What, Exactly, Is an Interventional Radiologist?
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During my training as an interventional radiologist, my family, patients and colleagues in other specialties would ask me exactly what it was that I did. Only after training another six years after medical school, I’ve come to realize that the answer is far more complex than the question would imply.
In the simplest of terms, interventional radiologists use cutting-edge imaging equipment to perform minimally invasive procedures. We are part radiologist because we must interpret imaging studies like X-ray, computed tomography (CT) and ultrasound to diagnose abnormalities inside patients. But we are also part surgeon (or more aptly coined “interventionalists”), as we use this imaging to guide a combination of needles, wires and catheters to treat these abnormalities. While this explanation provides insight into how our specialty works, it still doesn’t answer what it is that we do... | ||||||||||||
How I Finally Decided on the Right Specialty for Me
Stephanie K. Nguyen
March 08, 2018
Stephanie K. Nguyen
March 08, 2018
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About this time last year, I wrote a piece about what to consider when choosing a specialty. Now that I've gone through most of the core clerkships, I have a better idea of what my interests are and the aspects of my future career that I want to prioritize. After many, many long hours of careful consideration, I've chosen interventional radiology.
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Women in IR
M. Victoria Marx, MD, FSIR
2018-2019 President, Society of Interventional Radiology
M. Victoria Marx, MD, FSIR
2018-2019 President, Society of Interventional Radiology
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Frequently Asked Questions
INTERVENTIONAL RADIOLOGY
What is the typical day in IR?
Interventional radiologists usually arrive at the hospital between 7 and 8 am. They round on inpatients and review the day’s scheduled procedures before the first case. The workday primarily consists of performing procedures in an angiography suite using x-ray guidance. Some procedures are done with CT guidance or using ultrasound only. In private practice the average interventional radiologist will perform about a dozen cases in a day. The workday runs until 5 or 6 pm. In between cases interventional radiologists will dictate procedure (postop) notes, perform inpatient consultations, and sometimes also read diagnostic films (x-rays, CT scans, MRI scans, etc.).
Clinic schedules vary by practice. Most practices have ½ to 1 day of traditional clinic hours scheduled per week. Additionally, interventional radiologists sometimes have clinic visits scheduled in between procedures. Overall, the ratio of procedure or operating time to clinic time is greater in IR than in most surgical fields.
What do interventional radiologists see in clinic?
Just like surgeons, interventional radiologists see patients for pre-procedure consultations and post-procedure follow-ups. The spectrum of diseases treated by IR is extremely broad – everything from cancer to vascular malformations to peripheral arterial disease.
What is IR call like?
Call frequency is proportional to the size of your group. The more partners you work with, the fewer call nights you will take each month. Groups can range from just two physicians to over a dozen interventional radiologists. All interventional radiologists, including residents and fellows, take home call.
Interventional radiology plays a critical role in managing very sick patients on call. Urgent or emergent cases can include acute bleeding (gastrointestinal bleeding, hemoptysis, trauma), drain placement (acute cholecystitis, obstructed kidney, abscesses), and stroke therapy among many others.
Are there “turf battles” with other specialties?
In short, the answer is yes. But this is not unique to interventional radiology. There are turf battles between otolaryngologists, plastic surgeons, ophthalmologists (oculoplastics) and oral and maxillofacial surgeons when it comes to cosmetic surgery. Both neurosurgeons and orthopaedic surgeons compete for spine surgery cases. What is the common theme in all these examples? The procedures are interesting and lucrative.
Interventional radiologists occasionally have turf battles with vascular surgeons over the management of peripheral arterial disease. Once in a while you may even hear a cantankerous surgeon say: “You shouldn’t do endovascular interventions if you can’t perform open surgery.” I often counter that if this were the case, then there would be no interventional cardiology (cardiothoracic surgeons would be doing heart catheterizations), and gastroenterologists wouldn’t be performing endoscopy (colorectal surgeons would be doing all the colonoscopies). Besides… interventional radiology INVENTED these procedures!
Interventional radiologists usually arrive at the hospital between 7 and 8 am. They round on inpatients and review the day’s scheduled procedures before the first case. The workday primarily consists of performing procedures in an angiography suite using x-ray guidance. Some procedures are done with CT guidance or using ultrasound only. In private practice the average interventional radiologist will perform about a dozen cases in a day. The workday runs until 5 or 6 pm. In between cases interventional radiologists will dictate procedure (postop) notes, perform inpatient consultations, and sometimes also read diagnostic films (x-rays, CT scans, MRI scans, etc.).
