The Antegrade Flow Show

Dr. Venkatesh Ramaiah: "Dr. Ted Diethrich lessons carried forward"

June 30, 2021 Tim Season 1 Episode 102
The Antegrade Flow Show
Dr. Venkatesh Ramaiah: "Dr. Ted Diethrich lessons carried forward"
Show Notes Transcript

For our very first guest episode, we’re honored to welcome Vascular Surgeon, Dr. Venkatesh Ramaiah. Dr. Ramaiah is a world-renowned expert in the treatment of Peripheral Arterial Disease, Aortic Aneurysms, Carotid Artery Disease, and Venous Disease. Dr. Ramaiah also currently serves as Chief of Complex Vascular Services at HonorHealth and is the founder of Pulse Cardiovascular Institute in Scottsdale, Arizona. As a surgeon who has constantly tested himself, techniques, and new technology as it has emerged, we dive into Dr. Ramaiah’s mindset and process of testing and adopting new technology! Tune in to everything from how you walk into the OR and create an environment of focus, becoming a surgeon in India to then move to the United States, and lessons learned over 25+ years of experience. 


01:00 Meet Dr. Ramaiah!

03:00 Changing the game with cutting-edge technology.

05:30 How cardiovascular surgery is trending to change over time.

06:20 What lessons from pitfalls and cutting-edge technology have helped you become more effective?

11:50 What gaps would you like to be closed to approach better patient care?

13:00 Improving technology and cutting down radiation exposure. 

14:30 How The Protego System is working towards limiting radiation exposure to surgeons, staff and patients.

17:00 Working with hostile anatomy and high-risk patients.

19:00 What is your process when adopting new technology?

22:00 Thoughts on small startup companies introducing new technology.

26:20 What did your journey look like deciding to become a Surgeon in India, and then moving to the US?

30:00 Was there a decision point when you decided between going to the UK vs the US?

31:00 Was it intimidating coming to Arizona Heart and working with Dr. Diethrich?

34:15 Why is it so important to you to be on the cutting edge of research?

36:40 Is there anything you learned from Dr. Diethrich that you teach to your students now?

39:00 What has it been like doing conferences with live cases?

42:20 Do you think there is value in multi-specialty conferences?

43:00 What piece of advice would you give yourself 20 years ago?

45:30 Advice Dr. Ramaiah has for new fellows starting their journey.

48:40 How to connect with referring physicians and market yourself as a surgeon.

Show Notes:

·       Check out Dr. Ramaiah’s website: https://pulsecardiovascular.com/

·       Check out Dr. Ramaiah’s LinkedIn profile: https://www.linkedin.com/in/venkatesh-ramaiah-md-facs-a770203

·       The Antegrade Flow Show website: www.antegradeflow.com

·       Names and companies mentioned have links included in the transcription.


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Dr. Venkatesh Ramaiah: 

Dr. Diethrich https://vascularnews.com/obituary-edward-b-diethrich/  was always the first one in and the last one to leave. And if you did something, he would always do something better. If he did 1 he would do 10. So it was a very competitive environment, but not in the sense that, you know, it sort of made you hesitant or put you down anything, it was just a very healthy competitive environment.

 

Tim Ferriter:

Welcome to the Antegrade Flow Show where we explore ways to improve your health, your practice, your business and your life. We do this by looking at how the past has shaped us, and how we advance into the future while having a pulse on the flow of today.

Welcome to the antegrade flow Show. I'm your host, Tim Ferriter www.antegradeflow.com . I come with a background of more than 20 years in the medical device, startup, big company space. I've worked with those organizations and during that time have had the opportunity to work with some of the top KOL’s, thought leaders in the world. This is about talking to them and bring their experience their knowledge to these conversations. So thanks for joining the antegrade flow Show. Today our guest is I'm really lucky to have Dr. Ramaiah https://pulsecardiovascular.com/venkatesh-ramaiah-md/ I'm lucky enough to work with him myself. Dr. Ramaiah just background most of you probably know definitely this background, so it's a bit repetitive. He's a vascular and endovascular surgeon with more than 25 years of experience. Dr. Ramaiah fulfilled his vascular fellowship under Dr. Edward Dietrich at Arizona Heart Institute https://en.wikipedia.org/wiki/Abrazo_Arizona_Heart_Hospital . He served as the medical director and director of vascular surgery for 20 years at Arizona heart Dr. Ramaiah is a world-renowned expert in the treatment of peripheral arterial disease aortic aneurysms, carotid artery disease and venous disease. He's authored over 90 peer reviewed publications as well as numerous textbook chapters and continues to act to be actively involved in clinical research. As the principal investigator of several ongoing studies, and Dr. Ramaiah currently serves as chief of complex vascular services at Honor Health https://www.honorhealth.com/ , and is the founder of Pulse Cardiovascular Institute https://pulsecardiovascular.com/ , the first cardiovascular outpatient surgery center in Scottsdale, Arizona. Dr. Ramaiah. Thank you, sir, for joining us. It's good to see you. Did you get a chance? I know you're, you're an avid golfer and doing all these things to improve the swing? Did you get a chance to get out recently? 

 

Dr. Venkatesh Ramaiah: 

Yeah, I actually got up this morning, early morning, six o'clock tee time, and then got back to work at about 11 o'clock. 

 

 

 

Tim Ferriter:

And look and I can see I don't know people probably can't see it. But I can see you are in the work scrubs and hat and everything. So you are a busy man, how to golf and go anything notable. Sometimes yes, sometimes no.

 

Dr. Venkatesh Ramaiah: 

I got one, birdie.

 

Tim Ferriter:

Well, good. I know you're getting those clubs tuned in. So maybe a few lessons there. So always trying to improve the game? 

 

Dr. Venkatesh Ramaiah: 

Yeah, absolutely. It's, it's a work in progress. 

