to show how we do endografts. We show them pre and post images and then how the grafts are positioned. For the residents and fellows, it is a way for them to learn how to manage these complex aneurysms themselves. We will go through the case the first few times together, and I will show them how to use TeraRecon and my thought process. Then I will have them come in on their own, make their own measurements for planning and save it. I will do my own planning independently on the same case and then we will pull them up side by side to compare so that they can learn.

WHAT DO YOU SEE ON THE HORIZON IN TERMS OF PROBLEMS THAT ARE GOING TO BE ENCOUNTERED IN THE HEALTHCARE INDUSTRY (FIVE OR TEN YEARS OUT)?

There are two different problems that I see in the next five to ten years. The first is the need and the ability to help with training because we have an ever increasing number of residents and fellows coming out  of school that need to have exposure to a broad variety of cases. Simulations are a good way for them to learn how to do some of these techniques in a safe environment, to do a kind of do dry run, if you will. I think TeraRecon is going to be there with us as we are trying to help teach these residents and fellows to be safer, so when they finally go out and do their own procedures or are doing procedures with us, they are much more facile and have a good working knowledge of how we made the decisions that we did.

The other thing is going to be is an economic issue. Obviously healthcare costs are going to be increasingly constrained. The more accurately you plan a case, less components you are going to use. You are not going to have increased inventory or put stents in because you had not appropriately planned it out. Being cost conscious, I think there is a good role for TeraRecon to help the surgeon with a dry run, see where the stents are going to land, and to make sure that you have the right components.