Clinic schedules vary by practice. Most practices have ½ to 1 day of traditional clinic hours scheduled per week. Additionally, interventional radiologists sometimes have clinic visits scheduled in between procedures. Overall, the ratio of procedure or operating time to clinic time is greater in IR than in most surgical fields.
What do interventional radiologists see in clinic?
Just like surgeons, interventional radiologists see patients for pre-procedure consultations and post-procedure follow-ups. The spectrum of diseases treated by IR is extremely broad – everything from cancer to vascular malformations to peripheral arterial disease.
What is IR call like?
Call frequency is proportional to the size of your group. The more partners you work with, the fewer call nights you will take each month. Groups can range from just two physicians to over a dozen interventional radiologists. All interventional radiologists, including residents and fellows, take home call.
Interventional radiology plays a critical role in managing very sick patients on call. Urgent or emergent cases can include acute bleeding (gastrointestinal bleeding, hemoptysis, trauma), drain placement (acute cholecystitis, obstructed kidney, abscesses), and stroke therapy among many others.
Are there “turf battles” with other specialties?
In short, the answer is yes. But this is not unique to interventional radiology. There are turf battles between otolaryngologists, plastic surgeons, ophthalmologists (oculoplastics) and oral and maxillofacial surgeons when it comes to cosmetic surgery. Both neurosurgeons and orthopaedic surgeons compete for spine surgery cases. What is the common theme in all these examples? The procedures are interesting and lucrative.
Interventional radiologists occasionally have turf battles with vascular surgeons over the management of peripheral arterial disease. Once in a while you may even hear a cantankerous surgeon say: “You shouldn’t do endovascular interventions if you can’t perform open surgery.” I often counter that if this were the case, then there would be no interventional cardiology (cardiothoracic surgeons would be doing heart catheterizations), and gastroenterologists wouldn’t be performing endoscopy (colorectal surgeons would be doing all the colonoscopies). Besides… interventional radiology INVENTED these procedures!
DIAGNOSTIC RADIOLOGY
For students who are procedurally inclined, the idea of dedicating half your residency to mastering diagnostic radiology as part of an IR/DR residency can seem unappealing at first. There are a few common misconceptions that contribute to this:
“I don’t think I can work in a dark room all day”
There’s no denying that as a medical student, diagnostic radiology is not a particularly fun rotation. You sit in a dark room looking over the shoulder of someone who is scrolling through CT images at a mile a minute pace. It’s easy to imagine getting bored. But nothing could be further from the truth.
The analogy I like to give is that it’s not much fun to watch someone else play a video game - especially when you're not familiar with the objectives of the game. It is infinitely more fun to read a study and be in control of the mouse than to watch someone else do it. Once you train your eyes and mind to read a CT study, you simply see things that non-radiologists cannot, and the work becomes immensely fascinating.
And if you worry you may fall asleep working in the dark, just ask yourself how often you fall asleep waching a movie at a movie theater.
“I don’t think I can do without patient contact”
Diagnostic radiologists certainly don’t have the degree of patient interaction that a family practitioner does, but, at the same time, they aren’t in total isolation. For example, diagnostic radiologists interact with patients in mammography – counseling them and performing diagnostic procedures. Musculoskeletal radiologists perform arthrograms prior to interpreting MRI scans of the joints. And, of course, interventional radiologists have extensive patient contact just like any surgeon, cardiologist, etc.
Another oft-overlooked aspect of diagnostic radiology is that you are able to impact the care of more patients than most other clinicians. An emergency medicine physician may see 20 patients during a 10 hour shift. During that same period, a diagnostic radiologist will have read imaging studies on 80 different patients. They will have seen the same pathology and impacted the care of as many patients as four emergency medicine physicians combined!
Many students interested in IR also consider procedurally-oriented medicine subspecialties like cardiology or gastroenterology. If you find that you are fascinated by all of these specialties, consider asking yourself what skill sets you want to master:
“I don’t think I can work in a dark room all day”
There’s no denying that as a medical student, diagnostic radiology is not a particularly fun rotation. You sit in a dark room looking over the shoulder of someone who is scrolling through CT images at a mile a minute pace. It’s easy to imagine getting bored. But nothing could be further from the truth.
