Anna Maria Belli

How did you come to choose medicine as a career? What drew you to interventional radiology?

I chose medicine by default really. I loved pure sciences but did not think I could make a career of them. Medicine seemed an attractive option which could combine my love of science with a stable career structure. After qualifying, I was working in an ear, nose and throat department when I first came across interventional radiology being used to reduce blood loss during surgery for a juvenile nasal angiofibroma. It seemed such an elegant solution. I was immediately interested.

Which innovations in interventional radiology have shaped your career?

I work in the vascular field and in the Eighties and Nineties there were a lot of innovative technologies being introduced to supplement angioplasty such as arterial stents, atherectomy catheters and lasers. It was a very exciting period and I still find vascular intervention exciting. There is always something new on the horizon.

Who were your mentors in interventional radiology and what do you still remember of their wisdom?

A lot of people had influence on my career, but my main mentors were David Cumberland, David Allison and Mike Dean. They believed in my ability, taught me what they knew and encouraged me. David Cumberland taught me that the enemy of good was perfect and that it is better to stop when you have a good result than to carry on and ruin everything. David Allison taught me to behave as a clinician. Mike Dean gave me the confidence to overcome my diffident nature. He was the person I would phone for advice, and I still do.

Could you describe an early moment in your career in interventional radiology when you were amazed by what the specialty could achieve?

The case that first drew my attention to interventional radiology was such a moment. The clinical team was preparing for surgery and requesting large amounts of blood as this was an operation notorious for massive blood loss. Embolization of the nasal angiofibroma was performed the day before surgery and anticipating heavy blood loss, the surgeons were astounded and relieved that there was virtually no blood loss. Unfortunately I did not see the embolization first hand but attended the meeting where the radiologist showed his embolization and was blown away by his skill.

Can you describe a memorable case and how interventional radiology came to the rescue?

One of my early memorable cases was when I was still a young consultant. A young girl in her twenties had a tonsillectomy at another hospital and bled torrentially. She was transferred to my hospital and the senior vascular and ear, nose and throat surgeons came to request that I perform an embolization as the least invasive option for her. I had never done this and was a little nervous but agreed. It all went extremely smoothly. The procedure was swift and the recovery smooth, and she was discharged from intensive care the next day. The confidence the surgeons showed in my ability and their encouragement made me realise that the best outcome for patients is when we work together using our different training and skills to their advantage, rather than competing with each other.

You have pushed hard to get uterine fibroid embolization accepted by other specialties and indeed, noticed by patients… What were you up against and how did you and others achieve this?

There was initial reluctance on the part of many gynaecologists to accept an intervention that was so different from their current management and offered by a specialty that they did not know very well. Far from needing to be persuaded, it was the patients themselves who drove the changes by demanding that they were given information about all the options available to them and that included embolization. They participated in the discussions and National Institute for Health and Clinical Excellence (NICE) committees of which I was a part. Because of this, a full fibroid service is incomplete without embolization. And gynaecologists have benefited from this collaboration as centres offering the spectrum of services receive more referrals.

You are involved in more than one trial measuring uterine artery embolization versus other uterine-sparing procedures… Could you explain your key findings and what you have learned about the need to fully infarct fibroids with embolization?

The FUME trial is the first randomised trial between uterine artery embolization and abdominal myomectomy aiming for fibroid clearance. Myomectomy and embolization both suffer from the fact that by preserving the uterus, there is potential for fibroid re-growth and recurrence of symptoms. Just as attaining 100% infarction rates should prevent re-growth after embolization, fibroid clearance surgery should reduce the re-intervention rate following myomectomy. We learned that both treatments were effective in achieving a satisfactory symptomatic response, but uterine artery embolization had a shorter hospital stay and a more rapid recovery whilst myomectomy had a smaller re-intervention rate at two year follow-up, although the rate of re-intervention in both groups was lower than reported in the literature.

What questions is the FEMME trial seeking to answer?

The FEMME trial is a UK multicentre, randomised trial comparing all forms of myomectomy, not hysterectomy, with uterine artery embolization i.e. uterine-preserving treatments. The aim is to recruit 400 pre-menopausal women to each arm and to follow them up for five years to assess symptomatic response, complication rates, re-intervention rates, effects on ovarian function and to obtain data on fertility. The question of the effect of uterine artery embolization on fertility is especially important. The results of uterine artery embolization on fertility have been prejudiced by the fact that up until recently, this treatment has been offered to older women whose families have been complete and those actively seeking pregnancy have been excluded unless there were contraindications to surgery.

What are your other current areas of research?

I am interested in the role of drugs with devices and am participating in randomised, controlled trials to compare these technologies with percutaneous transluminal angioplasty. I am also looking at the role of interventional radiology in obstetrics, especially treatments that can prevent haemorrhage.

You have worked in interventional radiology in various parts of the UK. How has the subspecialty grown since the time you first started out?

It has grown beyond all recognition. When I first started, the number of interventional radiologists was so small, that everyone in the UK knew everyone else in the field. The British Society of Interventional Radiology was like a small club. I attended the first meeting in 1988 and there was just a roomful of people. Now it has several hundred UK members. CIRSE is similar. The first meeting I went to took place in a tennis club in Sardinia. Now there are a few thousand members and few venues large enough to hold the annual meeting.

Interventional radiology is a constantly evolving specialty due to new technical developments and cross-fertilization between vascular and non-vascular interventions leading to innovative therapies. Interventional oncology is a perfect and exciting example of this. What developed as a niche subject in diagnostic radiology is now a recognised subspecialty offering cost-effective, life-saving solutions and proving essential to the function of major hospitals and trauma centres.