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A World of Intervention
Preview of the 29th annual SIR conference
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"Interventional radiology is one of the best-kept secrets in medicine," says Michael C. Brunner, MD, of the department of radiology at Swedish Covenant Hospital in Chicago and president of the Society of Interventional Radiology (SIR). But all that's about to change. And perhaps it's no one's fault but interventional radiology itself.
"Because some of our techniques have stood the test of time by proving their usefulness, some of the very people who used to refer patients to IR are now trying the techniques themselves," Brunner says. "In order to deal with that problem and take better care of the patients, we've been working toward refining an outpatient practice so that patients can seek care more directly."
This doesn't mean the field is trying to get away from physician referral; rather, he says they are trying to make that referral a more natural process. "We are trying to set up practices where a primary care physician or a patient can refer into an office practice and not have to do an extraordinary amount of work to get there," he explains.
Under Brunner's leadership this year, the SIR set a lofty goal – to have 80 percent of interventional radiologists meet the society's benchmarks for clinical practice for 2006. It's a big bill to fill, but the SIR is measuring up to the responsibility. To support the initiative, the SIR executive council created a Clinical Practice Task Force aimed at "transforming IR to a clinically based specialty."
Brunner describes clinical practice as the "typical medical practice model." He also thinks it's a more appropriate means of specialty practice. "Previously, others would decide what needed to be done and would then ask us to do it," he says. "That's not particularly good for patients trying to make an enlightened decision about their care."
And while Brunner's term of office will officially end at the SIR's annual conference (March 25–30 in Phoenix), there is another eager and capable leader ready to continue the effort.
"We have developed a strategic plan and a new pathway with 10 pilot programs in the next year focused on providing fellows with more clinical management skills," says SIR President-elect Janette D. Durham, MD, MBA. "This is exciting because we have all the behind-the-scenes stuff done and now we get to implement it."
The shift will be one of the main focuses of the annual meeting, as well as highlighting the advances in venous insufficiency, radiofrequency ablation and stroke – this year's symposium topics.
Sufficient Advances
Venous insufficiency is an abnormal circulatory condition with decreased return of blood from the leg veins up to the heart, with the pooling of blood in the veins. When the valves in the vein become weak and close improperly, they allow blood to reflux. Varicose veins, as a result of dilation under pressure, become elongated, rope-like, bulged and thickened.
Nearly half the U.S. population has venous disease – 50 percent to 55 percent of women and 40 percent to 45 percent of men. Of those, 20 percent to 25 percent of the women and 10 percent to 15 percent of the men will present with visible varicose veins.
"There hasn't been a really good way to treat [venous insufficiency] in the past," Durham says. "Surgery usually leaves patients with more scars than benefits and there's a lot of recurrence. And injections work well for small nests of veins but not for big veins." But this is no longer the case.
Now, by using duplex ultrasound, an interventional radiologist can assess the venous anatomy, vein valve function and venous blood flow changes. "With some recent work largely done by interventional radiologists, we found that a more efficient means of treating the disease process in its entirety has resulted in some very successful outcomes that can help a large number of people with painful, aching varicose veins," says Brunner. "The minimally invasive techniques we have are perfectly suited for the interventional radiologist because they involve the skill sets we have gained with ultrasound-guided intervention and diagnosis, using minimally invasive techniques for treating this disease process in a multi-faceted approach."
This is an especially important advancement as venous insufficiency and reflux, in more severe cases, can cause skin discoloration and ulceration, which can be very hard to treat.
High-Risk Relief
RFA, or radiofrequency ablation, continues to draw even more interest as multiple practitioners, not just interventional specialists, begin to recognize its potential. Brunner says RFA offers the opportunity to treat otherwise difficult areas that often require surgery. RFA is being tested for cancers that can't be removed by surgeons because of their size or location, or due to the risks associated with surgery.
Durham says she's excited that RFA could be an option for her high-risk patients. "The hope is that with small, multiple lesions, you could irradiate them using RF," she says. "The good news is that it can be done in an outpatient environment and it doesn't require surgery so the patients can go home quickly."
Brunner is impressed with the ongoing RFA research. "The work that started in the liver has progressed to the point where research is now looking at it for treating patients with lung tumors, bone tumors and other solid organ tumors."
The SIR reports that studies are underway to determine the potential benefits of RFA as a treatment for a variety of cancers, including RFA's ability to relieve pain and suffering from cancers of the kidneys, adrenal glands, lungs, bones and prostate.
"From my standpoint, the RFA approach shows a great deal of promise," says Brunner, indicating the new uses are not yet exhausted. "It's also possible that patients who are currently being treated with chemoembolization may be better treated by a combination of local therapy and RFA and systemic high-dose therapy."
Education Initiative
Rounding out the three symposium topics is carotid stenting: an upcoming star in the treatment of stroke victims. Brunner says the amount of disease being treated in the carotids is "phenomenal," and Durham agrees.
"I think carotid stenting has more interest than any procedure ever facing us," she says. But she's not the only one who has taken an interest. "Surgeons, cardiologists, neuroradiologists and interventional radiologists are all excited."
"The major reason for our encouragement in this area is because of the high extent of carotid disease," says Brunner. "We view this as a procedure that will help a large number of people."
Because stroke is the No. 3 killer in the country, the SIR recently voiced their approval of newly-introduced U.S. House and Senate stroke legislation, which could boost stoke awareness, diagnosis, treatment and recovery. The Stoke Treatment and Ongoing Prevention Act of 2003 (H.R. 3658, STOP Stroke Act) was introduced in December and the Senate's version (S. 1909) was initiated in November.
Brunner explains: "A lot of what the legislative approach has been is to educate the public in the same ways they now recognize the symptoms of a heart attack. It's a matter of educating the public to get patients to facilities earlier by having a multi-disciplinary, coordinated approach so that you can diagnose patients in the emergency room, have the right diagnostic tests done rapidly and get the patients transferred or treated by the appropriate personnel."
The Cardiovascular and Interventional Radiology Research and Education Foundation (CIRREF), the SIR's investigation-focused branch, further examined new stroke practices and practice implementation at a recent two-day conference. Durham says CIRREF's focus is a valuable investigation. "While at an SIR meeting we might hear "how' to treat carotid stenosis – something to prevent stroke – CIRREF's focus is different – not "how' do I do this but "why' I should."
"In past years, we've had a very narrow definition as to who interventional radiologists are," Brunner says. "Now, by broadening our inclusiveness of individuals within the society and cross-pollinating the skill sets these individuals bring, we are allowing ourselves to grow as a specialty and maintain access to the care we want our patients to have."
Just as time continues to change the face of radiology practice, so the face of the SIR must continue to change. "We have no idea to what extent innovations will go," Brunner says. "What we do know is that because we have a knack for being adaptive, for being innovative in problem solving, we've also got skill sets that are constantly evolving. We will be part of that process and as long as we don't forget who we are and what got us to this stage, we're going to be successful."
— Deven Kichline is the associate editor at RT Image magazine. Questions and comments can be directed to dkichline@rt-image.com.
