BSIR faculty highlights specialty developments worth watching

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L to R: Clare Bent, Peter Littler, Robert Morgan, Raman Uberoi (at BSIR 2022)

In the opening session of the British Society of Interventional Radiology (BSIR) annual scientific meeting 2022 (2–4 November, Glasgow, UK) titled ‘What’s up, Doc?’, four faculty members spelt out for attendees what they consider to have been the most noteworthy advancements in the specialty of late, as well as their forecasts for interventional radiology’s (IR) direction of travel. Advances from the vascular, interventional oncology (IO), non-vascular, and non-clinical spheres featured in the session, with the latter consisting of a call to encourage trainees into IR to meet the current workforce shortfall.

In Robert Morgan’s (St George’s Hospital, London, UK) vascular-focused presentation, he first drew attention to a paper that had reported favourable results of the use of paclitaxel-coated balloons below the knee for patients with peripheral arterial disease (PAD) including no risk of death. He reminded the audience that a previous meta-analysis of studies involving paclitaxel-coated devices had suggested an increased risk of all-cause death, which had been ascribed to paclitaxel-coated device use. During his presentation, he stated that no study published since 2018, looking at single-cause mortality and involving the use of paclitaxel-coated devices above or below the knee, had found an increased risk of death associated with paclitaxel-coated devices.

Morgan also described the IMPERIAL randomised study comparing the Eluvia (Boston Scientific) and the Zilver PTX (Cook Medical) drug-eluting stents (DES), which had concluded that there was no significant difference in patency at two years between the two DESs. However, there was a slight benefit in target lumen revascularisation rate for the Eluvia DES, which just reached significance.

Morgan discussed the positive results of the randomised controlled trial DISRUPT PAD III, which compared Shockwave Medical’s peripheral lithoplasty system plus drug-coated balloon (DCB) for treating moderate and severely calcified femoropopliteal arteries with standard balloon angioplasty. He described the findings as “providing proof of concept for intravascular lithotripsy” as a treatment for heavily calcified femoropopliteal occlusive lesions.

Robert Morgan presenting at BSIR 2022

Another study that Morgan referenced was an analysis of Medicare data from 2011 to 2019 published in the Journal of Vascular and Interventional Radiology (JVIR) in November 2022. This study examined clinicians’ use of medical devices including drug-eluting balloons (DEBs), DESs and atherectomy in treating PAD patients in the USA. Morgan described an attached commentary as being relatively “scathing” of existing practice with excessive non-evidence based used of atherectomy compared with DEB/DES. Morgan concluded by stating that the evidence supports much more widespread use of DCBs and DESs compared with atherectomy devices, although the two techniques may be complementary in selected patients.

Peter Littler’s (Freeman Hospital, Newcastle upon Tyne, UK) focus was on IO, detailing advances in the techniques used in selective internal radiation therapy (SIRT), noting that for the first time, this type of cancer treatment has been included in international guidelines. Advanced catheters like the SWIFTNinja steerable catheter (Merit Medical) and personalised dosimetry, where individual cancer patients can be given amounts of radiation catered to the nature of the tumour, are among the developments in SIRT. Littler cited a study in The Lancet that evidences considerable improvements in survival rates after such tailored treatment.

Advances have also been made, Littler said, in ablation. Littler, who carries out ablation procedures on the liver, noted the benefits of stereotactic needle guidance technology. He then shared details of the novel ablation technology histotripsy, a non-invasive, ultrasound-based technique that works “like 3D sculpting” that is currently only being used in the HOPE4LIVER trial. Littler offered the suggestion that many of the technologies he detailed would be more widely available in the immediate future.

Clare Bent (University Hospitals Dorset, Bournemouth, UK) then gave her take on the “exciting new interventions and applications” in the benign non-vascular world of IR—an area that is “expanding at a fast pace”.

Clare Bent presenting at BSIR 2022

Musculoskeletal (MSK) embolization has grown as a discipline, Bent informed the BSIR audience, with genicular artery embolization (GAE) having the largest evidence base. Experimental studies have demonstrated a link between angiogenesis and pain, shown as hyperaemia on angiographic imaging, Bent detailed, enabling targeted therapeutic embolization. Bent also described several other applications including embolization of plantar fasciitis, with reductions in both plantar fascial thickness and pain following treatment. The next step for MSK embolization, she advised, is for the IR community to secure investment into further scientific research, the results of which may then help move these techniques from “marginal” to “mainstream”.

Bent also gave an overview on the use of glue, over coil, embolization to reduce cost, radiation dose and increase durability of the embolic endpoint, using pelvic vein and prostate artery embolization as examples of where this alternative technique may be advantageous. Moreover, and despite its “slow uptake in the UK”, radiofrequency ablation for benign symptomatic thyroid lesions has been endorsed by many societies worldwide. News of National Institute of Health and Care Excellence (NICE) guidance stating that microwave ablation can be used provided standard arrangements are in place for clinical governance, consent, and audit has been released since Bent gave her presentation.

“Expanding on existing techniques can change lives,” Bent concluded, adding cryotherapy for Morton’s or amputation stump neuromas to her list of novel IR applications.

Raman Uberoi (Oxford University Hospitals, Oxford, UK) rounded off the first session of the meeting by addressing the non-clinical side of IR, choosing to home in on recruitment of interventional radiologists in line with achieving a fit-for-purpose national service specifically as worthy of focus. He began by outlining the “huge range and complexity – has grown and grown, is exploding” of IR procedures, and how this has seen interventional radiologists branch into different subspecialties. However, the small numbers in these subspecialties make providing a 24/7 IR service challenging, the audience heard. Therefore, Uberoi incited delegates to “think carefully” about how the “next generation” of interventional radiologists can and should work.

Raman Uberoi presenting at BSIR 2022

The speaker made some suggestions as to how the specialty can “make things better for future interventional radiologists”. Among these was the adoption of specific IR training and formal assessment, as the subspecialty increasingly diverges from diagnostic radiology, Uberoi explained. The European Board of Interventional Radiology (EBIR) examination is an example of an accreditation model that has been proven to work worldwide, with a dedicated curriculum to match the exam content.

Future improvements to training, the presenter went on to note, could include in non-operative, more “human factors that are pertinent to our practice”, as well as coverage of day-to-day catheter skills.

Although the IR workforce has, on average, grown by 4% year on year over the last five years, Uberoi underlined the “unacceptable risk for patients” that the insufficient number of interventional radiologists in the UK is causing—50% of UK trusts were “unable to provide adequate 24/7 IR services in 2021,” Uberoi stated.

Therefore, the presenter left the audience on a to-do list for future-proofing IR services, involving increasing advertising to attract more IR trainees, protecting time for specific IR training, and ensuring trainees are exposed to ‘on-call’ earlier—“you should not be doing your first independently once you have become a consultant”.

“There are opportunities to collaborate across the spectrum,” Uberoi concluded, highlighting stroke as an area that lends itself to cross-disciplinary working. However, he emphasised how “we [in BSIR] have to drive the changes” and “work with the [Royal College of Radiologists]” so that improved patient quality of care is the outcome.

This article was amended on 30th November to correct an error.


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