 

Tim Ferriter: 

Well, good. Well, good. Hey, listen. So you know, I just want to jump right into this and kind of the antegrade flow show is to kind of look at the past, look at the future and, and kind of the flow of today. But I was recently talking to a friend of yours, Jeff Elkins https://www.linkedin.com/in/jeff-elkins-687529107/, and he gave me a quote, that was awesome. And I think it applies to you. He says tenacity and persistence is the common attribute for early game changers. And that's who you are, that's what you are. And, you know, I've been lucky enough to work with you recently with you know, I think new technology and cutting-edge technology. And that's kind of where I want to start with, you know, you know, going back in time, and looking at some of this stuff, you know, cutting edge, I think you're involved with bringing new technology to market for years. And you know, all the firsts you've been a part of, from early 2000s with talent and you know, first in the USA, I think at Arizona heart. You know, you go back to and I think maybe go before this, maybe Dr. Dietrich and Goldfarb and yourself involved with Teflon and the early days, maybe with Endologix https://endologix.com/united-states/ , even Gore's tag device https://www.goremedical.com/ , maybe back in 2005 and beyond, but not not perfect on the dates there, but Teurumo https://terumoaortic.com/  recently with relay pro pivotal study Aptus https://www.medtronic.com/us-en/healthcare-professionals/products/cardiovascular/aortic-stent-grafts/heli-fx-endoanchor.html you and I worked together on Aptus some time, you know, and I want to start there because you know, I think you're you're you're a leader and tell us about being on the cutting edge. You know, Jeff talks about the tenacity and persistence and it's certainly a lot of work on the front end to take risks like this. Can you talk a little bit about how all those years of, of being there is, you know excites you?

 

Dr. Venkatesh Ramaiah: 

You know, I started at Arizona heart as a fellow in 1997. And then after a year at Eisenhower hospital https://eisenhowerhealth.org/ , I joined Arizona heart in 1999. And so for 20 years. From then on, we were all involved in cutting edge technology, bringing new products to market, showcasing new procedures. Dr. Dietrich had an International Congress that we hosted every year in February, at the Phoenician, and that was a host of new talent, cutting edge, high end vascular surgical techniques, state of the art treatments from across the world. I would attend that International Congress in February and so, right from the very beginning, we were involved in making product better, and also bringing a new product to the market. And I think, as Jeff Elkins said, I think tenacity, a true vision, and a deep passion in what you're doing, helps you, you know, to overcome all the obstacles that you have, that you come up with, you know, bringing a product to market is extremely difficult. It takes a lot of work, it takes a lot of money, a lot of hours commitment, and you can never lose hope to so vascular surgery is very interesting, because it's evolving, and it has been evolving over the last 20 years. And I think it's, it's going to evolve even more, as it becomes more and more less invasive, more and more endovascular, and more and more moving to the outpatient setting. And where that's where I think cardiovascular procedures are generally going to be done as an outpatient procedures. Just as ortho, EMT, general surgery, all moved to the outpatient. I think cardiovascular eventually, a lot of the procedures will be moving into the outpatient setting. 

 

 

 

Tim Ferriter: 

Yeah, and it's your view is just it's so unique to hear your perspective. And we have all different listeners from you know, years and years of experience to two fellows who you mentioned coming through your fellowship early on, under Dr. Dietrich, can you go back to some of those early times? And I think this is the benefit of your experience, and maybe just this conversation, let's go to talent https://pubmed.ncbi.nlm.nih.gov/21055897/ , let's go to those early days at talent. And are there pitfalls that you experienced? That became something I always kind of say the a word is anticipation, if you can see the road ahead. You've played that game before it's like your golf clubs, you you know when to pull a certain you know, a club at a certain turn or whatever the elevation or or distance might be, you know what those pitfalls might be? Because, and I want to talk a little bit about your you know, your experience there and your mentorship under Dr. Dietrich, but let's go way back to talent, is there something that jumps out from those years ago that was applicable to other cutting-edge technologies and being able to kind of, you know, just just like anything in life, the experience you have helps you become more effective as time passes.

 

Dr. Venkatesh Ramaiah: 

So, I think I think we can focus on three aspects of vascular. The first one is obviously endografts, I had the great opportunity to be talking to meeting Dr. Parodi https://en.wikipedia.org/wiki/Juan_C._Parodi . He was he was the pioneer of bringing in endografts with AAA aneurysms into the market. And we've been involved in all the trials, even before any RECs and EBT. We were approved in 1999, September. So we were doing endo graphs, we were making endografts. In the back rooms, we were involved in a company that was allowed us to create endografts, that could be available within 24 to 48 hours based on the anatomy. And so we've been we've been hands on with the creation of endografts. right from the very, very beginning. Talent obviously was a really good endograft. It was probably the third or the fourth to the market. But it was a good draft. And the thing as I can, some of my experience with endografts is a lot of them have come and gone. We don't have any RECs anymore, we don't have the EBT device anymore, talent has been morphed into something else. And so over a period of 10 to 20 years, the graphs have taken on different construction, different architecture, different profiles. 

 

And now if you really look at how and the logic says morphed itself, from the standard ptfa de crown and metal framework to polymer technology, and low profile technology, I think that's my whole experience with endografts over the years, including abdominal and thoracic endografts. The next stage in endografts is obviously treating complex anatomy, which fenestrated grafts that involve renals, SMEs and celiacs, branched endografts that involve the visceral branches, and also the carotids and the subclavian branches. So I think that's where the next forefront of endograft will go. And if we can make graphs that can be able to get into these branches, then we can definitely decrease the amount of morbidity and mortality involved in these large huge operations for the arch enteric abdominal aneurysms. And that's how aortic surgery is morphing. And the next thing that that was really interesting in terms of aortic surgery is the hybrid approach. A lot of times, you can bypass the SMA celiac and put fenestrated grafts to the renals. Similarly, you can D branch and put grafts and so this combination of hybrid aortic surgery is another aspect of less invasive surgery that is gaining steam right now. 