The analogy I like to give is that it’s not much fun to watch someone else play a video game - especially when you're not familiar with the objectives of the game. It is infinitely more fun to read a study and be in control of the mouse than to watch someone else do it. Once you train your eyes and mind to read a CT study, you simply see things that non-radiologists cannot, and the work becomes immensely fascinating.
And if you worry you may fall asleep working in the dark, just ask yourself how often you fall asleep waching a movie at a movie theater.
“I don’t think I can do without patient contact”
Diagnostic radiologists certainly don’t have the degree of patient interaction that a family practitioner does, but, at the same time, they aren’t in total isolation. For example, diagnostic radiologists interact with patients in mammography – counseling them and performing diagnostic procedures. Musculoskeletal radiologists perform arthrograms prior to interpreting MRI scans of the joints. And, of course, interventional radiologists have extensive patient contact just like any surgeon, cardiologist, etc.
Another oft-overlooked aspect of diagnostic radiology is that you are able to impact the care of more patients than most other clinicians. An emergency medicine physician may see 20 patients during a 10 hour shift. During that same period, a diagnostic radiologist will have read imaging studies on 80 different patients. They will have seen the same pathology and impacted the care of as many patients as four emergency medicine physicians combined!
Many students interested in IR also consider procedurally-oriented medicine subspecialties like cardiology or gastroenterology. If you find that you are fascinated by all of these specialties, consider asking yourself what skill sets you want to master:
Would you prefer to achieve mastery of primary care (internal medicine) en route to becoming a cardiologist or gastroenterologist?
OR
Would you rather achieve mastery of all imaging modalities (x-ray, CT, ultrasound, MRI, nuclear medicine) en route to becoming an interventional radiologist?
OR
Would you rather achieve mastery of all imaging modalities (x-ray, CT, ultrasound, MRI, nuclear medicine) en route to becoming an interventional radiologist?
IR/DR Residency
APPLICATION ADVICE
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How competitive is IR?
IR was the most competitive residency in the 2017 Match. What do program directors look for? Because it can be difficult to compare transcripts from different medical schools, many program directors place considerable emphasis on USMLE Step scores. Medical school transcripts are scrutinized, though greater emphasis is usually placed on performance during 3rd year clinical clerkships. A strong research background can also help students stand out. What board scores are necessary to secure an IR/DR residency position? Data for Step 1 scores for IR/DR residency are not available yet, but we can use diagnostic radiology data as a baseline. The mean Step 1 score of US Matched Applicants is 240. Step 2 scores can help an applicant if they are substantially higher than the Step 1 score. The mean Step 2 CK score of US Matched Applicants in diagnostic radiology is 245. Is research important? Research that leads to peer-reviewed publications or presentations demonstrates that a candidate understands the scientific method, and has experience in compiling data and synthesizing it into a clinically meaningful conclusion. Additionally, research that is relevant to radiology and/or interventional radiology demonstrates a genuine interest and commitment to the specialty. US seniors who matched into diagnostic radiology have an average of 2.8 research experiences and 3.9 publications. Should applicants do away rotations? Away rotations can be a great opportunity to audition for a program that you are really interested in. But you must be prepared to perform at your best. |
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AMSER Guide to Applying for Radiology Residency
Version 8 - June 2017 |
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Text-In Questions
Below are answers to questions texted in during the most recent symposium
GENERAL IR
Is it possible to perforate or puncture vessels when doing procedures?
Absolutely. Vessel injury is a risk with any procedure - even nonvascular procedures. Catheter and wire skill development is a part of IR training. Equally important is being able to see subtle vessel injuries on imaging during procedures. This is one example where diagnostic radiology training gives IRs a distinct advantage over other specialists in performing endovascular procedures.
For cholecystostomy tube placement - is the liver routinely pierced en route to the lumen of the gallbladder?
Cholecystostomy tubes can be placed directly into the gallbladder or through the liver parenchyma (transhepatic). Many prefer the transhepatic route because it poses a lower risk of bile peritonitis should the catheter become dislodged. A path through the liver parenchyma also "anchors" the tube better.
