Canada’s recent recognition as a subspecialty at the national level has helped to raise awareness amongst other disciplines, healthcare policymakers and hospital administrators. “We will use this momentum to promote the value of interventional radiology to these same groups by providing evidence that our interventions reduce longer term hospital and societal costs through reduced hospital stay and patient morbidity while still improving outcomes,” Robert Joseph (Bob) Abraham, president of the Canadian Interventional Radiology Association (CIRA) 2015–17 tells Interventional News. Abraham is a professor in the Diagnostic Imaging and Interventional Radiology Department, Dalhousie University in Halifax, Canada.
When did you first decide on a career in medicine and why did you choose interventional radiology?
I was always fascinated by how things work and I loved to tinker and build as a child. I would build go-karts, motorised air planes and the like. I also had a great passion for maths and problem-solving, and really enjoyed working with people. Through my mother, a medical doctor, I learned that medicine offered a career that brought all of my passions together. In medicine, you are dedicated to improving people’s lives by working on the most complex of all systems; the human body. One uses problem solving skills at multiple levels,, and of course there is constant interaction with people. I discovered interventional radiology in my senior year when I followed one of my patients to observe a pulmonary angiogram. I was absolutely fascinated by the skill of the operator and his ability to insert a catheter through a small nick in the skin at the groin and then thread it through the heart and deep into the lungs all the while watching the progress in real time on a monitor. This was video games on steroids with the additional fact that he was making a huge impact on the patient’s life and care. I was absolutely hooked! Even that early in the day, I could envision that the future for interventional radiology was enormous. I thought to myself: “What if we could someday use a catheter to actually remove the clot in the lungs?” It is amazing to see how that has come about, as interventional radiology now plays a major role in the treatment and removal of clots in various conditions including pulmonary embolus.
Who were your mentors and what wisdom did they impart to you?
My mother instilled the importance of hard work, perseverance and dedication. She also taught me the value and importance of always listening to your patient and to treat each patient as if they were a family member. The individual who opened my eyes to the world of interventional radiology on the day I watched that pulmonary angiogram was Dave Gordon, who had trained under Ron Colapinto in Toronto. Dave and his partner, Alphonse Johnson, took me under their wing in residency in Dalhousie University, trained me in the fundamentals of catheterisation and showed me the great promise of the subspecialty. My mentor during my fellowship at the Royal Melbourne Hospital in Australia was professor Kenneth Thomson. Ken is a well-known pioneer in our field and is an SIR Gold Medallist and a CIRSE Distinguished Fellow. He showed me the importance of keeping cool under pressure, and how with proper planning and the innovative use of interventional radiology techniques and devices, one can maximise one’s ability to achieve a successful outcome during any procedure. I witnessed some miraculous results in very difficult circumstances because of his skill, innovation and perseverance, and I benefited greatly from his teaching and guidance.
Which innovations in interventional radiology have most influenced your career?
We have seen numerous revolutions in our field with new procedures and indications using existing technology as well as incredible product innovations that have revolutionised and enhanced how we perform well-established procedures. It never ceases to amaze me how I can now routinely recanalise complete arterial occlusions extending from the upper thigh all the way down into the foot, and in fact, sometimes navigate through the foot and back up the other side to allow me to significantly improve blood flow to the lower leg. These procedures are saving limbs where amputation is often the only option. I could not imagine being able to do something like this ten years ago. The fact that we can now treat abdominal aortic aneurysms percutaneously using low profile stent grafts is also truly remarkable. The well-known internet video of a patient hopping off the table and waving as he walks off after one of these procedures will stay with me forever.
What is interventional radiology’s place in Canada’s healthcare system?
The quality of interventional radiology in our country has always been top notch, and interventional oncology, general embolization, venous access, dialysis fistula intervention and non-vascular interventions predominate. There are also several centres including mine where we treat aortic and peripheral vascular disease.
Market research confirms Canadian interventional radiology has lagged significantly in comparison to all other G7 nations with regards to per capita interventions. That is, interventional radiology is profoundly underutilised in Canada and this relates to multiple barriers to adoption including a lack of awareness of the benefits of interventional radiology amongst other clinical specialities, hospital administrators and healthcare policy makers.
Interventional radiology has been chronically under-recognised and underfunded in our single-payer system where annual department-based hospital budgets hinder adoption of procedures which are considered “expensive” in the Canadian budgetary model due to the higher upfront costs of the technologies being used. As well, providing a minimally invasive outpatient interventional radiology-based alternative for a patient that would otherwise have required surgery does not reduce operating room costs as the operating room time and hospital bed are simply filled by another patient on the waiting list, and so overall utilisation and short-term costs are therefore higher. We need to change this line of thinking and provide health policymakers and administrators with the evidence that interventional radiology leads to improved patient outcomes, decreased morbidities and mortalities, more cost-efficient treatments, shorter hospitalisations, decreased waiting times and, ultimately, reduced costs in the long run. We need to show how valuable interventional radiology is to our healthcare system.
As the CIRA president for 2015–17, what were your goals for the organisation?
During my tenure, I wanted to ensure that we have a long-term plan in place to address the challenges faced by Canadian interventional radiologists. To do this, the CIRA Board embarked on a strategic planning process that lays out key action items including promoting and advocating for interventional radiologists amongst other specialities, healthcare administrators, policymakers and the public; supporting our members in the transition to a longitudinal clinical care model; fostering collaborative research across the country; improving communication and interaction between our members; and promoting interventional radiology as a career choice for medical students and residents.
Our recent recognition as a subspecialty at the national level has helped to raise awareness amongst other disciplines, healthcare policymakers and hospital administrators. We will use this momentum to promote the value of interventional radiology to these same groups by providing evidence that our interventions reduce longer term hospital and societal costs through reduced hospital stay and patient morbidity while still improving outcomes.