 

Tim Ferriter:

And that that perspective is is huge because your abdominal up there. You know, the thoracic, the arch and beyond, when you jump back and look at the challenges in, in different parts of the anatomy, maybe you come first with abdominal and work, you know, say north, can you talk about the early days, and maybe it's even Gore's tag, I think maybe back in 2005, or looking back to the early days. And you and I worked together in some cases, I think with, you know, the valiant grafts from Medtronic https://www.medtronic.com/us-en/healthcare-professionals/products/cardiovascular/aortic-stent-grafts.html  and, and how the life has that I like how you break it up in three parts, where we come from maybe where we're at and where it's going. With your perspective. 

 

Dr. Venkatesh Ramaiah: 

Yeah, I mean, right now, thoracic endografts have sort of taken a step behind abdominal I think abdominal endografts have morphed into the deep into finished radiographs, branch graft chimneys, and also they become very low profile thoracic, and the graphs are still not become as low profile as you'd like them to be. Other people are working on it. And I think thoracic, at least initially, I thought would be a much better approach for branch endograft, since we can access the carotid and the sub gradients, you know, from the arm from the outset. And so I think there's a lot of work involved, obviously, it's stroke risk is what concerns everybody, when you deal with the arch and the A sending, and the thoracic aorta. Gore is done well, I think we were one of the first few to do gold, I think it was in April of 2004. And then we started doing training courses, Gore was a great help in establishing our Congress or Research Center, they played a pivotal role in bringing thoracic endo grafting, you know, to Arizona heart and then spreading it out to the rest of the country in the world. So Gore has been a good player in the endograft market and in the aortic market, for sure.

 

Tim Ferriter:

When you look to the future, you mentioned profile size and worrying about you know, the complications in the thoracic space, what gaps do you see? And maybe that's it, I just kind of set it, but what gaps specifically, would you like to kind of be closed, to approach just better patient care from that perspective.

 

Dr. Venkatesh Ramaiah: 

I think the longevity of the endografts, you see, you know, once you put something into your body, it's supposed to last your lifetime. And I think we're still working on it, you know, especially for abdominal endografts, you know, you need to have fixation, you need to have the graft, not migrate and come down. And second, you need to have seal. And so I think those are the two main components of making a successful endograft. The neck of the aneurysm is probably the most important sector when you're doing abdominal endografts. And I think if the neck is not healthy, long enough to get a good seal and fixation, then I think we face complications accordingly. But I think, going forward, not only in terms of profile, but I think they will be areas of improvement, where fixation will become extremely important. Seal will become extremely important. And I think with the parliament technology, a lot of this will give us much better handle of even type two endoleaks, with filling of the sack and things like that. So I think it's a work in progress, I think aortic surgery is you have to be committed to it. It's long hours. Radiation is another topic that we can touch on when you're doing these complex aneurysms, with branches and chimneys and stuff like that. 

 

So how do you limit your exposure to radiation is a very important aspect. And then that takes us to the imaging technology, which will help us decrease the time the contrast that we use, and the radiation that we use in these complex procedures. So all of these merge into one, you know, if you get a great device, but then it takes a long time, then you need to cut down your radiation, you need to cut down the amount of dye that you use. And so I think sometimes these hybrid procedures are helpful. But to get into the crux of the problem, you have to bring in all these other features to you got to make sure that you're not exposed to radiation in these long procedures. So your radiation risk has to be cut down with the improvement of new technology that limits the amount of exposure, the contrast usage, and of course, the wires and the catheters and the other things that you need and the skill level that needs to be done. So it's a highly involved training program. And I'm glad that I was at Arizona heart to be involved in not only my own training, but also in training all our fellows and other people all around the world. 

 

Tim Ferriter:

Yeah, I want to hit touch really quick back on the radiation exposure because I think that's something that you know, you and your your colleagues more than anybody is in that room with more exposure. I think just recently I was reading or seeing something that maybe it's Dr. Zwiebel https://www.linkedin.com/in/bruce-zwiebel-963950103/  out of Tampa General https://www.tgh.org/  is he's got this this approach to maybe having a solution. Have you seen that? Can you talk about maybe the future of protecting you know, yourself and your peers? 

 

Dr. Venkatesh Ramaiah: 

Oh, absolutely. In fact, at the Scottsdale International Forum https://sif2021.com/  in in March, we showcased the Protego system https://imagediagnostics.com/protego/ , which is basically a system that sort of is it's almost like a room from above the patient's body. And so everybody in the room is protected. And we did a couple of cases measuring the radiation exposure to the cardiologists, to the staff in the room to the anesthesiologist, and that radiation levels were almost zero. So we are working on it. I mean, it's a work in progress. And I think at the Shea campus, we already have the protego system. And there are other systems that come in, like you mentioned, that are coming up. And I think this is going to be key in, in doing these complex procedures and limiting the amount of radiation to the physician and not only the physician, but also the staff, and definitely the patient himself, too. 

 

Tim Ferriter:

Yeah, and maybe especially those hybrid cases or the fenestrated cases, things like that. So it's an it's good that they're addressing that. 

 

Dr. Venkatesh Ramaiah: 

And so not only with that radiation, but also imaging, you know, I mean, there are, there are a couple of imaging systems that do CT overlay, like side are or even centerline biomedical, they're coming up with overlay CTS, and also with catheters that have, you know, like, almost like seeking a seeking a missile or something like that. So you can go right through the, through the fenestration into the orifice of the renal or the SME. And so that decreases the time to cannulation decreases, the procedure decreases radiation decreases dye usage, and anesthesia time. So it's headed there, I think all of these technologies will eventually become so much more advanced, that you can literally drive these catheters into those offices. 

 

Tim Ferriter:

Yeah, that's great. I'd like to see that continue to, to grow and be more widely adapted. So so everybody can be benefit from it. In the entire room. You know, I've been there with you. One thing you mentioned, too, was was fixation, right? So you have hostile anatomy, maybe that abdominal aortic neck, maybe it's a short neck, hostile neck in any way. And I know, again, years ago, you were an early pioneer. And with the endo anchor right after this, I worked with that, as well. So I've been in cases with you. And so that's maybe one solution. Can you talk a little bit more about some of those adjunct, you know, pieces to therapies tools? To answer that all continuing perplexing, hostile anatomy. 

