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Inaugural Interventional Radiology Day at Charing Cross

Monday, 08 Aug 2005 00:00

The 27th Charing Cross International Symposium began with an inaugural interventional radiology (IR) day, titled 'Interventional Radiology Controversies and Challenges', chaired by Professor Andy Adam of St. Thomas' Hospital, London, UK.

The opening session, IR Horizons, was given by Professor Anders Lunderquist - one of the founders of the IR discipline - who discussed interventional treatment and management of ischaemic stroke in his presentation entitled, 'Quick Cool of the Brain'.

Lunderquist said it was surprising that little had been reported on benefits of hypothermia in treating the debilitating condition. "Hypothermia is the only treatment currently available that can protect the brain from damage in a patient with reperfusion after an occlusion of an artery has been removed," he said. In addition, Lunderquist said that hypothermia when initiated early can reduce or eliminate brain damage in patients resuscitated from cardiac arrest.

He stated that its use had so far been limited as only whole body hypothermia is available in clinical practise. Furthermore, Lunderquist said that the procedure does have limitations, such as the considerable time to prepare ice packs and cooling blankets and to reach the target temperature of 32-33 degrees celcius (one to four hours), which is a vital statistic when every minute is crucial. In addition, he noted that whole body hypothermia can lead to complications such as heart arrhythmia (due to potassium shift), haemorrhages (due to the inactivation of platelets) and pneumonia (during the re-warming period). Despite this, Lunderquist cited two studies, from Europe and Australia, that have shown that hypothermia in patients resuscitated from cardiac arrest had reduced mortality rates.

As a result, Lunderquist investigated if it was possible to use the inherent heat system changed by the body to produce fast and selective hypothermia of the brain. This was achieved through reperfusion through the internal jugular vein in pigs. Blood was aspirated from one femoral vein, passing the blood through a cooling device and back into the internal jugular vein in retrograde direction. Thermometers were placed in both hemispheres of the brain and rectum to monitor temperature.

Within four to five minutes after the perfusion of the blood the target level was reached (32-33 degrees celcius). Continued reperfusion resulted in the temperature of the brain being reduced further, whilst the body temperature remained at almost a normal level. By using body blankets the body temperature could be stabilised or increased if desired. Lunderquist did indicate that the human anatomy has a different heat change system and therefore urged additional research.

In conclusion, Lunderquist said that reperfusion of the internal jugular in humans might cool the arterial inflow to the brain. He suggested that the technique could be included in the interventional management of ischaemic stroke and could also be used in the treatment of patients with cardiac arrest. A clinical study of primates is currently underway to understand the bio-chemical changes and additional process in the brain.

In the following session, 'The Future of Interventional Radiology', Andy Adam discussed the roles of interventional and diagnostic radiology (DR). He began by stating the deficiencies of IR, claiming that interventional radiologists can spend years learning information that is not used in everyday practice and that such skills can vary from hospital to hospital as training is dependant on who is teaching you. Furthermore, Adam argued, there is no formal training in either interventional techniques or equipment. For example, he cited the lack of formal instruction given to highlight the difference between an occlusion balloon and an angioplasty balloon.

Adam said the traditional mantra was that "interventional radiology and diagnostic radiology belong together". Which he interpreted as, "There is no discipline called interventional radiology; it's just a term for a collection of skills used by organ-based diagnostic radiologists to intervene on patients".

He stated that this absence of formal recognition of IR means there is freedom to move laterally within radiology. "One is not an interventional radiologist or diagnostic radiologist, but a radiologist, therefore you can move at will and intervention is optional," Adam said. Radiologists may leave intervention even if appointed as radiologists with an interest in IR, but this makes manpower planning very difficult.

Furthermore, Adam predicted that an increase in numbers of radiologists is not guaranteed to translate into comprehensive provision in organ-based practice in IR, especially "out of hours". The vast majority of hospitals will not be able to afford a diagnostic radiologist for chest intervention, another for GI and another for urology.

Adam believes there are three types of radiologists; those that like practical procedures; those that prefer image interpretation and dislike sharp instruments; and those that are happy to do both. Adam believes that diagnostic radiologists who like intervention should be able to do so, however, they are a small minority and therefore the availability of interventionalists cannot be guaranteed, especially out of hours.

Most interventional radiology has to be practised across a range of organ systems. The workload in most hospitals is insufficient for single-organ specialisation (exceptions: monospecialty hospitals, neuroradiology). However, on the whole most interventional radiologists will practise across a range of organ systems.

