How are children treated at your local hospital? Asks paediatric interventional radiologist Alex Barnacle (London, UK) of healthcare providers today. Her question brings attention to the “insurmountable barriers” which paediatric interventional radiology (IR) faces, even in large, specialised centres. Affecting change, Barnacle’s outreach efforts span the globe, and her involvement with international societies is ongoing. Here, Barnacle—consultant paediatric interventional radiologist at Great Ormond Street Hospital for Children—shares the lasting impact made by her mentors, an early case that changed treatment management for the condition, and the collaborative work that must be done to resolve inequalities in paediatric IR.
What attracted you to a career in medicine, and what made you choose paediatric IR?
I was fascinated by paediatrics even as a medical student, but it took a long time to work out where exactly in paediatric healthcare I would thrive. I trained in neonatal intensive care, paediatric surgery and general paediatrics before being inspired by a wonderful paediatric radiologist and mentor—Jo Fairhurst—to consider paediatric radiology. After obtaining my paediatric qualifications, I transferred into radiology with the firm intention of becoming a diagnostic paediatric radiologist but fell in love with IR along the way.
For a while I was in turmoil, trying to choose between the two. I was fortunate enough to then be introduced to another key mentor, Derek Roebuck, who was developing a paediatric IR service at Great Ormond Street Hospital in London, UK. It was incredible timing, because he was probably the only one practising paediatric IR in the UK at the time and I immediately knew this was the career I had been searching for.
Who have been your mentors throughout your career and what is the best advice they have given you?
I have been inspired and encouraged by so many people along the way, and it continues, of course. Often, all it takes is one small thing someone says or does to leave a lasting impression or prompt us to reflect and change.
I am inspired by colleagues in industry, by the nurses and radiographers I work with, and by trainees as much as I am by senior interventional radiologists. Adam Mitchell was an inspiration in my very first year as a radiology trainee and taught me to be brave. James Jackson instilled in me a passion for treating vascular malformations. Within paediatric IR, Roebuck shaped both my career and my ambitions but I have also been inspired by many senior interventional radiologists within the wider paediatric IR community around the world.
Anna Maria Belli has been a key influence and support in my career, always encouraging me to break down barriers and aim high. And there are many brilliant women in IR who are role models for me and continue to inspire me to pursue excellence in IR and equality in our field—Laura Crocetti, Maureen Kohi, Gloria Salazar, and Tze Wah are just a few of these women.
Could you describe a case that has been the most memorable throughout your career thus far?
Only three years into my consultant career, I was referred a very young child with a lymphatic malformation of her orbit which had caused devastating consequences. I was familiar with treating malformations elsewhere in the body but never in the posterior orbit and I couldn’t find anyone in the UK who had treated one. I reached out to colleagues in the USA and Australia who supported me remotely. I performed three sclerotherapy procedures for her, with great trepidation. But the response of the malformation was truly remarkable and in a very short space of time she was pain free and getting back to being a happy and wonderfully courageous child. Since then, I have treated many, many children with this condition and together with some other interventional radiologists around the world, we have changed the management of this condition and the lives of these children. I am still in touch with this first patient and will always be grateful to her parents for trusting me with their precious daughter’s health when this was such a novel approach.
You are currently involved with the first Getting It Right First Time (GIRFT) initiative for IR in the UK. How has this experience been and what has been learned during the process so far?
It is a really innovative programme in England which takes a very detailed look at individual clinical specialties. Last year, the GIRFT programme for IR was launched and I am honoured to be the clinical lead. We review all the national IR data available and visit every hospital in England that performs IR. So far, my colleague Gill Kitching and I have visited 10 hospitals—only 112 to go!
We are looking for unwarranted variation in practice, particularly in patient outcomes, efficiencies in clinical care pathways and costs. Many departments are facing significant challenges in delivering the level of care they aspire to, particularly with current economic constraints, and we are often seeking support and advocate for them. And there are also teams who have developed novel ways of working and are delivering excellence in some areas of IR; we are mining for those pockets of excellence and aiming to disseminate examples of best practice. It is a privilege to visit so many IR departments and explore these themes with colleagues around the country. We are still in the early stages of the programme but emerging themes for me have been the relative disadvantages that some non-vascular IR services encounter compared to vascular IR services, and the lack of specialised training for nurses in IR. At the end of the project, we will publish a national report of our findings and recommendations.
