Interventional Radiologists- Where will they go next? Dr Simon Travis MB ChB FRCR Vascular/Interventional Radiologist Nottingham University Hospitals

What is an Interventional Radiologist?

Global Statement Defining Interventional Radiology J Vasc Interv Radiol 2010; 21:1147–1149 1. Expertise in diagnostic imaging and radiation safety. 2. Expertise in image-guided minimally invasive procedures and techniques as applied to multiple diseases and organs. 3. Expertise in the evaluation and management of patients suitable for the image-guided interventions included in the scope of IR practice. 4. Continual invention and innovation of new techniques, devices, and procedures.

History 1964 Angioplasty 1966 Embolization therapy to treat tumors and spinal cord vascular malformations by blocking the blood flow 1967 The Judkins technique of coronary angiography, the technique still most widely used around the world today 1967 Closure of the patent ductus arteriosis, a heart defect in newborns of a vascular opening between the pulmonary artery and the aorta 1967 Selective vasoconstriction infusions for hemorrhage, now commonly used for bleeding ulcers, GI bleeding and arterial bleeding 1969 The catheter-delivered stenting technique and prototype stent 1960-74 Tools for interventions such as heparinized guidewires, contrast injector, disposable catheter needles and see-through film changer 1970’s Percutaneous removal of common bile duct stones 1970’s Occlusive coils 1972 Selective arterial embolization for GI bleeding, which was adapted to treat massive bleeding in other arteries in the body and to block blood supply to tumors

1973 Embolization for pelvic trauma 1974 Selective arterial thrombolysis for arterial occlusions, now used to treat blood clots, stroke, DVT, etc. 1974 Transhepatic embolization for variceal bleeding 1977-78 Embolization technique for pulmonary arteriovenous malformations and varicoceles 1977-83 Bland- and chemo-embolization for treatment of hepatocellular cancer and disseminated liver metastases 1980 Cryoablation to freeze liver tumors 1980 Development of special tools and devices for biliary manipulation 1980’s Biliary stents to allow bile to flow from the liver saving patients from biliary bypass surgery 1981 Embolization technique for spleen trauma 1982 TIPS (transjugular intrahepatic portosystemic shunt) to improve blood flow in damaged livers from conditions such as cirrhosis and hepatitis C 1982 Dilators for interventional urology, percutaneous removal of kidney stones 1983 The balloon-expandable stent (peripheral) used today

1985 Self-expanding stents 1990 Percutaneous extraction of gallbladder stones 1990 Radiofrequency ablation (RFA) technique for liver tumors 1990’s Treatment of bone and kidney tumors by embolization 1990’s RFA for soft tissue tumors, i.e., bone, breast, kidney, lung and liver cancer 1991 Abdominal aortic stent grafts 1994 The balloon-expandable coronary stent used today 1997 Intra-arterial delivery of tumor-killing viruses and gene therapy vectors to the liver 1999 Percutaneous delivery of pancreatic islet cells to the liver for transplantation to treat diabetes 1999 Developed the endovenous laser ablation procedure to treat varicose veins and venous disease

Why Interventional Radiology Shorter Hospital Stays Money Saving Reduction in Transfusion Requirements Better QoL for patients Faster Recovery High Intensity Localised treatments

What’s Our Role in Chronic Care? Vascular Treatment of Ischaemic limbs Diabetic foot ulcers Management of Aneurysms of the Aorta and Visceral vessels Vascular Access Management for Renal Replacement Therapy Varicose Vein Ablation Renal Artery Disease AVM management

Oncology Vascular Access (ports and lines) Image Guided Biopsy Tumour Ablation RF Cryo Microwave Focused U/S Tumour Embolisation with Chemotherapy SVC Stenting for SVCO Portal Vein Embolisation Prior to Hepatic Resection

Gastrointestinal Percutaneous Bile Duct Management Colonic Stenting as a Bridge to Surgery (CREST trial) Oesophageal Stenting Gastrostomy Insertion TIPSS for Ascites Control in Hepatic Cirrhosis

Other Conditions Uterine Fibroid Embolisation for Symptom Relief Vertebroplasty for Pain Relief Tunnelled Pleural and Ascitic Drains

What’s Our Role in Acute Medical Care? Control of Haemorrhage Uterine Postpartum (Health Commission report on Northwick Park) Acute Aneurysm Rupture Acute Aortic Dissection Post Traumatic Vascular and Visceral Injury GI Haemorrhage Acutely Ischaemic Limbs DVT and PE management Emergency Venous Access in Dialysis Patients

What’s New? Renal Artery Denervation for Difficult to Control Hypertension Prostate Embolisation Desolving Stents

Renal Artery Denervation Transarterial Catheter directed RF Ablation of Renal Sympathetic Nerves Good results from proof of principal cohort study (45 patients with drug resistant hypertension)

Prostate Embolisation for BPH Injection of micro particles (100-200 micron) into the prostatic arteries to shrink the organ Promising results in animal and human studies Day case procedure with the potential for a return towards normal micturition with out medication (better QoL and cost saving)

How Will We Affect Health Care in The Future Save Money Reduced Bed stays Reduced Transfusion Requirements More Rapid Patient Recovery More Rapid Return to Normal Life/Work Improve QoL for Patients More Procedures by the month Better Cancer Outcomes

Interventional Radiology Has been recognised as a distinct subspeciality by the Royal Colleges We now have our own training program We have our own syllabus 3 years of Radiology Training followed by 3 years of Interventional Training

Finally

Train Patients to do Their Own Procedures?