Why did you decide to opt for medicine?
I really wanted to be a veterinary surgeon and medicine was a distant second. I had the good fortune to live near a veterinary surgeon, when growing up in Ireland, who took me on calls at the weekends to demonstrate what he thought was the terrible lifestyle of a country veterinary surgeon. However, I had been weaned on James Herriot’s All Creatures Great and Small and saw only the romance and excitement of the veterinary lifestyle. The showdown came when I finished my school leaving exams and told my mentor I wanted to be a veterinary surgeon just like him. He was in total shock because he thought he had shown me how terrible his life was with night calls and driving to very poorly prepared farms with little equipment and no help. After a long conversation, he advised me to do dentistry. Having spent some time in the dentist chair as a child, I figured this was not something that I could conceivably spend my life doing. I finally decided to spend some time with the local general practitioner, after which I decided on medicine with the eventual aim of becoming a general practitioner in rural Ireland. Clearly, there was some drift from this course, but once I discovered interventional radiology I was captivated.
Which innovations in interventional radiology have shaped your career?
I think the two most crucial innovations that I still find very rewarding and potentially life-saving for patients are: abscess drainage and embolization.
The idea is that you can drain an abscess percutaneously in a septicaemic patient using image guidance and a small catheter can help save life, particularly in post-operative patients. Similarly, embolizing a bleeding vessel, either in the bronchial artery for haemoptysis, the mesenteric arteries for gastrointestinal bleeding, or solid viscera for trauma, is another life-saving technology. There are many other innovations such as angioplasty, stenting, vertebroplasty, stroke therapy, all of which have made huge contributions to patient care. However, I still derive most pleasure from abscess drainage and embolization.
What do you still remember from your mentors in interventional radiology?
Some of my early mentors were Dr David Legge who taught me how to perform angioplasty and Dr Dennis O’Connell (recently deceased) who showed me how to perform direct carotid puncture with a three-piece Seldinger needle for carotid angiography. The latter, of course, is a thing of the past, but I do remember being in awe of the fact that one could do this without any significant sequela. Dr O’Connell also kick-started my academic career with the idea for my first paper, which was not on an interventional radiology topic, but got me hooked on research and academia. When I moved to Massachusetts General Hospital, Peter Muller, Steve Dawson and Art Waltman were great teachers and I loved the fact that they would take on the most difficult cases and never give up until every avenue was exhausted.
A moment in interventional radiology which took your breath away…
My first connection with radiology, and indeed interventional radiology, was when I was completing a medical residency. One of my surgical resident colleagues asked me if I would like to help on a paper that he was doing on angioplasty. At that stage, angioplasty was in its infancy and I knew little or nothing about the technique. However, I did the research with him on approximately 80 angioplasties and I was amazed at this technique that had such a dramatic benefit for patients in terms of quality of life and limb salvage. At that point, I was hooked.
Which randomised controlled trials have had great impact on the subspecialty recently?
A randomised controlled trial of vertebroplasty versus conservative therapy was reported in 2009 in the New England Journal of Medicine. The trial was significantly flawed in terms of methodology, in that MR was not used as an inclusion criterion and the trial included patients with vertebral body fractures up to a year old. This trial demonstrated no significant difference between vertebroplasty and a sham control arm.
When the study was published, Medicare refused to pay for any further vertebroplasty treatments in the USA and similar outcomes occurred in other countries. This trial illustrates the power of level I evidence in dictating healthcare policy. Later, the results of the NEJM trial were disproved in the VERTOS II and other trials. However, a recent meta-analysis by Staples et al (BMJ 2011), casts a further shadow on the efficacy of vertebroplasty. So, the story is not yet finished and further level I evidence is required.