You are currently on the executive committees of CIRSE and BSIR. How do these roles cross-pollinate with your daily practice?
It has been one of the unexpected privileges of my career to work with senior colleagues in the executive committees of the British Society of Interventional Radiology (BSIR) and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE), as well as previously in the Society for Pediatric Interventional Radiology (SPIR). I find it hugely rewarding to collaborate on exploring future directions for our specialty and finding ways to support our talented colleagues at the coalface of IR. Leadership roles like these challenge me to develop very different skills to those typically used at the angiography table, and to broaden my horizons. I love exploring ways to bring people together to achieve their goals. It is an honour.
Are you still involved with ICECaP, the first paediatric ablation registry in Europe? If yes, what is the status of the registry?
The ICECaP registry is recruiting patients undergoing cryoablation for both benign and malignant disease. Our aims are to confirm that cryoablation is safe in small children and to establish which diseases cryoablation is most effective for. Paediatric IR case numbers for procedures like this are always going to be low in individual centres so it is imperative that we collaborate across institutions and countries to collate and examine our practice and provide much-needed outcome data to guide the development of IR for children.
What is an unmet need in paediatric IR today?
There are so many unmet needs in paediatric IR. Paediatricians, paediatric surgeons and children’s hospitals are still frustratingly slow to recognise the value that IR brings for children and their families. There is huge underinvestment in paediatric IR; it is maddening to see colleagues struggling to deliver IR procedures with exceedingly limited resources, even in large, specialist institutions. There are very few training posts in paediatric IR, especially outside of North America, which of course means a lack of paediatric interventional radiologists.
Paediatric interventional oncology (IO) is significantly hampered by the absence of IR options in almost all treatment and study protocols. And we are held back by the lack of paediatric-specific equipment. Most of the time we can find workarounds with standard adult IR devices and kit, but now even this is heavily impacted by the recent changes in European medical device regulation. There are now almost insurmountable barriers to device development for paediatric use and we are seeing longstanding devices removed from the market or being labelled as ‘contraindicated for paediatric use’.
My colleagues and I recently published a research needs assessment for paediatric IR which highlighted a number of barriers to meaningful research in our field, despite widespread interest within the paediatric IR community for collaborative research.1 The paper emphasises some important areas for us and our clinical teams to focus on going forward.
In my opinion, the area of greatest need, and an area in which IR can undoubtedly impact children’s healthcare, is in paediatric oncology. As in adult IO, we need to keep pushing our oncology colleagues for a seat at the table, so that we can demonstrate to them what we can do and together explore how IR can contribute to paediatric cancer care. I am thrilled that the European Society for Paediatric Oncology (SIOP Europe) will be welcomed as part of the CIRSE 2025 congress (13–17 September, Barcelona, Spain). SIOP Europe is the only pan-European organisation representing all professionals working in the field of childhood cancer and our most valuable partner in furthering paediatric IO in Europe.
What is your advice to young interventional radiologists entering the field of paediatrics today?
Paediatric IR is a hugely rewarding career path, and you will be part of an immensely warm and welcoming international community. Seek out paediatric IR colleagues at all of the major IR congresses to develop links with us and share ideas, and join us at the annual SPIR meeting (14–16 October, Sydney, Australia). Reflect on how children are treated in your local hospitals—are they are being offered the same IR options that adult patients are? Almost certainly not. Can you influence that? It will take all of us to change many of the current inequalities in paediatric IR care.
What does your life outside of medicine look like?
I have a busy and fun life outside of work. My husband Andy and I play a lot of tennis, and we enjoy travelling together. I am passionate about art, exploring and appreciating fine art in galleries around the world, but also drawing and painting myself. I have recently gone back to art school in the evenings and have a very small exhibition coming up at the end of the year.
References
- Temple et al. Fostering research in pediatric interventional radiology: needs assessment and suggestions for support. Pediatr Radiol 2023 Oct;53(11):2245-2252. doi: 10.1007/s00247- 023-05722-6).