We are embarking on new clinical-based fellowships across the country that will train our newest recruits under a longitudinal clinical model of care, but will also need to provide education and resources for established interventional radiologists in this regard. We need to encourage all interventional radiologists to take full responsibility for the patients they treat, establish direct referral paths, seek admitting privileges and become comfortable with the overall care of our patients. We have a long way to grow to match other G7 countries and as we grow, we will need to find ways to attract and encourage new physicians to choose interventional radiology as a career in order for there to be enough of us to match the future growth.
Which aspects of interventional radiology do you foresee a strong growth for in Canada?
Interventional oncology will continue to grow in Canada, particularly if we remain proactive in building collaborative multidisciplinary teams to care for these patients. I also believe our involvement in the treatment of peripheral vascular disease and aortic diseases will continue to grow as we strive to work with our surgical colleagues and other healthcare workers in collaborative teams. It will take time to forge these relationships, but in the end the patients will benefit greatly from such an approach.
What interventional radiology research from Canada are you most proud of?
Ron Colapinto was one of our pioneers and his early technical work with transjugular intrahepatic portosystemic shunt (TIPS) and peripheral intervention has led the way for others here in Canada. It is great to see that his keen interest in furthering our field through research and innovation has continued with the likes of David Liu, Lindsay Machan (both Vancouver) and Gilles Soulez (Montréal) amongst many others. These individuals are true luminaries and great mentors and what they have achieved is nothing short of astounding. The work in Canada has included development of drug coating technology, novel embolic agents, as well as high level clinical research in all areas of interventional radiology. More recently we have seen award-winning outcomes research on the use of drug-coated balloons for peripheral vascular disease coming out of Newfoundland. It is fantastic to see all corners of Canada making a real difference to positively impact our field and improve the care of our patients.
You have a particular interest in radioembolic particles. What are the important developments in the field?
We are embarking on a new era in embolization where imageable embolic agents will provide us with information that has not been available before. This will allow us to learn so much more about these treatments thereby allowing us to improve on how these procedures are performed and, in turn, improve patient outcomes. I believe imageable embolic agents will help us to standardise, optimise and personalise embolization treatments, will result in a better understanding of embolization endpoints and allow for confirmation of adequate treatment of a target artery or tumour. With yttrium- 90 (Y-90) radioembolization, there is the potential to quantify the radiopacity of infused radiopaque radioembolic agents within the tumour with radiopacity mapping and then correlate this with radiation dose administered to tumour. Developing new products is not an easy task and I am lucky to be surrounded by a brilliant, highly skilled, dedicated team who all have the same passion for research and innovation as I do.
What are the current interesting research questions regarding radioembolic particles?
There has been tremendous research in radioembolic therapy over the past 20 years, but there is still much to learn. Some of the questions I have relate to optimising the treatment as I would like to better understand optimum particle size range, activity at time of administration, distribution in tumour and the like. We also need a better understanding of the additional factors that come into play when dealing with different tumour types. I believe we need different strategies when treating hepatocellular carcinoma vs. treating metastatic neuroendocrine tumours or metastatic colorectal cancer. In addition, we need proper data to allow us to personalise these treatments, not only for different tumour types but also for differing tumour volumes, tumour location and tumour vascularity. I am particularly excited by the promise of radiation segmentectomy and lobectomy and the potential for these treatments to be first-line therapy one day. I believe imageable Y-90 radioembolic microspheres will help us in understanding a lot of the current unknowns and help us develop customised treatment strategies that will improve outcomes.
Interventional radiology has always had close ties to the device industry. What are the some of the benefits and pitfalls of this relationship?
Collaboration between interventional radiologists and industry can result in great research and product innovation that ultimately benefits our patients. However, this collaboration must be respectful, professional and beyond reproach. This is best accomplished by ensuring that there is full and complete disclosure of any financial compensation and/or conflict of interest. It is not only reputation and credibility of the interventional radiologist or industry partner that is at risk here, but also the integrity of how we conduct our scientific investigations. Interventional radiologists need to exercise sound judgement throughout, and we and industry representatives need to keep the common goal of improving the care of patients, and maintaining their trust and confidence, at the forefront of any collaboration or interaction.
Please describe a memorable case.
I could think of many, but the cases that really have demonstrated the power of interventional radiology have been with embolization. I have performed embolization for patients with severe bleeding who were literally within seconds of death and, similar to the story of raising Lazarus, these patients have been able to stand and walk on their own within a few hours of our embolizing the bleeding site. These incredible life-saving events have occurred after traumatic haemorrhage but, equally, some of the most profound results seen have been with post-partum haemorrhage. Not much can be better than seeing a mother cuddling with her newborn so soon after such a harrowing and potentially catastrophic event.
What are your interests outside of medicine?
I do as much as I can with my family—my wife and best friend, Natalie, my daughter Zoe (19), my son Nikhil (15) and our rescue dog, Marlie. They are my biggest fans (even the dog!) and I cannot thank them enough for their huge support, particularly their patience. We all do our best to help improve the world by volunteering for and supporting numerous causes particularly related to human and animal welfare and social justice. We are also huge sports lovers. I played waterpolo for my university, but I would probably drown if I tried to play now. The sport I now love is golf as I find it a wonderful way to enjoy the outdoors while spending time with family and friends. It is a sport where I am constantly trying to improve. It is all about striving to be the best that you can be. I took up guitar later in life and absolutely love it. My family are adept at music with voice, guitar, drums and piano in our domain. In fact, we used to get together in a recording studio each year to make a music album together which was a lot of fun. I really look forward to doing that once again someday soon.