The use of carotid stenting to treat symptomatic patients with significant internal carotid artery stenosis became popular in the late Nineties. A number of randomised controlled trials were performed comparing carotid stenting with surgical endarterectomy. These include the CAVATAS trial, the SPACE trial, EVA-3S and ICSS trials. The results of these trials appeared to show that surgical endarterectomy is the appropriate treatment for patients with symptomatic carotid disease, unless there is unfavourable anatomy, or the patient refuses surgery. In this case, the rush to adopt new technology and new devices has been significantly dampened by a number of randomised trials. This is entirely appropriate with the introduction of a new technique or procedure. However, the more recent CREST trial (NEJM 2010) showed no significant difference in overall complications between carotid stenting and surgical endarterectomy. Faced with this conflict in the literature, centres will need to decide which is appropriate for their patients based on local factors such as resources, training and skill levels.
It is also gratifying to see that the efficacy of new procedures such as fibroid embolization have been verified by the EMMY, and other trials. I think this is the future for interventional radiology. All new procedures should be verified by level one evidence.
Could you identify three key areas where the need for evidence is particularly loud?
The first that comes to mind is chronic cerebrospinal venous insufficiency (CCSVI). This is seen in some circles as a miraculous discovery for the treatment of patients with multiple sclerosis.
However, the pathophysiology of CCSVI and its mechanism of action are not clear. In my opinion, any intervention for CCSVI should be subjected to rigorous scientific interrogation, just as any other new technique. Another area that has exploded in recent years is the insertion of optional inferior vena cava (IVC) filters. The number of optional IVC filters being placed has risen exponentially across the Western world. The long-term effect of the increase in filter placement remains unknown.
There is now an expanded array of prophylactic indications for filter placement, because of the optional nature of the IVC filters on the market. However, many of these filters are never removed and we do not know the long-term filtration efficacy of these new filters. Level I evidence regarding placement of optional filters for “prophylactic indications” is urgently needed.
The other area that springs to mind is the innovative techniques performed in interventional oncology today. There are so many new techniques that it is difficult to decide, which one to use in a given situation. Comparative randomised controlled trials between the different technologies are well worth exploring to further define appropriate indications for the various techniques on offer.
What are the strengths and weaknesses of interventional radiology?
The main strengths of interventional radiology are its minimally invasive nature, innovation, improvements in image guidance and rapid advancement in the technology of catheters, balloons, stents, embolic material and other devices. A more clinically-based approach to interventional radiology is a must and a major advantage for patients.
The fact that one can treat someone with haemoptysis, critical limb ischaemia, septicaemia from an abscess, jaundice and a patient with poor nutrition, all in the same day is a major testament to the training, skill, dexterity and know-how of interventional radiologists, globally.
This very same diversity is also a perceived weakness in that one cannot be an expert in clinical care in every speciality. However, I believe that clinical care should extend to the periprocedural time and immediate aftercare. I believe that interventional radiology is growing from strength to strength and weaknesses are perceived mainly by those who have an interest in the techniques performed by interventional radiologists.
A case where interventional radiology came to the rescue...
There are many memorable cases, but perhaps the most intriguing was a man in his forties who was knocked down by a double-decker bus outside the front door of our hospital. He was taken immediately to A&E and resuscitated. His blood pressure was 60/20 and he had an ultrasound scan which showed no fluid in the abdomen and plain X-rays which showed a completely shattered pelvis. The wheel of the bus in fact, had run over his pelvis. Attempts to control the bleeding in the pelvis with compression binding were unsuccessful. We were called to theatre to embolize the internal iliac arteries. Both internal iliac arteries were embolized within approximately 15 minutes. His blood pressure immediately came up to 90/60 and he stabilised and made an eventual good recovery. This is a good example of how embolization can be a life-saving procedure in these types of patients. This case illustrates what I have believed for some time; No level 4 hospital can deliver high level medical care without a strong interventional radiology service.
What honours do you look back on with pride?
I have given a number of eponymous lectures for various societies, which is always an honour, but perhaps the most significant honour to date is being elected the president of CIRSE (2011–2012). It is very humbling to receive the support of my colleagues and peers throughout my tenure on the CIRSE Executive Committee and CIRSE Board.
What are your current research interests?
Currently, we are performing research on inflammatory markers in peripheral vascular intervention, pedal angioplasty, subintimal angioplasty and optional filter retrieval.