Do IRs ever prescribe medications that require regular follow-up (i.e. long-term anticoagulation)? Who follows these patients? IRs? Internal med?
IRs commonly prescribe medications after procedures. Anticoagulation may be the most common type of prescribed medication. Often IRs will collaborate with primary care physicians in managing anticoagulation after procedures like venous thrombectomy, IVC filter placement or peripheral arterial interventions.
How can IR assist patients who are unable to have contrast studies?
Patients with contrast allergies can be premedicated with steroids prior to their IR procedure. For patients with poor renal function, CO2 can be used instead of typical iodinated contrast agents.
STENTS
Do these coils/stents last forever? Do clots / infections develop on them?
No medical device is guaranteed to last forever - whether it’s a hip replacement or a pacemaker. Having said that, the long term efficacy of coils is quite high. If appropriately placed, coils will induce immediate vessel occlusion by thrombosis. Over time, they will cause a chronic inflammatory response with fibrosis. Stent patency, on the other hand, is quite variable. It depends on the type of stent, location placed, disease being treated, etc. Bare metal (uncovered) stents rarely become infected, but it is possible. Covered stents (or stent-grafts) are more prone to infection, though the rate is also quite variable and based on multiple factors.
I've heard that some stents are made of plastic material that get incorporated into the vascular wall. Do these offer any advantages over more traditional stents?
Bare metal stents become incorporated into vessel walls through a process called neointimal hyperplasia. Over time neointimal hyperplasia can cause narrowing of the vessel lumen, or there can be progression of the underlying disease (e.g., atherosclerosis). Covered stents, which are typically comprised of a nitinol mesh that is covered with PTFE material, are touted as preventing tissue ingrowth into the vessel lumen. Which type of stent is better really depends on many factors including the underlying disease and vessel location. Even then, it’s a topic of debate.
Bioabsorbable stents are a hot topic in stent research. Traditional metal stents (both bare and covered) are associated with thrombosis and oftentimes require long-term antiplatelet therapy. The metal in the stents can also affect subsequent imaging (CT or MRI). Additionally, the stents may interfere with, and in some cases preclude, future surgical options. Bioaborbable stents would theoretically avoid all of these limitations. I suspect that this technology may start to become available around the time that many of you begin your IR training.
EMBOLIZATION
When would you use embolization materials vs cauterization?
Cauterization is typically used during surgery to control bleeding. A surgeon must directly visualize a bleeding vessel in order to cauterize it. Embolization is used to control bleeding without surgery.
How do you choose embolization options. When would you use particles vs beads vs coils?
The pathology being treated usually dictates what embolic agent to use. Beads and particles are essentially the same thing, and are used when the target vessel is small and tissue ischemia is desired. For example, when treating tumors or uterine fibroids. Coils are used when treating larger vessels and to avoid vessel ischemia. For example, when treating a gastrointestinal bleed, we are aiming to plug up the injured vessel only. If one were to inject particles, it would cause ischemia of the bowel.
What platelet level required for effective coil embolization?
A platelet count greater than 50,000/mcl is ideal.
What types of complications are associated with embolization? How frequently do they occur?
Nontarget embolization is the primary complication associated with embolization. This is a very rare complication in the hands of an experienced interventional radiologist. Embolization of unintended vessels can cause ischemia, abscess, or even organ failure depending on what vessels are involved. Vessel injury (dissection, perforation, etc.) in the process of accessing a vessel during embolization is another complication that can occur.
What can you do in the event of a misplaced embolization?
Nontarget embolization is the term used to describe when embolic agents are deposited outside the intended location. Sometimes coils can retrieved with snares. There is nothing that can be done to "undo" embolization if particles or glue is injected into nontarget vessels.
Wouldn't UFE embo cause infertility?
There is a risk of premature menopause with UFE. This risk is between 1-10% with women over 45 years of age at greatest risk. UFE is not recommended for women who desire future pregnancy, though in some rare circumstances, it may be the best option if the patient is not a surgical candidate for myomectomy.
INTERVENTIONAL ONCOLOGY
What types of cancer can chemoembolization be used on? Can it be used on early stage lymphoma?
Chemoembolization is commonly used for primary and metastatic liver cancers (e.g., hepatocellular carcinoma, cholangiocarcinoma, metastatic colorectal cancer, metastatic neuroendocrine tumors, etc.). It is not an established treatment for lymphoma.
