A former president of the British Society of Interventional Radiology (BSIR) and current vice president of the Cardiovascular and Interventional Radiological Society of Europe (CIRSE), Anna-Maria Belli speaks about how important it is that interventional radiology’s clinical responsibility is acknowledged by IR having admitting rights, beds, junior teams and clinics. She also speaks to Interventional News about the UK multicentre FEMME trial, lost training opportunities on late-night calls, and more. Belli is a consultant radiologist, and a professor of interventional radiology, St George’s Hospital and Medical School, London, UK.
How did you come to choose medicine as a career? What drew you to interventional radiology?
I chose medicine by default really. I loved pure sciences but did not think I could make a career of them. Medicine seemed an attractive option that could combine my love of science with a stable career structure. After qualifying, I was working in an ear, nose and throat department when I first came across interventional radiology being used to reduce blood loss during surgery for a juvenile nasal angiofibroma. It seemed such an elegant solution. I was immediately interested.
Which innovations in interventional radiology have shaped your career?
I work in the vascular field and in the Eighties and Nineties, there were a lot of innovative technologies being introduced to supplement angioplasty such as arterial stents, atherectomy catheters, and lasers. It was a very exciting period and I still find vascular intervention exciting. There is always something new on the horizon.
Who were your mentors in interventional radiology and what do you still remember of their wisdom?
A lot of people had an influence on my career, but my main mentors were David Cumberland, David Allison and Mike Dean. They believed in my ability, taught me what they knew and encouraged me. David Cumberland taught me that the enemy of good was perfect and that it is better to stop when you have a good result than to carry on and ruin everything. David Allison taught me to behave as a clinician. Mike Dean gave me the confidence to overcome my diffident nature. He was the person I would phone for advice, and I still do.
Could you describe an early moment in your career in interventional radiology when you were amazed by what the specialty could achieve?
The case that first drew my attention to interventional radiology was such a moment. The clinical team was preparing for surgery and requesting large amounts of blood as this was an operation notorious for massive blood loss. Embolization of the nasal angiofibroma was performed the day before surgery and anticipating heavy blood loss, the surgeons were astounded and relieved that there was virtually no blood loss. Unfortunately, I did not see the embolization first hand but attended the meeting where the radiologist showed his embolization and was blown away by his skill.
Can you describe a memorable case and how interventional radiology came to the rescue?
One of my early memorable cases was when I was still a young consultant. A young girl in her twenties had a tonsillectomy at another hospital and bled torrentially. She was transferred to my hospital and the senior vascular and ear, nose and throat surgeons came to request that I perform an embolization as the least invasive option for her. I had never done this and was a little nervous but agreed. It all went extremely smoothly. The procedure was swift and the recovery smooth, and she was discharged from intensive care the next day. The confidence the surgeons showed in my ability and their encouragement made me realise that the best outcome for patients is when we work together using our different training and skills to their advantage, rather than competing with each other.
You have pushed hard to get uterine fibroid embolization accepted by other specialties and indeed, noticed by patients… What were you up against and how did you and others achieve this?
There was initial reluctance on the part of many gynaecologists to accept an intervention that was so different from their current management and offered by a specialty that they did not know very well. Far from needing to be persuaded, it was the patients themselves who drove the changes by demanding that they were given information about all the options available to them and that included embolization. They participated in the discussions and National Institute for Health and Clinical Excellence (NICE) committees of which I was a part. Because of this, a full fibroid service is incomplete without embolization. And gynaecologists have benefited from this collaboration as centres offering the spectrum of services receive more referrals.
You are involved in more than one trial measuring uterine artery embolization versus other uterine-sparing procedures… Could you explain your key findings and what you have learned about the need to fully infarct fibroids with embolization?
The FUME trial is the first randomised trial between uterine artery embolization and abdominal myomectomy aiming for fibroid clearance. Myomectomy and embolization both suffer from the fact that by preserving the uterus, there is potential for fibroid re-growth and recurrence of symptoms. Just as attaining 100% infarction rates should prevent re-growth after embolization, fibroid clearance surgery should reduce the re-intervention rate following myomectomy. We learned that both treatments were effective in achieving a satisfactory symptomatic response, but uterine artery embolization had a shorter hospital stay and a more rapid recovery whilst myomectomy had a smaller re-intervention rate at two-year follow-up, although the rate of re-intervention in both groups was lower than reported in the literature.
What questions is the FEMME trial seeking to answer?
The FEMME trial is a UK multicentre, randomised trial comparing all forms of myomectomy, not hysterectomy, with uterine artery embolization i.e. uterine-preserving treatments. The aim is to recruit 400 pre-menopausal women to each arm and to follow them up for five years to assess symptomatic response, complication rates, re-intervention rates, effects on ovarian function and to obtain data on fertility. The question of the effect of uterine artery embolization on fertility is especially important. The results of uterine artery embolization on fertility have been prejudiced by the fact that up until recently, this treatment has been offered to older women whose families have been complete and those actively seeking pregnancy have been excluded unless there were contraindications to surgery.
What are your other current areas of research?
I am interested in the role of drugs with devices and am participating in randomised, controlled trials to compare these technologies with percutaneous transluminal angioplasty. I am also looking at the role of interventional radiology in obstetrics, especially treatments that can prevent haemorrhage.