 

Dr. Venkatesh Ramaiah: 

So there are many ways to fix the endograft. You know, right now, we rely on hooks and bobs that are either suprarenal or infrarenal, like the gold graft has infrarenal, or at the renal fixation, the other endografts, like Endurant https://www.medtronic.com/us-en/healthcare-professionals/products/cardiovascular/aortic-stent-grafts/endurantii.html and Cook https://www.cookmedical.com/ , have suprarenal fixation, including the Ovation https://endologix.com/united-states/  and the Aptus device. Anchors were an extremely interesting concept, because it sort of mimicked suturing, you know, I mean, you mimic these procedures to open procedures and see how you can get the best by making them endovascular. So literally, if you can suture endovascularly, something to the neck, that will stay there for a very, very long time. And I worked with Medtronic, Medtronic also had securant, which was like a Ansan, clip, you know, suture material that was also anchoring to the aortic wall. And then of course, Aptus came in and now you have endo anchors from Medtronic, I think it's a great concept, especially in those cases where the neck anatomy is not the ideal situation. And the patient is extremely high risk for open procedures, I think you can put the graft in and then anchor them with a series of anchors all around the proximal neck. And I think the data has shown that endo anchors do really well with preventing type one endoleaks and preventing migrations. 

 

Tim Ferriter:

Yeah, it really has. And that's good to see. That's another tool again, in your toolbox when you let's dig a little bit deeper there. And just because that space you bring in, you know, let's say this, in this point, part, your early phase in this technology that's similar. And, you know, similar to a suture for an open aneurysm, and being entered into the market and all I think the pitfalls or the rejection for something like that. That's like, that's just kind of out of the box. And I've never done that before. I'm worried. And I guess I asked you that to reflect on all of the early rejection that said, I don't know about this new technology. We're all comfortable, right? We're staying where we're at, and we don't like change. So I know that's the same and in your world as well. How do you address that? especially early on? Right? You go back to an your ex in the days with Dr. Dietrich. How are you guys addressing that now you obviously you continue to grow the space and bring better patient care through all of the back to Jeff's, quote, tenacity and persistence. 

 

Dr. Venkatesh Ramaiah: 

Well, surgeons are the worst actually. They're very distance. They're very resistant to change. Something that works for them, well, they'll keep doing it. In fact, a lot of the surgeons were doing a new record almost till 2015 even though you know, we had shown that it was migrating. But then you got to pick and choose your cases you get the best results and you stick with the technology. So, I have given lectures as to how do you adopt new technology, what makes a surgeon change his practice? So the couple of things one, the first thing that attracts me to new technology is the concept. It's a great idea. I'm interested in this idea, like polymer technology https://endologix.com/role-liquid-polymers-endograft-design/  for endograph is it was it was a totally different concept altogether. So once the concept is intriguing and attracts my attention, I then look at the product. Is the product there? Has it reached? The goal? Or the goal that it's going to serve? Or is there are there going to be so many iterations that it's going to take at least another 5,6,7 years to get there? So just the concept is not important is important. But also how far have you reached to achieving that concept? Once you've reached a goal, or a standard that you say, yes, you know, we've almost reached a concept, maybe an iteration here or there, then I look at the data, then you look at the trials, you look at the data, you look at what exactly is going on, you study the device, you study the concept. 

 

And if you think the data is good, then you look at the ease of use. Because sometimes you can have a concept, you can have a product, but it's so technically challenging, that it is not worth your time. And then finally, you will also look at the cost of that new technology, what does it take to bring that technology into into your practice? And so 1 2 3 4 and then finally, you look at the company to because you know, involved in a lot of companies and some companies, what they do is they make the product and then move out of the space? Are they committed? Are they willing to change and make it better? Are they willing to make iterations that eventually we will set that goal and reach that concept. So all of these factors weigh in when I evaluate new product, and if I think, finally, after evaluating all this, hey, this is a good product makes sense, data is good. It's the ease of use is good, it's economically, financially, okay, then I bring it into my practice, and I will not ding the product until I then overcome my own learning curve. So I will go for the training, I'll do 1 2 3 4 10 to life, overcome my own learning curve. And after that, if I think I'm getting good results, the concept is good that the product is performing as recommended, as intended, then I bring it into my practice. And I keep track of everything that that I do with that particular product for the next whatever years or so, so that we can just collect the data accordingly. That's how we approach new technology. 

 

Tim Ferriter:

Yeah, that's a great systematic approach. And you have the the history have been proved proven correct. Right with what you've been a part of now shifting a little bit from graphs when you let's say, Come contemporaneously to a shockwave or a silk road, or even I know you're using the Jeti system. These are not established companies historically, right? It's not like a Medtronic or a Gore or a Cook or Endologix, right? That factor is maybe an unknown. Is there another piece to that that says, you know, what, and the companies I mentioned are, you know, well established now, but when you first saw they, maybe no one knew that name. How do you? How do you address that unknown factor in your algorithm? 

 

Dr. Venkatesh Ramaiah: 