RE: interventional oncology When using cryoablation, is the extreme cold localized to the tips of the needles where the ice ball forms? Or do you need to worry about coldness ascending more distally on the needle and harming adjacent tissue?
The iceball forms only at the tip of the needle. The remainder of the needle shaft is not affected.
Are there different instances when you would use chemoembolization vs radioembolization for liver cancers or are they interchangeable and simply institution specific?
The optimal indications for chemoembolization versus radioembolization are still being investigated and debated. Protocols vary by institution.
NEURO-IR
Is the neurointerventional radiology training tract going to change with the new IR residency? What are the current training routes?
The new IR/DR residency will not affect the neurointerventional radiology training pathway. There are currently three different pathways to become a neurointerventional radiologist. You must complete one of three residency programs: radiology, neurosurgery or neurology. If you complete a radiology residency program, you typically need to complete a diagnostic neuroradiology fellowship (1 year) and then an additional fellowship in interventional neuroradiology (1-2 years).
tPA has a relatively short window of time wherein it can be administered. Does neurointerventional clot removal extend this timeframe? Can it be used in patients who wake up with stroke symptoms after being in bed all night?
Mechanical thrombectomy does not extend the recommended time window for intravenous tPA. Mechanical thrombectomy is recommended for an ischemic stroke with large vessel occlusion. In cases of “wake up stroke”, in general, no active intervention is indicated. However, its decision should be very carefully made by an expert team of acute stroke specialists based on clinical circumstances and advanced imaging findings.
FUTURE OF IR
Looking at the history info sheet, the last date listed was 1999. Have there been any major advances since then?
There have been tremendous advances this century. Interventional oncology has been at the forefront in the 2000s. We have seen the advent of radioembolization (Y-90), drug-eluting beads for chemoembolization, and microwave ablation. There is work on MRI-guided high-intensity focused ultrasound therapies for fibroids - and potentially for other tumors. There is significant ongoing work to perfect prostate artery embolization and early investigations into bariatric embolization as well. As noted above, bioabsorbable stents are also on the horizon.
Are there any major challenges or lags in technology that are currently keeping the field of IR from progressing more rapidly?
There is not another field in all of medicine that is progressing as rapidly as IR. Period.
Does IR currently involve regenerative medicine procedures? (For example, stem cell transplants or therapy)
Patients are often referred to IR for central line placement prior to stem cell harvesting or infusion (e.g., for treatment of leukemia). IRs are also involved in islet cell transplantation. Once the pancreas has been harvested and the islet cells are isolated, an interventional radiologist will access the portal venous system to transplant the islet cells.
IR TRAINING & CAREER
What is the best pathway for peds IR? IR first then peds? Or peds first then IR?
Peds first, then IR. The diagnostic skills learned in a pediatric fellowship will serve as a foundation for the procedural skills you will learn in IR. Additionally, you don’t want to have a 1 year hiatus between the time you acquire your procedural skills and you begin your pediatric IR practice.
Did any programs participate in the IR match this year? Do you know how competitive (e.g. board scores, # applicants) the match was?There were only 7 IR/DR programs that participated in the 2016 Match, so it’s important to remember that the sample size is small. But there were 135 applicants for 15 positions. Early projections of the 2017 Match suggest that the ratio of applicants to positions may be 3:1.
What's the outlook for robotic IR? Do you think it will be a threat regarding future jobs?
Robotic IR is in it’s infancy. Only a few institutions around the country have even used the equipment. It may prove useful for complex cases with difficult anatomy. I do not see it being a threat to jobs. Remember that, just like with robotic surgery, the robot is just another tool for interventional radiologists to use. They don’t replace the physician.
Can you talk about the lifestyle? Busier than surgeons/comparable?
The lifestyle of an interventional radiologist is probably most comparable to a surgical subspecialist (e.g., urologist or otolaryngologist). Additional information regarding the day-to-day schedule of an IR can be found in the FAQ section above.
I've seen very different IR practice styles. Some are very clinical with in-patient admitting privileges/clinics and others are not. How fast is this change to practicing clinically occurring? When will this be widely adopted?