Anders Lunderquist
Anders Lunderquist
Johannes Lammer
Johannes Lammer

Furthermore, he claims that the knowledge base required for the interventional radiologists is different than that for the diagnostic radiologist. It is neither possible nor desirable to make interventional work obligatory either during training or during daily consultant practice. Forcing unwilling radiologists to do intervention is wasting valuable diagnostic skills. Therefore, an unwilling interventionist will not be as good as an enthusiastic one and will not engage in research.

Adam suggested that those interested and able to become interventional radiologists should be selected and trained with a "surgical" pattern of knowledge and ensure IR is practised clinically. As a result, sub-specialities should include vascular IR, non-vascular IR and an organ-based IR.

Adam believes that in the future, there should be a common core of knowledge with radiologists, but training should diverge after two years to allow them to learn what they really need to learn, such as instruments, techniques, sedation and analgesia, in order to become clinicians. Adam said this clinical pattern of practice is the key to the future of IR, which should include ward rounds, out-patient clinics and cross-referrals with other clinical disciplines. This would encourage prospective surgical trainees to enter IR, provide consistent services in all major hospitals and assure the future of IR.

However, Professor Dierk Vorwerk, Inglostadt, Germany, argued that diagnostic and interventional radiologists should stick together. He believes that DR is the dominant speciality, demonstrated by the sheer numbers of DR and IR procedures, and therefore IR should remain a part of DR.

Vorwerk agreed with Adam that interventional radiologists need greater education in pain management, minor surgery, emergency treatment, pharmocotherapy and interventional radiology. However, for IR solid expertise is needed in mammography, ultrasound, CT, MRI angiography and DSA. This, Vorwerk said, is because imaging is always the key technology. IR needs to be up-to-date in imaging to use the latest imaging innovations for interventional procedures, as the interventional technique is always based upon the imaging platform. Therefore, if IR and DR were separated, access to the latest technologies would be reduced. IR currently contributes a major part of research in radiology, Vorwerk argued.

Most interventional radiologists in Europe practise their speciality part-time while also doing at least some diagnostic work, as they need to perform imaging in order to survive in their business. If IR is separated, radiologists will go out in favor of DR, meaning expertise will therefore be lost. As a result surgeons, cardiologists and angiologists may move in, not as individuals, but as a discipline, and this - Vorwerk claimed - will be the end of IR. He concluded that there should be speciality training in radiology and that it should be recogised that IR is a sub-discipline.

Professor Manuel Maynar, Las Palmas, Spain, said there should be specific training for the minimally-invasive (endovascular) specialist. He claims that medicine and surgery has always evolved and now was the time to create an endovascular specialist. He claims current training approaches (for the American Radiology Board) involves two years clinical work, two years DR and two years on endovascular training. A similar scheme has been established by the neurological associations. However, Maynar claims this approach is limited due to the narrow perspective based on their original field of training - the training being biased as it is based on the original training.

In addition, there is no mandated recertification of skills. The most common of these approaches is "Fly by night" training - "see one, do one teach one". However, this type of training is heavily dependant on the sales representative for advice during the procedure and the consequences are suffered by the patient. There is also poor reporting of cases and an underutilisation in complex cases. Maynar called for regional, national and global databases to assess institutions and the effectiveness of procedures and devices alike.

Maynar said that if physicians wish to be trained in endovascular techniques, they should apply to a central body who will authorise their application based on their skills and national requirements. In addition applicants should be made to complete a training programme. Such a programme, Manyar agrued should take three years; year one should be based on a general programme of vascular surgery; year two learning should be clinical and endovascular techniques; and year three should be training given in advanced applications (gene therapy, robotics). This should be coupled with CME courses, certification on new and emerging technologies and recertification after five years. These steps, Mayner claimed, would ensure appropriate training, regulation and certification of an endovascular specialist.

Johannes Lammer, Vienna, Austria, proposed the creation of a new IR curriculum, claiming that the current system merely serves to confuse the patient when they consider which physician should treat them (vascular/cardiovascular surgeon or interventional radiologist). Lammer said the interventional radiologist needs to know how to diagnose and treat comorbidities, organise direct referral from family/subspecialities, clinical staff/practise and the time to perform such duties. Lammer stated that such time should not just be spent reading mammographies.

Therefore, Lammer called for the creation of the specialist - the "Interventionalist". Such a specialist could have a background in radiology, surgery or medicine, but receive training in the other core subjects, resulting in the interventionalist who is able to treat vascular and non-vascular diseases.

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