Cardiovascular and Interventional Radiological Society of Europe
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ProgrammeTopic highlightsWhy all the different faces of IR should stay and work together

Why all the different faces of IR should stay and work together

We spoke to Dr. Uberoi to learn more about his presentation at CIRSE 2022.

Catch his lecture in the session, “The different sides of an IR.”

Interventional radiology (IR) has become a key specialty, integral to the management of virtually every patient group. During the COVID 19 pandemic, interventional radiology demonstrated its vital role in saving lives and improving outcomes, providing 24/7 onsite services. Interventional radiology has developed rapidly in the last 50 years from being considered a crazy and way-out concept to becoming the leader in cutting edge and innovative treatments. This fledgeling discipline has challenged the medical establishment to rethink how we manage patients, enhancing and, in many instances, replacing established treatments. As IRs, we have developed from within radiology, but have evolved to become radically different from our imaging colleagues. The process of evolution is constant and we need to think about where we are heading and how to shape our future, beginning by first reflecting on where we are now, how we got here and where we need to progress in the future.

 

IR developed from a significant unmet need to treat patients less invasively, more safely and for a broader range of pathologies. In 1923, angiography was first successively used in man, initially requiring a surgical cut-down. Then in 1953, Sven-Ivar Seldinger pioneered the Seldinger technique, which allowed for the first time, major procedures to be undertaken percutaneously [1]. In 1955, Goodwin published the first description of percutaneous nephrostomy [2]. This was followed by Charles Dotter, who undertook the first percutaneous angioplasty for critical ischemia and effectively founded interventional radiology. In 1973, percutaneous angioplasty leapt forward with the emergence of double-lumen balloon catheters leading to percutaneous coronary angioplasty in 1977. Stenting, though proposed in 1969, came of age in the 1990s using metal stents, and more recently, temporary stents, stent-grafts and biological stents increasing the range of pathologies we can treat. Transcatheter embolisation also became a key core IR procedure with the first case in 1965. With improvements in embolic agents and catheter technology IRs could reach and treat a much greater range of diseases, supported by imaging technologies such as higher resolution fluoroscopy, Ultrasound, fast CT and MRI scanning. These technologies established the concept of minimally invasive percutaneous image-guided treatments. In the mid-1970s, Gerard Debrun developed a detachable latex balloon catheter for the treatment of carotid-cavernous fistulae and giant intracavernous aneurysms [3] and the subdiscipline of neuro-intervention was born. In 1990, the invention of the Guglielmi detachable coils by Guido Guglielmi revolutionised the treatment of intracranial aneurysms [4], and this became established as the first-line technique for intracranial aneurysms following the highly successful results of the International Subarachnoid Aneurysm Trial in 2005 [5]. These successes paved the way for an explosion of developments in IR treatments for benign and malignant diseases. Inevitably the increasingly huge range and complexity of these procedures meant IRs have started to branch out into different subdisciplines such as vascular, non-vascular, neuro, venous, urology, paediatric and oncology IR, and this list continues to expand.

 

All these disciplines have a common past but also a shared future and we need to think carefully about how we provide services in the future and the training of the next generation of IRs. The core skills required are the same for all IR subdisciplines. Still, the number of IRs in each discipline can be small, limiting the ability of IRs to provide procedures 24/7, as recently evidenced by the role out of stroke thrombectomy. It is no good being able to provide an excellent service during the day and then for this to become someone else’s problem overnight and weekends. IRs need to take responsibility for delivering these services by working collaboratively and sharing the workload across subdisciplines. When there is a vacuum, other specialities will feel empowered to take over our techniques, picking and choosing the areas they wish to practice. Charles Dotter early on recognised the need to take clinical responsibility with direct access to patients, a message we have failed to heed.  The results of this can be seen, with the loss of coronary angioplasty and, in many countries, endovascular treatments.