There has certainly been a change in the practice of IR over the last decade. The old way of doing things was to follow the diagnostic radiology model. That is, passively waiting for procedures to be requested by referring physicians - much like you would a CT or MRI. This is no longer the case. All current IR fellowships and future IR/DR residencies are required to have clinic as well as admitting privileges. Private groups around the country have been adopting this model as well. I would expect that within the next few years the old model will be completely phased out in private practice.
How many hours a week do IR specialists work in academic centers?
Academic IRs work approximately 50 hours per week. Most academic IRs dedicate 5-10 hours per week to academic work including research, resident/fellow teaching, lectures, etc.
It seems that IR performs a vast variety of procedures. In everyday practice, what kind of variety can an individual IR doc expect to see? (Do many specialize to specific areas or do fellowships?)
There is tremendous variety in IR no matter what practice setting you are in. In any given day you can treat patients with renal failure (fistula/graft interventions), cancer (interventional oncology), gastrointestinal pathology (transjugular liver biopsies, TIPS), etc.
IR is itself currently a fellowship of diagnostic radiology. Most interventional radiologists perform the full spectrum of IR procedures, though in some larger IR practices and in academic centers some IRs have their niche areas of expertise. Once the interventional radiology residency system is in place, we may very well see superspecialty fellowships in interventional oncology, vascular disease, etc.
Would going the direct IR pathway hinder me in the slightest from being able to work primarily as DR if I changed my mind or needed a change of pace? I hear at a lot of academic programs, IR does mostly IR. How do you keep fresh in DR work?
If you complete an IR/DR residency you will be board certified to practice both diagnostic radiology and interventional radiology. So there will be no hindrance from a board certification perspective. It’s not uncommon to see older interventional radiologists cut back on procedures and practice more diagnostic radiology. It’s no different from an interventional cardiologist who no longer wants to take STEMI call and would rather spend their entire day in clinic.
Is it possible to perforate or puncture vessels when doing procedures?
Absolutely. Vessel injury is a risk with any procedure - even nonvascular procedures. Catheter and wire skill development is a part of IR training. Equally important is being able to see subtle vessel injuries on imaging during procedures. This is one example where diagnostic radiology training gives IRs a distinct advantage over other specialists in performing endovascular procedures.
For cholecystostomy tube placement - is the liver routinely pierced en route to the lumen of the gallbladder?
Cholecystostomy tubes can be placed directly into the gallbladder or through the liver parenchyma (transhepatic). Many prefer the transhepatic route because it poses a lower risk of bile peritonitis should the catheter become dislodged. A path through the liver parenchyma also "anchors" the tube better.
Do IRs ever prescribe medications that require regular follow-up (i.e. long-term anticoagulation)? Who follows these patients? IRs? Internal med?
IRs commonly prescribe medications after procedures. Anticoagulation may be the most common type of prescribed medication. Often IRs will collaborate with primary care physicians in managing anticoagulation after procedures like venous thrombectomy, IVC filter placement or peripheral arterial interventions.
How can IR assist patients who are unable to have contrast studies?
Patients with contrast allergies can be premedicated with steroids prior to their IR procedure. For patients with poor renal function, CO2 can be used instead of typical iodinated contrast agents.
STENTS
Do these coils/stents last forever? Do clots / infections develop on them?
No medical device is guaranteed to last forever - whether it’s a hip replacement or a pacemaker. Having said that, the long term efficacy of coils is quite high. If appropriately placed, coils will induce immediate vessel occlusion by thrombosis. Over time, they will cause a chronic inflammatory response with fibrosis. Stent patency, on the other hand, is quite variable. It depends on the type of stent, location placed, disease being treated, etc. Bare metal (uncovered) stents rarely become infected, but it is possible. Covered stents (or stent-grafts) are more prone to infection, though the rate is also quite variable and based on multiple factors.
I've heard that some stents are made of plastic material that get incorporated into the vascular wall. Do these offer any advantages over more traditional stents?
Bare metal stents become incorporated into vessel walls through a process called neointimal hyperplasia. Over time neointimal hyperplasia can cause narrowing of the vessel lumen, or there can be progression of the underlying disease (e.g., atherosclerosis). Covered stents, which are typically comprised of a nitinol mesh that is covered with PTFE material, are touted as preventing tissue ingrowth into the vessel lumen. Which type of stent is better really depends on many factors including the underlying disease and vessel location. Even then, it’s a topic of debate.
