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From bathing moose to water pump pliers: Extreme IR is back 

29 days ago

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SIR TODAY 2023 | Tuesday, Jan. 10

As reliable as death and taxes, the Extreme IR session is back for SIR 2023, on Saturday, March 4, 1–5 p.m.. Over the course of 4 hours, attendees can experience the great successes, failures and ingenuity of IR at the ever-popular session.

SIR Today spoke with Ziv J Haskal, MD, FSIR, who is co-moderating the session once more with Michael D. Dake, MD, FSIR, to find out what thrills, surprises and lessons attendees can expect this year. Watch for another article in a future edition of SIR Today, in which Dr. Haskal describes his inspirations as a 2023 Gold Medal recipient.

Extreme IR has been an immensely popular session over the years. How and when did it get started?

Ziv J Haskal, MD, FSIR

Ziv J Haskal, MD, FSIR: I conceived of the course in the late ’90s and coined the name to combine the spirit of IR with that of extreme sports. The first Extreme IR was held in the Grand Teton National Park and was half lectures, half activities like rock climbing, rafting, etc. The main event, the “Hike to CME,” was a full-day, 15-mile, 2,400-foot hike to Lake Solitude where a few hardier members would jump into the frozen water. The lecture was given on the trail, overlooking Cascade Canyon, a river and a bathing moose.

Since then, it has morphed into an annual SIR annual meeting event (sans moose), and I gradually tightened it into the rapid-fire case-based format and dynamic dialogue that attracts so many people every year. At times, the circumstances of the procedure were extreme, not the case itself. Overall, though, we celebrate successes and extraordinary work, as well as the courage and character of those who bring terrifying complications that teach us all.


Why do you feel it’s important to share those complication stories?

ZH: My mentor used to tell me that just because it happened, doesn’t mean you have to take a picture of it. Everyone finds that line very funny, but I disagree with its sentiment. If something unexpected happens, I always take a picture of it and I seek occasions to share or teach from it. So often, when you ask an audience how many others have experienced a similar, potentially devastating complication, it’s stunning to see how many people will raise their hands or come forward speak about it later.

The truth is that so many of us are practicing alone and may not have partners to talk to about these things. And that severe complication can be dispiriting, crushing or debilitating. Sharing these in such fora hopefully preps us the risks, and even potential lethality intrinsic to our daily work, and prevents tunnel vision in the moment.

During Extreme IR when we present these cases, I always make a point of asking what we’ve learned from the case. What should we avoid, what things do we take for granted? How do we discuss this better and better prepare ourselves and our patients in case a simple procedure turns extreme? IR is not ‘simple’, risk free, easy things. It’s our job to make complexity look simple, but we have to be mentally prepared and planning for variability, the unexpected, and worse.


Why do you feel the session is so popular?

ZH: It’s the quality of the cases, the diversity of the presenters, the dynamic format, the spontaneous dialogue, the rapport that my co-moderator Mike Dake and I have, and the frank drama of the event. It’s meaningful, but fun. The content is curated over months of preparation, but the event is unscripted. We know what we have, we’ve seen every slide, but we set no order to the cases, nor what we’ll say or do.

But ultimately, it’s about the dynamic and vanguard aspects that pushed us all into this amazing specialty. We all want to see that half-court shot swish or see how the 2-minute rally turns the game.


How are cases selected?

ZH: The cases are all curated. I reach out to individuals I know and ask them to send me lists of potential cases. In parallel, I reach out through social media, conferences and other events, to individuals I don’t know or barely know, and ask them to send me lists of cases. I hand out secret invitations sealed in wax and accept crypto. Then I make a stone soup from the content.

Currently, we have about 10 open slots left for cases and we’re looking to fill them with individuals who haven’t been involved in the session before. If you have a case you think might make a great addition, there’s still time to reach out to me at  


What’s planned for this year’s program?

ZH: Who knows? Note the title: The Sirens Are Calling. It’s a reference both to ambulances, and to those creatures that enticed sailors onto the rocks with their alluring voices. There are always surprises. But there will be a lot of content—likely around 40 cases—and plenty of heavy hitters presenting, alongside some new faces. There are few pleasures greater than highlighting rising stars and students making their first-ever scientific presentations. As the master of ceremonies, it’s my role to make them shine. It quietly honors those mentors who did the same for me, in my younger days


Part of what makes the program appealing is that it can be a bit unpredictable at times. Does that pose any particular challenges in planning?

ZH: Always, and that uncertainty is what makes it tricky for Mike and me—and exciting for the audience. The order of presenters is made on the fly, based on what suits us at the moment, designed to ensure the best possible experience for attendees. The audience knows something magical is going to happen, and then we wait for it. In the past, the magic moment has been a dumbstruck room watching the last-ditch use of wiped down water pump pliers to extract an embedded broken vertebroplasty cannula, or listening to a presenter dial-in from Riyadh. Ultimately, they get this tribal sense that they belong to this incredibly exciting community—and that sense is part of why they’re there, in IR and at the SIR annual meeting.


Although you completed your term as JVIR Editor in Chief in 2020, I understand you've continued your editorial work with a forthcoming book on extreme IR. Can you share any details about that publication at this point?

ZH: The book will be out soon—it’s in production: Extreme IR. 101 extraordinary cases. The ultimate IR endovascular coffee table book.


Still planning out your meeting highlights? Be sure to mark your calendars for Extreme IR!

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