 

Although imaging remains at the core of IR, the way IRs utilise imaging has radically changed. Undertaking emergency life-saving procedures, palliative or curative treatments such as tumour ablation, angioplasty, coiling of aneurysms, and stroke thrombectomy require clinical knowledge and skills. These are common to all IR disciplines but fundamentally different from those currently taught in many radiology programs. To achieve the best possible results, IRs have to be skilled technically to deliver interventions effectively and safely, but they also need to play an integral part in the patient’s overall clinical care including patient counselling, selection, post-procedural management and dealing with complications. For IRs to exercise safe and effective clinical care, core skills have to be nurtured during training as for any other clinical specialists [6]. Clinical competency should include exposure to out-patient clinics, ward work, drug management, follow-up, shared responsibility with other specialists, and data collection for national registries within a structured governance practice. With the natural evolution of clinical radiology, IRs in all the subdisciplines have become more akin to imaged guided surgeons with direct clinical responsibility for patients. The training and assessment processes need to reflect this; however, national exams and assessments often focus predominantly on imaging and diagnostic skills.

 

Many countries have already started to change the models for IR training and provision of clinical care [7]. In the US, IR has become a specialty within radiology since 2012 [8]. A white paper has been developed in Australia to consider the creation of an IR specialty with an appropriate curriculum and a similar process is underway in Ireland, Egypt and India. The assessment process took an enormous leap forward with the creation of the European board of interventional radiology examination (EBIR) by CIRSE in 2010. This is now a well-established, internationally recognised examination accrediting IRs. The EBIR has also recently been adopted by the German and Dutch exam boards as part of their assessment or re-accreditation process. Similarly, a national assessment process for IRs has been established in Greece to reflect modern IR training accreditation needs. These are all positive steps and we have a tremendous opportunity to work together across the IR disciplines to shape our future.

 

Raman Uberoi

 

John Radcliff Hospital, Oxford/GB

 

Raman Uberoi is an interventional radiologist consultant for the Oxford University Hospitals. He was the clinical director of John Radcliffe Hospital from 2003 to 2012. He was the president of BSIR from 2015 to 2017 and the Royal Society of Medicine Radiology from 2016 to 2018. Dr. Uberoi is the senior editor for Clinical Radiology, British Journal of Radiology, and the deputy editor of CVIR; he has published over 150 articles. Currently he is the EBIR Curriculum revision chair and EBIR Committee chairperson.

 

References

  1. Rösch J, Keller FS, Kaufman JA. The birth, early years, and future of interventional radiology. J Vasc Interv Radiol 2003; 14: 841–53.
  2. Goodwin WE, Casey WC, Woolf W. Percutaneous trocar (needle) nephrostomy in hydronephrosis. J Am Med Assoc 1955; 157: 891–4. doi: https://doi.org/10.1001/jama. 1955.02950280015005
  3. Debrun G, Lacour P, Caron JP, Hurth M, Comoy J, Keravel Y. Inflatable and released balloon technique experimentation in dog — application in man. Neuroradiology 1975; 9: 267–71.
  4. Guglielmi G. History of endovascular endosaccular occlusion of brain aneurysms: 1965-1990. Interv Neuroradiol 2007; 13: 217–24. doi: https://doi.org/10.1177/ 159101990701300301
  5. Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet 2005; 366: 809–17. doi: https://doi.org/10.1016/S0140- 6736(05)67214-5 12. Campbell BC, Mitchell PJ, Kleinig TJ,
  6. Ahmed K, Keeling AN, Khan RS, Ashrafian H, Arora S, Nagpal K, Burrill J, Darzi A, Athanasiou T, Hamady M. What does competence entail in interventional radiology? Cardiovasc Intervent Radiol. 2010 DOI: 1007/s00270-009-9732-2
  7. Selby JB Jr, Darcy MD, Smith TP, Kaufman JA, Kim HS. Semin Intervent Radiol. 2014.Evolution of a specialty: the case for the association of chiefs of interventional radiology.
  8. Kaufman JA The Interventional Radiology/ Diagnostic Radiology Certificate and Interventional Radiology Residency Radiology: Volume 273: Number 2—November 2014