Bioabsorbable stents are a hot topic in stent research. Traditional metal stents (both bare and covered) are associated with thrombosis and oftentimes require long-term antiplatelet therapy. The metal in the stents can also affect subsequent imaging (CT or MRI). Additionally, the stents may interfere with, and in some cases preclude, future surgical options. Bioaborbable stents would theoretically avoid all of these limitations. I suspect that this technology may start to become available around the time that many of you begin your IR training.
EMBOLIZATION
When would you use embolization materials vs cauterization?
Cauterization is typically used during surgery to control bleeding. A surgeon must directly visualize a bleeding vessel in order to cauterize it. Embolization is used to control bleeding without surgery.
How do you choose embolization options. When would you use particles vs beads vs coils?
The pathology being treated usually dictates what embolic agent to use. Beads and particles are essentially the same thing, and are used when the target vessel is small and tissue ischemia is desired. For example, when treating tumors or uterine fibroids. Coils are used when treating larger vessels and to avoid vessel ischemia. For example, when treating a gastrointestinal bleed, we are aiming to plug up the injured vessel only. If one were to inject particles, it would cause ischemia of the bowel.
What platelet level required for effective coil embolization?
A platelet count greater than 50,000/mcl is ideal.
What types of complications are associated with embolization? How frequently do they occur?
Nontarget embolization is the primary complication associated with embolization. This is a very rare complication in the hands of an experienced interventional radiologist. Embolization of unintended vessels can cause ischemia, abscess, or even organ failure depending on what vessels are involved. Vessel injury (dissection, perforation, etc.) in the process of accessing a vessel during embolization is another complication that can occur.
What can you do in the event of a misplaced embolization?
Nontarget embolization is the term used to describe when embolic agents are deposited outside the intended location. Sometimes coils can retrieved with snares. There is nothing that can be done to "undo" embolization if particles or glue is injected into nontarget vessels.
Wouldn't UFE embo cause infertility?
There is a risk of premature menopause with UFE. This risk is between 1-10% with women over 45 years of age at greatest risk. UFE is not recommended for women who desire future pregnancy, though in some rare circumstances, it may be the best option if the patient is not a surgical candidate for myomectomy.
INTERVENTIONAL ONCOLOGY
What types of cancer can chemoembolization be used on? Can it be used on early stage lymphoma?
Chemoembolization is commonly used for primary and metastatic liver cancers (e.g., hepatocellular carcinoma, cholangiocarcinoma, metastatic colorectal cancer, metastatic neuroendocrine tumors, etc.). It is not an established treatment for lymphoma.
RE: interventional oncology When using cryoablation, is the extreme cold localized to the tips of the needles where the ice ball forms? Or do you need to worry about coldness ascending more distally on the needle and harming adjacent tissue?
The iceball forms only at the tip of the needle. The remainder of the needle shaft is not affected.
Are there different instances when you would use chemoembolization vs radioembolization for liver cancers or are they interchangeable and simply institution specific?
The optimal indications for chemoembolization versus radioembolization are still being investigated and debated. Protocols vary by institution.
NEURO-IR
Is the neurointerventional radiology training tract going to change with the new IR residency? What are the current training routes?
The new IR/DR residency will not affect the neurointerventional radiology training pathway. There are currently three different pathways to become a neurointerventional radiologist. You must complete one of three residency programs: radiology, neurosurgery or neurology. If you complete a radiology residency program, you typically need to complete a diagnostic neuroradiology fellowship (1 year) and then an additional fellowship in interventional neuroradiology (1-2 years).
tPA has a relatively short window of time wherein it can be administered. Does neurointerventional clot removal extend this timeframe? Can it be used in patients who wake up with stroke symptoms after being in bed all night?
Mechanical thrombectomy does not extend the recommended time window for intravenous tPA. Mechanical thrombectomy is recommended for an ischemic stroke with large vessel occlusion. In cases of “wake up stroke”, in general, no active intervention is indicated. However, its decision should be very carefully made by an expert team of acute stroke specialists based on clinical circumstances and advanced imaging findings.
FUTURE OF IR
Looking at the history info sheet, the last date listed was 1999. Have there been any major advances since then?