The first thing is to know about these products, because these, these are relatively smaller companies, they startup companies, they're more like in a niche area of of the world or the country. And so going to meetings, meeting with people, visiting the booths, reading journals, you know, all of this will then allow you to at least realize that new technologies on the horizon. And that's how I first heard about Shockwave https://shockwavemedical.com/ , and then of course, tcar or Silk Road https://silkroadmed.com/ . And then of course, thrombectomy, which is a huge part and parcel of vascular and venous disease, too. So if you go to peripherals to again, same approach, you know, we were putting balloons, we were putting stents in the SFA, everything was doing well. And then we saw the stents fracturing. And then the concept came about of removing the plaque atherectomy came into the picture. A lot of people didn't believe it, the results were not the greatest. And then of course, drug coated balloons came into the picture. So taking the blackout, treating the artery with something that prevents restenosis and maintaining the potency for longer times. Again, again, it's an evolving field. And that's and that's how you get into this new technology. small startup companies, obviously, are very exciting to deal with, because everybody is on is like, charged, or it's new technology. You know, we've got something that nobody has. And but then again, you got to watch these startups because a lot of these startup companies fail. And so you got to take all of these with a pinch of salt and go according to that algorithm that I mentioned, to make sure that this is some technology that is beneficial to the patient, and will sustain it for long term, not a flash in the pan thing, that sort of thing. So I think Shockwave is doing very well I just I just used it the other day in an SME highly calcified lesion. We use it for access for abdominal surveys, recently they have started to use it in coronaries ticker is another groundbreaking procedure, I think the company has done really well in in pushing it into the VQI’s portion of the study so that, you know, it's more easily reimbursed to. And that was the failure of the earlier carotid stent processes because we couldn't do asymptomatic patients without being enrolled in a trial. So TCAR has very good results. So far, I've done a fair amount of those with excellent results in high-risk patients. And then thrombectomy. I think that market of thrombectomy is huge. You know, there are different players in the thrombectomy space, whether it be DVT, venous or arterial, we've got a number, you got just basic suction and expert catheters for embolization. You've got Inari https://www.inarimedical.com/ , you've got Penumbra https://www.penumbrainc.com/ . And now with the new Jeti system https://www.jeti.tv/ , I think the thrombectomy space is becoming very, very competitive. 

 

Tim Ferriter:

Yeah, no, I like that you comment on those, because it's just shows again, the vastness of the approach you bring to patient care, and that you've, you've been there from that beginning. And I do want to go to the beginning really quick and kind of with the idea of of this conversation, you know, I do know, you try to give back. And personally, I get a chance. I'm lucky enough. I'll tell everybody to work with Dr. Ramaiah, in the O R. And I'll say I say this, you know, your energy, your positiveness. It's just, you know, infectious every day, and it's a joy to work with you. And I know you you maybe and maybe I'm wrong here in details. But I think you work with Dr. Samir Mehta https://www.linkedin.com/in/sameer-mehta-40586b18/  to kind of give back to India, maybe with technology. And and I want to kind of go that direction a little bit, because you've been blessed. And you're kind of given back what what were those influences early on? In maybe mother father? Or can you talk a little bit about, you know, that side of makes Dr. Ramaiah who he is?

 

Dr. Venkatesh Ramaiah: 

Well, I grew up in, in a small town in southern India, and then moved to Bombay when I was I think three or four years old, or maybe a little older. So all my high school, right from kindergarten, to college, and then medical school was in Bombay. Bombay is a good city. I mean, it's the biggest one of the biggest metropolitan cities in India. And so we were exposed to, you know, all the kinds of things that you do in a big city. Initially, I actually got into engineering, both my sisters were in the medical fields. And that was like, maybe I shouldn't go into the medical field. And so I went into engineering. And then of course, I just didn't like it, in the sense that it was very dry. I was very interested in a lot of sports at that time to you know, soccer, table tennis, field hockey, cricket, bridge chess. And so when I got into medical school, I think I just grabbed it having given my hand at engineering to and then in medical school to I was not that you know, crazy about medicine, because, you know, we started with biochemistry, physiology, but I think the thing that really drew me was surgery. 

 

When I did my first surgical rotation, I then realized that yeah, this is where I belong. And from then on, it was all surgery, and even even coming to America, I was very hesitant to come to America because it was extremely difficult for foreign grads to get surgical fellowships or trainings or residency is extremely difficult. I came to America and got a residency in 1992. So the 1990-91 was extremely difficult for foreign grads to get surgical residency. I did have a fellowship in London at King's College https://www.kcl.ac.uk/, in hepato-biliary and that's generally the track that Indian doctors generally take because we are British trained, and our training is sort of recognized. And so we do get into the system in London or in Britain very easily, relatively easily. But you know, you stay in that system, whereas in America, it's extremely difficult to get into the system. But if you really prove yourself, then the sky's the limit. And so those are the two differences between between Europe and Britain, Britain and, and the US in terms of surgical training. And I it was not easy for me also to finish my surgical rotation or surgical residency, I was very fortunate to get a preliminary spot out of you know, like 100 interviews, I got one preliminary spot in Philadelphia. And then I was fortunate enough to then work hard enough to get a full five-year residency program. Remember, I was a fully qualified trained surgeon with a master's in surgery when I came to the United States, and I had to do another five years of residency. So I did almost 10 years of general surgery residency before I went into vascular So, but it's all experience. It's all training increases your confidence, your skill level, your acuity or ability to identify problems, and it gives you a whole perspective of how medicine is, is practiced in different parts of the world. So overall, it's been an extremely fruitful experience, even though it did take me a little longer, but hey, at the end of it all, it was all worth it. 

 

Tim Ferriter:

Yeah, absolutely. And we're blessed to have you when you look at that, maybe that, that the fork in the road where you could have gone to the UK or come to America, was there a decision point there? Maybe your peers went up to London? Can you? And I have no idea what your answer is for this. But it seems like a point in someone's life where you could be raising your family, your girls, you know, you guys been in the UK right now, or we're here in the States? Is there some influence that made you go this route? 

 

Dr. Venkatesh Ramaiah: 

Well, why my brothers and sisters were here in America at that time. And so I had a tremendous amount of support. And my wife was here that time a future wife https://pulsecardiovascular.com/anita-ramaiah-md/ , at least at that time. And so I had a lot of support, you know. And the other thing was, I could always go to England at any time in my career. But to give it the best, I think was the best option was to do it, give it give my best try in the United States. If it didn't work. Yeah, I could always go back to England, or I could go back to India, where I was a fully trained and qualified surgeon. So I covered all bases, basically. 

 

Tim Ferriter:

You got him all covered. So you can hear you're out. Yes. Are there. Let's jump to Arizona heart. So so you have this amazing mentor and Dr. Ted Dietrich, and you carry on the legacy through all that, you know, you continue with Arizona harden what you've brought to the industry, can you can you jump back to those first days? Was it intimidating, come into Arizona hard work with him the first days? Let's talk about those early days, let's put yourself in the shoes of of the fellow who's just coming into the first year of their time. And and that that equivalent of Dr. Thursday equivalent. Dr. Diehtrich, is there and what does that feel like talk about those early early days? 