You have worked in interventional radiology in various parts of the UK. How has the subspecialty grown since the time you first started out?
It has grown beyond all recognition. When I first started, the number of interventional radiologists was so small, that everyone in the UK knew everyone else in the field. The British Society of Interventional Radiology was like a small club. I attended the first meeting in 1988 and there was just a roomful of people. Now it has several hundred UK members. CIRSE is similar. The first meeting I went to took place in a tennis club in Sardinia. Now there are a few thousand members and few venues large enough to hold the annual meeting.
Interventional radiology is a constantly evolving specialty due to new technical developments and cross-fertilization between vascular and non-vascular interventions leading to innovative therapies. Interventional oncology is a perfect and exciting example of this. What developed as a niche subject in diagnostic radiology is now a recognised subspecialty offering cost-effective, life-saving solutions and proving essential to the function of major hospitals and trauma centres.
As a physician with a long-term interest in teaching, what improvements in interventional radiology education and training do you hope to see in Europe?
Training in Europe varies enormously between countries. There needs to be a uniform standard and a curriculum stipulating training requirements in interventional radiology. The European Board of Interventional Radiology (EBIR), which was introduced in 2010, provides evidence of achieving a certain standard as participants have to submit a logbook, provide evidence of training and pass an exam. This is the first step in the right direction.
If you had a wishlist with three areas you could improve in interventional radiology practice, what would they be?
Firstly, I would like our clinical responsibility to be acknowledged by having our own admitting rights, beds, junior teams, and clinics. Secondly, I would like to see radiology trainees selected according to whether they wish to be diagnostic or interventional radiologists, so that appropriate numbers of each can be admitted for training. Naturally, there will be a certain amount of cross-over in the first three years, but this would assure adequate numbers of interventional radiologists.
Thirdly, interventional radiology trainees should be available for interventional radiology on call. In our current system, a consultant interventional radiologist can find themselves doing a difficult procedure in the middle of the night with a trainee who has no relevant experience or interest in interventional radiology. This leads to a lost training opportunity and a tough night.
What are the honours you have received that you look back on with pride?
Being made a professor of interventional radiology was a great moment. I did not believe it would happen, as there were so many hurdles to cross. My inaugural lecture was the first time that my family had heard me lecture. I am just sorry that it was too late for my father to appreciate as it would have made him incredibly proud. It is also a source of great pride to have been elected the president of the British Society of Interventional Radiology in 2001. I was supported by so many brilliant colleagues. I felt very proud that they had faith in me.
I consider it a supreme honour to have been elected vice-president of CIRSE. Whether I will look back at my time in the office with pride remains to be seen, but I am certainly proud to have been entrusted with the role.
What do you hope to achieve as vice-president of the CIRSE executive committee?
I think that CIRSE is going from strength to strength. It has had great leaders who have achieved so much in the past few years that it is difficult to see what more can and should be done. But of course, there is always more. I am particularly interested in interventional radiologists acquiring clinical status. Other specialties like haematology have come out from the labs and have beds and admitting rights.
There is no other discipline that performs therapeutic procedures without taking clinical responsibility and ownership. We are not simply technicians and, as Charles Dotter, warned, should not act as such, particularly when most of us have been practicing physicians or surgeons before going into interventional radiology.
Which new techniques and technologies will you be watching closely in the future?
There are quite a few. I think drugs are going to have a big impact on interventional radiology practice and I find the new treatments for cancer, delivering therapy directly to the tumour, fascinating. The role of stem cells is still in its infancy, but again this has incredible potential. I am also very interested in renal denervation. It will be interesting to see whether the results remain good when rolled out into more general practice.
What are your interests outside medicine?
I am always surprised that anyone has time for these as family and work take up a lot of time, but I have been renovating a Grade II listed early 17th-century farmhouse, which has been great fun. I hesitate to mention it, but I have also taken up clay pigeon shooting and pheasant shooting, which I have found I am quite good at and I love!
- Royal College of Radiologists (RCR)
- British Society of Interventional Radiology
- Cardiovascular and Interventional Radiological Society of Europe (CIRSE)
- British Institute of Radiology
1992 to date Consultant radiologist, Professor of Interventional Radiology
St George’s Hospital and Medical School
1990–1992 Senior lecturer/honorary consultant radiologist, Royal Postgraduate Medical School/Hammersmith Hospital
1987–1990 Senior lecturer/honorary consultant radiologist, University of Sheffield/Royal Hallamshire Hospital
Membership international committees
2011–13 Vice-president of the Cardiovasular and Interventional Radiological Society of Europe (CIRSE)
2009–2011 Treasurer of CIRSE
2010 Chairperson of the Interventional Radiology Committee of the European Congress of Radiology (ECR)
2009 Member of the Programme Planning Committee of the ECR for 2011
2007– 2009 Chairman of the Rules Committee, CIRSE
1997–1998 Chairman of the Subspecialty Training Curriculum Subcommittee of RCR
Service on national committees
2000–2009 Radiology member of the Committee of Safety of Devices of the Medicines and Healthcare Products Regulatory Agency (MHRA)
2001–2003 President, British Society of Interventional Radiology
2002–2008 Member of the Interventional Procedures Advisory Committee National Institute for Health and Clinical Excellence (NICE)
2008–2009 Member of the Safe Site Surgery Expert Reference Group of the National Patient Safety Agency (NPSA)