There have been tremendous advances this century. Interventional oncology has been at the forefront in the 2000s. We have seen the advent of radioembolization (Y-90), drug-eluting beads for chemoembolization, and microwave ablation. There is work on MRI-guided high-intensity focused ultrasound therapies for fibroids - and potentially for other tumors. There is significant ongoing work to perfect prostate artery embolization and early investigations into bariatric embolization as well. As noted above, bioabsorbable stents are also on the horizon.
Are there any major challenges or lags in technology that are currently keeping the field of IR from progressing more rapidly?
There is not another field in all of medicine that is progressing as rapidly as IR. Period.
Does IR currently involve regenerative medicine procedures? (For example, stem cell transplants or therapy)
Patients are often referred to IR for central line placement prior to stem cell harvesting or infusion (e.g., for treatment of leukemia). IRs are also involved in islet cell transplantation. Once the pancreas has been harvested and the islet cells are isolated, an interventional radiologist will access the portal venous system to transplant the islet cells.
IR TRAINING & CAREER
What is the best pathway for peds IR? IR first then peds? Or peds first then IR?
Peds first, then IR. The diagnostic skills learned in a pediatric fellowship will serve as a foundation for the procedural skills you will learn in IR. Additionally, you don’t want to have a 1 year hiatus between the time you acquire your procedural skills and you begin your pediatric IR practice.
Did any programs participate in the IR match this year? Do you know how competitive (e.g. board scores, # applicants) the match was?There were only 7 IR/DR programs that participated in the 2016 Match, so it’s important to remember that the sample size is small. But there were 135 applicants for 15 positions. Early projections of the 2017 Match suggest that the ratio of applicants to positions may be 3:1.
What's the outlook for robotic IR? Do you think it will be a threat regarding future jobs?
Robotic IR is in it’s infancy. Only a few institutions around the country have even used the equipment. It may prove useful for complex cases with difficult anatomy. I do not see it being a threat to jobs. Remember that, just like with robotic surgery, the robot is just another tool for interventional radiologists to use. They don’t replace the physician.
Can you talk about the lifestyle? Busier than surgeons/comparable?
The lifestyle of an interventional radiologist is probably most comparable to a surgical subspecialist (e.g., urologist or otolaryngologist). Additional information regarding the day-to-day schedule of an IR can be found in the FAQ section above.
I've seen very different IR practice styles. Some are very clinical with in-patient admitting privileges/clinics and others are not. How fast is this change to practicing clinically occurring? When will this be widely adopted?
There has certainly been a change in the practice of IR over the last decade. The old way of doing things was to follow the diagnostic radiology model. That is, passively waiting for procedures to be requested by referring physicians - much like you would a CT or MRI. This is no longer the case. All current IR fellowships and future IR/DR residencies are required to have clinic as well as admitting privileges. Private groups around the country have been adopting this model as well. I would expect that within the next few years the old model will be completely phased out in private practice.
How many hours a week do IR specialists work in academic centers?
Academic IRs work approximately 50 hours per week. Most academic IRs dedicate 5-10 hours per week to academic work including research, resident/fellow teaching, lectures, etc.
It seems that IR performs a vast variety of procedures. In everyday practice, what kind of variety can an individual IR doc expect to see? (Do many specialize to specific areas or do fellowships?)
There is tremendous variety in IR no matter what practice setting you are in. In any given day you can treat patients with renal failure (fistula/graft interventions), cancer (interventional oncology), gastrointestinal pathology (transjugular liver biopsies, TIPS), etc.
IR is itself currently a fellowship of diagnostic radiology. Most interventional radiologists perform the full spectrum of IR procedures, though in some larger IR practices and in academic centers some IRs have their niche areas of expertise. Once the interventional radiology residency system is in place, we may very well see superspecialty fellowships in interventional oncology, vascular disease, etc.
Would going the direct IR pathway hinder me in the slightest from being able to work primarily as DR if I changed my mind or needed a change of pace? I hear at a lot of academic programs, IR does mostly IR. How do you keep fresh in DR work?
If you complete an IR/DR residency you will be board certified to practice both diagnostic radiology and interventional radiology. So there will be no hindrance from a board certification perspective. It’s not uncommon to see older interventional radiologists cut back on procedures and practice more diagnostic radiology. It’s no different from an interventional cardiologist who no longer wants to take STEMI call and would rather spend their entire day in clinic.