 

Dr. Venkatesh Ramaiah: 

But I was nervous of is there's no question about it. I mean, you had really big shoes to fill. Dr. Diethrich was always the first one in and the last one to leave. And if you did something, he would always do something better. If he did one, he would do 10. So it was a very competitive environment, but not in the sense that, you know, it sort of made you hesitant or put you down or anything, it was just a very healthy competitive environment. Even the fellowship, we try to do as many cases scrubbing to as many cases and data because a taskmaster, he observed everything I can tell you that he had eyes and ears on every room, every place in the hospital, he monitored it, even though you didn't know about it, the staff were totally trained, and totally dedicated to the concept of the Arizona Heart Institute. It is something that will never be replicated again, ever. The way the institute was run the way the staff worked to do the cases, they didn't come and saying should we have 17 cases today? How can we postpone five of them, they came with the attitude of Oh my God, we got 17 cases, we better get these things done as quickly as possible. 

 

And so the moment the patient left the room, it was almost like, you know, like a NASCAR race https://www.nascar.com/ , where the car comes into the pit and the entire team, boom, boom, boom, and the car is gone. That was how Arizona Hart was we did 10 cases in each room 17 cases in a room, sometimes it was only a 58-bed hospital. But they were yours in the early years where we did more cases than even Cleveland Clinic https://my.clevelandclinic.org/departments/heart/depts/vascular-medicine  in terms of vascular cases. And so it was a very high standard to live up to. It was not easy. We spent days and nights, learning about catheters, wires, because you could only make a mistake once at the most maybe not even once. And so you need to learn not only will not only the physicians, not only the fellows, even the staff, even the OR staff, even the X-ray techs, they were so motivated to do the best that they could ever do. And then we were always on. on camera. Most of the time, we had visitors from all over the world coming into the Arizona Heart Institute. So you had to be not only on your best behavior, but also be on your best in terms of doing the procedures taking care of the patients. And you were pulled in so many different directions. It was not only doing the cases, not only seeing the patients, it was also research, it was also education. It was also training, it was traveling, it was publishing, it was presentations, conferences, catalog, lectures, it was it was a full day, every day was a full date, I was not 

 

Tim Ferriter:

Every day, a full day. And and I want to talk about that research side. I know you personally have been a part of and maybe the numbers higher, but I have 90, you know, peer reviewed publications. How is that important? And I guess you probably were a part of it from those days and you're just thrust into that activity there. And it's it's just what your life is. And it's it's been talked about that why that's so important to be on the cutting edge of research, you know, it might go hand in hand with with device. But can you talk about maybe that the lessons learned from from Dr. Diethrich, and how you carry that through today? 

 

Dr. Venkatesh Ramaiah: 

Well, Diethrich is always on the lookout for new procedures, how to make things better, how to how to bring in, you know, new technology to help his patients. And so right from the very beginning we had a very robust research

program. In fact, you know, Dr. Dietrich founded the Endologix company along with Miles Douglas https://www.linkedin.com/in/myles-douglas-md-777984a6/  and others. Of course, he's his founder a lot of things too. But I think his pet thing was research doing cutting edge research technology, we had an animal lab on the on the base of our Arizona Heart Institute building, we did new product, and we could always go into the annual lab to try out new catheters. And then that gives you an avenue to learn more, you know, and to mingle not only with the people who are doing it, but also with the companies that are bringing new product in. And that opens up a whole new VISTA of opportunity, not only for you, but also for your patients to bring in new technology. And so we were, we were part of a lot of trials, almost all of the carotid stent trials, all of the abdominal endograph trials carotid. And so it's part and parcel that you need to do. But of course, you have to be very, very attuned to doing research, because you cannot take it very likely you need to follow these patients, you need to follow the protocols, you need to have a good research team that puts in all the data and everything. And it's part and parcel of what we used to do. And the fellows were great, it was a great opportunity to teach the fellows and the fellows, they take part in all of this too. And we had a very robust support from all the ancillary staff. And so that's something I tell all the fellows who graduate in vascular or even medical students is, it's just not the procedures and the practice of medicine, it's sometimes you need to think out of the box to look into how to make things better. And that's the only way you can widen your horizons, and then make things better for yourself and for your patients. 

 

Tim Ferriter:

That's amazing when you and I can always ask the question for the listener and say, Can you think of two or three things? Let's see even technical, just techniques that that Dr. Diethrich might have taught you in all those, the routine. And I think, you know, the routine of doing something over and over makes you the expert, I think we stand on the shoulders of giants, if any of us have done anything, you know, in this world? And is there anything that you teach now, to your students, you'd say, you know, I picked that up, you know, years ago, two or three things.

 

Dr. Venkatesh Ramaiah: 

Difficult to think of off the top of my head, but every aspect of it, you know, even just entering into the room itself, you know, you enter into the room, and everyone's busy doing something else. And then nobody's focusing, everyone's talking about things. So just getting into the room. And making everybody focus is probably one of the best things I've ever learned. You know, you enter the room, and everyone's there, like 10 people in the room, the physicians here, everybody's talking, the moment Dietrich enter into the room, it was like, focused, you know, a focus, this is the procedure, nobody talks, you just do the procedure to the best. And then you get up. So that that focus, because the for me to the operating room is like a template. I do not play music in the operating room. And I do the day to day to a lot of people do I know and people find it good, but I never there would be no noise in the operating room. No, no singing, no dancing, you know, nothing. It was just focused, treated as your temple, and then go ahead and just do the case. So that that itself was the moment you entered into the operating room, you were focused, nothing else mattered. And so that that's one thing that I think I learned very early on in my career. The second thing, of course, is patients come first, he cared a lot about his patients. I mean, you know, he did the most difficult of cases that nobody else would do. And so maybe he didn't have the best of the results too. But he cared very deeply about his patients. And I still remember once, when a patient was not doing well, he was sitting in a corner of the room for almost an hour and a half, just contemplating stuff. And so those things stay with you, you know, so you need to deeply care about your patients, and do the best that you can. 