What do you hope to achieve in your term as president of CIRSE?
CIRSE now plays a leadership role in interventional radiology in Europe.
It is a society that started out as an educational society but has assumed this leadership role over the last eight to 10 years. The establishment of the permanent office in Vienna coincided with an increase in the quality of the annual meeting. The globalisation of interventional radiology has given CIRSE a very powerful role. There are a number of important issues that I would like to address during my term as president. These include:
- Undergraduate teaching of interventional radiology at medical schools throughout Europe.
- In the interest of patient safety, the introduction of an interventional radiology checklist.
- The introduction of a syllabus and curiculum for interventional radiology training and a further rollout of the European Boards in Interventional Radiology (EBIR) to different countries in Europe, in languages other than English.
What new techniques/technologies are you keeping an eye on?
There are some exciting new therapies and techniques coming on stream.
Currently, renal denervation for patients with poorly controlled hypertension is a very exciting technology. It is delivered percutaneouly and fits very well into the practice of interventional radiology. There is some promising research that has been published and I am awaiting further developments.
Another exciting development in peripheral vascular intervention is that of pedal angioplasty. This has been made possible by micro guidewires and small profile balloon catheters. This is an exciting and potentially limb-saving procedure for patients with diabetic foot. Lastly, the whole area of stroke therapy has changed dramatically in the last number of years. Interventional radiology and interventional neuroradiology currently play, and will continue to play, an active role in this area.
What are your interests outside of medicine?
My main interests outside of interventional radiology are family, cycling, golf and boating, reading and music. I have a very busy home life being married to an artist and we have four children, three of whom are in college.
I did play competitive soccer until the age of 42, when creaking knees forced me to retire. It took me some time to find an alternative sport but finally, I chanced on cycling and am now a keen cyclist completing many cycling sportives during the summer. The longest sportive was a recent 180km cycle in Southern Ireland finished in a cycling time of six and a half hours. I play golf occasionally and inconsistently, but I like the idea of competing against oneself, the elements and the course. I love to be on the water and I have a small boat which I use to cruise in inland waterways and the Irish Sea. Being on the sea is one of the most relaxing ways to spend time that I know.
I read avidly and listen to music constantly. I did play guitar for many years and would like to go back to guitar in the next few years.
Consultant radiologist, Beaumont Hospital, Dublin Professor of Radiology, Royal College of Surgeons in Ireland
Assistant in Radiology, Division of Abdominal Imaging and Intervention and assistant director of Ultrasound, Department of Radiology, Massachusetts General Hospital, Boston and Assistant professor, Harvard Medical School, Boston, Massachusetts
July 1982 Primary Medical Degree, University College Dublin, Ireland, MB, BCh, BAO
June 1989 MSc in Radiological Sciences obtained from University College Dublin, Ireland
Dec 1994 Certificate of Professional Achievement for Executive Development Course, Massachusetts General Hospital, Boston, USA
Awards and distinctions
1992 Cum Laude for poster presentation entitled: “Fluorodeoxyglucose PET Applications in the Abdomen and Pelvis: Potential Role in Oncologic Imaging”. Presented at the 78th scientific assembly of the RSNA.
1993 Certificate of Merit for poster presentation entitled: “Endoscopic Ultrasound of the GI tract”. Presented at the 95th scientific assembly of the ARRS, Washington DC, 1995
1997 Beaumont Hospital Sheppard Prize for “Magnetic resonance cholangiography with a local coil:technique, results and implications for clinical practice.”
Membership of societies (selected)
Member American Roentgen Ray Society
Member Royal College of Radiologists
Member Society for Minimally Invasive Therapy
Member Radiological Society of North America
Member Cardiovascular and Interventional Radiological Society of Europe
Member Society of Cardiovascular and Interventional Radiology (USA)
Member British Society of Interventional Radiology
Member Irish Radiological Society
Member and first president of Irish Society of Interventional Radiology
Member European Society of Gastrointestinal and Abdominal Radiology
Member European Society of Uroradiology
Member Society of Gastrointestinal Radiologists (USA)