 

Tim Ferriter:

Yeah, that's amazing. I want to grab one more piece of it, you know, in your experience in time, you know, and let's talk about the conferences, the congresses that you guys ran and led and what you learned. And it's amazing just hearing, you know, all that you're saying. So you start you know the day, and you're full speed ahead in all parts of your growth and you're learning from you know, being in the room, maybe down being in the lab research and preparing for that next conference. Can you talk about the experiences there, and I was kind of go back to pitfalls, because there's, there's some of your peers out there today that are are running a conference, maybe it's not too many years in, you know, they would like to hear some of those pieces of advice, those pitfalls, or what it was like early on trying to figure that out

 

Dr. Venkatesh Ramaiah: 

Conferences were huge, because I think Diethrich was the first one of the first to do live cases, you know, to showcase an operative procedure to the audience, or even maybe even on television. So he was one of the first ones to do so. And so it comes with a little bit of risk. You know, it comes and that is why the performance of live cases during a conference takes a lot of effort. You have to be very focused. You have to do exactly what's right for the patient. You have to do exactly what you would do you would do if there was actually no conference at all. And so just because you're doing a live case, and just because you have to, you know, do what you have to do or use what you have to do doesn't should not alter what you would actually do for the patient in it's in his best interest. And so life cases became your to pick and choose your patients. So we would, we would work up these patients. So much so that the procedure is almost done before even started. And it was a lot of work, we had to pick and choose the patients, we would start four o'clock in the morning, Diethrich would operate at four o'clock in the morning, you do a heart or two before he went into clinic, and that is the charm of Arizona heart, you could do a case, any time of day and night, whether it be electric or emergent. And the staff would love it. 

 

Tim Ferriter:

That's amazing. So those live cases, and I just a couple weeks ago, you had a live case, and then going back to Asia, Hong Kong or something like that. So that's something you still utilize today. So if I'm hearing you, right, if I'm if I'm starting a conference, if I'm a part of a conference, it's only a few years out, and I'm listening to the experience of Dr. Ramaiah. Dr. Diethrich, it's live cases are absolutely valuable. 

 

Dr. Venkatesh Ramaiah: 

You know, like I said, you know, the charm of doing live cases, should be done in such a way that it's safe, not only for the patient, but safe for everybody else, too. And sometimes I think even TCT and a lot of these societies frowned upon doing live cases. And so they set up a few, you know, sort of rules and regulations where the person doing the case should not be talking anything, somebody else should do the discussion in the talking. And so you really have to focus a lot when you're doing live cases, do not harm the patient at any at any cost. And if there's something you know, that doesn't work, I think it's too difficult to case, you know, just say No, we'll do it. We're not going to showcase this case or things like that. But more importantly, the conferences we're a bringing together, the top people in vascular from all over the world. And so that that it was looked upon as probably one of the best clinical conferences, new technology conferences, new procedure conferences, it may not have been looked upon as the most scientific of conferences such like maybe SVS https://vascular.org/  or things like that. But that is where you learnt state of the art, how to do things, the new technology, what are the nuances of new technology, showcasing some complications that can happen with new technology and things like that? So it was it was a very hands on conference with excellent with excellent performances? 

 

 

Tim Ferriter:

Do you think that there's a value in multi-specialty conferences? 

 

Dr. Venkatesh Ramaiah: 

Absolutely, absolutely. And I think vascular cardiovascular is become like that. I mean, we have a lot of interventionalists, who will do better flows, who do triple A's who do carotids eventually, you know, I've always said, if you can do it, as well as I can, you know, I may even bring my own patients on my own family members to you so. So it all depends on your training your level of skill, your results, and your commitment to what you're doing, you know, it don't dabble in anything, just become the best you can at that particular procedure. 

 

Tim Ferriter:

I like that's in life, right? You know, you got to become an expert, you know, follow your pathway, and, and add value. If I went to, you know, kind of just a couple of questions on, you know, giving advice to, to maybe our listeners, if you could talk to your younger self go back 20 years, you know, 15 years, whatever you would want to pick, what one piece of advice that you've learned that you would tell yourself, you know, to kind of help, you know, at least get to that goal quicker, or that learning just for more benefit over a period of years. what's what's one thing you've learned over the years that you wish you knew 20 years ago? 

 

Dr. Venkatesh Ramaiah: 

Wow, well like that. Because life is different. No, it's easy to give advice, but everybody faces different situations, you know, but the bottom line is this. I think the bottom line is, if you cannot do what you really like to do, or want to do, then do the best in what you're doing right now. Basically, you know, if I wanted to be a soccer player, but there's no way I could have become a soccer player, you know, but then the question is, if you cannot do you know what you love to do, then you better start loving what you're doing right now, you know, so you have to make the most of what, whatever situation you're in and make the most of it and become the best at it, whatever it may be. And some people are very lucky. You know, some people are very lucky because

they're doing what they love to do, like an artist or something like that, or a painter or piano or a musician or something like that. And some people become the best in what they they may not want to do but they're forced into it and they still become the best in what they do. And that's the whole goal. Right to be the best in what you're doing. 

 

Tim Ferriter:

Yeah, no, I love it because that's, that's definitely great advice for anybody listening. By the way the Euro Cup is is going right now. I think Italy just knocked off Oscar Do you have it? Do you have a Do you have a team and you know that you're you're backing there?

 

Dr. Venkatesh Ramaiah: 

I will always back to Argentina for the South Copa Cup and the World Cup. Sure. I used to watch the World Cup every night. I still remember the 1986 World Cup, I think it was Diego Maradona, and the hand of God and the hand of God and stuff like that. Soccer is big in India, cricket and soccer and field hockey in the USA CUP. I don't know, maybe Portugal.

 

Tim Ferriter:

Let's say they play tomorrow, you know, you know, I live in Australia. So I know that, you know, the ashes. And yeah, you're, you got some cricket there in your blood as well. So I'm sure you're, you're competitive at that point, you're, you know, when it comes up? 

 

Dr. Venkatesh Ramaiah: 

Absolutely. 

 

Tim Ferriter:

Yeah. Just a couple more questions, you know, and I kind of go back to the early, you know, listeners, you know, this type of thing, you know, we have a new generation of physicians, you know, coming through and listening. And, you know, what could you talk, if you gave, you know, you kind of done a lot of this already in this conversation, but at any tips, advice to a fellow just starting out what he or she might, might really want to appreciate, or just appreciate hearing from you, and their advice to kind of get off to the right start in their new their new life. 

 

Dr. Venkatesh Ramaiah: 

It's the medicine has changed. You know, I mean, I think, you know, we say medicine has changed, and people older to us, like, he could have said, our medicine has changed, too, you know, medicine has changed, it's become, it's become more of quality of life, which is not wrong, you know, it's more of decreasing reimbursements. It's long hours, long years, you know, you spent literally 10, 15 years, you know, becoming a physician or a surgeon or whatever. And at the end of it all, you know, the way medicine is run in the United States or even otherwise, is that time is frustrating. So what I would tell them is, you got to, you got to love what you do. If you really, if your heart's not in it, I think you will get very disillusioned with medicine, you know, over the years as you start to practice. And so you really got to like what you do money is not always the driving factor, though. It's extremely important in negotiations, and your contracts and everything. But more importantly, I think it's the working environment that you need to get into that, that helps you I think, you know, every morning you wake up, you should feel like you want to go to work that day, I wake up in the morning and say, you know, I don't want to go up, this guy is an idiot. And the working environment is not very good. People are not doing the right thing or things like that, that's the day I would quit. And so you have to be passionate in what you do, you have to be good in what you do. You got to have a really nice working environment that facilitates whatever you want to build or grow. And then finally, you got to take care of patients and do it and I think money will follow. 

 

Tim Ferriter: Yeah, I think it's good. You're getting good advice for life. And kind of Final thoughts or questions. You know, I know, again, being pioneer on the front edge of of cutting edge of things. Back in the Arizona heart days with Dr. Diethrich, I know you guys had some creativity there, and maybe even had an advertisement because you were getting patients from all over America, maybe the world. In Southwest Airlines. I think if you're sitting in an airline, you know, plane and you're the backseat is there in front of this magazine. 

 

Dr. Venkatesh Ramaiah: 

Was it? Was it Southwest or was it American? I thought it was a America West probably, I don't know,

America life because this is this is what Diethrich did. He developed medicine into different fields altogether. He started showcasing life cases and operations. And he started marketing, JT was the true marketer. He knew how to sell. But it was not that he just sold, you know, superficial stuff. But he sold it with a passion is to have a TV show, you know, on Channel three all the time. And he was he was the ultimate, ultimate marketer for any kind of product medicine in general, in particular, patients in particular. True is a great musician. He was like the master of ceremonies for every kind of procedure that you would want to think of. 

 

Tim Ferriter:

That's and that's just so just forward thinking right to be in the back of an airplane in America West at the point. And I guess it leads me to question what would you say? The best way to educate referring physicians on what vascular surgeons do? Because it may be sometimes that Yeah, the referrals don't flow because not that they don't want to just because they don't know they're not sure. Can you talk about what you guys found out early in the early days and marketing and you know, I always talk about branding is it's a lifetime strategy for whatever business you're in. But if people don't know about you could be doctor, you know, show Ramaiah on the mountaintop. If no one knows you're up there. And you're the best around? Well, it doesn't matter how good you are. So tell us about what best way to educate our referring physicians to what you guys do.

 

 

 

Dr. Venkatesh Ramaiah: 

There are different aspects to it. The one I really liked was face to face meetings. Sometimes we set up these lunch and learns you know, where you go and visit the family, kay doctors, we have sometimes dinner meetings, sometimes societal meetings, and then playing marketing but the best marketing I think, is word of mouth. When patients like you and then they sell everybody else and they tell your family doctors What a great

experience it is. So it all boils down to doing good work being nice to your patients, taking good care of them in a timely fashion. And then the word quickly spreads. So that that I think is the crux of how to sell yourself. Yeah, you have TV ads, you have papers, you have all the other stuff. But that is important, but it's mainly fluff. So but word of mouth, word of the patient to another patient, word of the patient to the physician, and physician to physician is the crux of how you sell yourself. 

 

Tim Ferriter: 

Yeah, that's great. Well, hey, thanks for your time. I know you're a busy guy. And I thought you might have just been coming off the golf course. But you did that at six o'clock this morning. And here you are, you know, all dressed up in that work. So is there anything that you'd like to add? I always kind of like, you know, anything that you know, that maybe we didn't hit on that that you'd like to share? Or just you know, again, thanks for your time? 

 

Dr. Venkatesh Ramaiah: 

No, it was great talking to you, Tim. I think I think this is a great opportunity to not only in the Phoenix market, but also across the country, to highlight physicians to highlight the experiences, to see what drives them, to see how they can help the younger generation, especially with the changing situation, healthcare and how healthcare is managed right now. I think these podcasts, these discussions, these conferences, these meetings go a long way to keep people aware of how things have changed, or how things will change in the future. Not only in vascular, but in all of medicine. Thank you. 

 

Tim Ferrriter: Yeah, that's great. That's what we're trying to do with this is to bring experts like you to everybody to listen to so thanks again and we'll see you in the OR. 

 

Dr. Venkatesh Ramaiah: 

Thanks, Tim.

 

Tim Ferriter:

Thanks for listening to the antegrade flow show where we explore ways to improve your health, your practice your business and your life. We do this by looking at how the past shaped us how we are going to advance into the future. While having a pulse on the flow of today. We'll have experts in the field speaking on future podcast, so please join us in future podcasts. Today's show is sponsored by Pax media at www.paxmediainc.com Pax Media takes care of physicians, social media, branding and reputation management, allowing the physician to focus on patient care. Go to www.paxmediainc.com for more information www.paxmediainc.com