Francisco Cesar Carnevale tells Interventional News why prostatic artery embolization is an amazing procedure and why more needs to be done for paediatric interventional radiology so that children get bespoke treatment. Carnevale is currently the chief of the Interventional Radiology Section, University of São Paulo, São Paolo, Brazil, and a pioneer in the field of prostatic artery embolization
How did you come to choose medicine as a career?
I used to read my sister’s biomedical science books and attend some activities with her at the university. It was my first contact with research, diseases and their treatment. I became excited by the possibility of being a doctor after having a conversation with my mother. She encouraged me and made every effort to help me build my career as a physician.
What drew you to radiology and interventional radiology?
I did a rotation in general and liver transplantation surgery before moving to interventional radiology. One of my greatest pleasures as a physician is to take care of patients and build a relationship with them. When I see my patients in consultation I usually spend an hour talking with each of them. This is a very special time and a privilege. Interventional radiologists have the ability to make the diagnosis and then to plan and to perform the treatment simultaneously in a minimally invasive manner. During my residency, I had the opportunity to see my first transarterial chemoembolization (TACE), biliary drainage and TIPS procedures. It was astonishing to see a portal-caval surgical shunt performed by the jugular approach. Those procedures were performed by interventional radiologists and I decided to become one.
Which innovations in interventional radiology have shaped your career?
Liver transplantation procedures were my first contact with the interventional radiology field. In 1997, after coming back from my first fellowship in the USA and my PhD in Spain, I received the invitation to be the chief and develop the paediatric interventional radiology section at the University of Sao Paulo Medical School in Brazil. I was excited by the idea of performing interventional radiology in children. It was amazing when little children came to me showing their biliary drainage catheters with drawings and paintings!
Who were your mentors in interventional radiology and what do you still remember from their wisdom?
I had the great opportunity to travel so much and observe many key opinion leaders in interventional radiology in the USA and Spain. In paediatrics, James Donaldson in Chicago, USA, gave me the chance to observe many procedures that I had never seen, and donated many paediatric devices that helped me to develop and treat many patients at the Children’s Hospital; in liver transplantation, Albert Zajko and his group from Pittsburgh, USA, gave me the confidence to perform a TIPS procedure; in non-vascular procedures, Horacio D’Agostino (Bull) from UCSD taught me how to use drainage catheters; in oncology, Sidney Wallace from MD Anderson Cancer Center opened my mind about the possibilities for interventional radiology in cancer; in arterial vascular treatments and the first abdominal aortic aneurysm endoprosthesis in Spain, Mariano De Blas and Manuel Maynar; in research and education, Miguel Angel de Gregorio in Zaragoza. Renan Uflacker was a great master who taught us how to build interdisciplinary relationships and how to write papers and book chapters.
Could you describe a moment early in your career when you were amazed by what interventional radiology could achieve?
In 1995, at the MD Anderson Cancer Center, I attended the 7th day memorial service of the physician and inventor Cesare Gianturco. I was astonished at how a physician could diagnose,plan and perform treatments using many different devices through minimally invasive techniques. Additionally, he designed and developed many of the devices. Unfortunately, I did not meet him, but he gave me the message and I was thrilled by the huge number of materials and procedures in the field of interventional radiology.
Can you describe a memorable case?
It is so hard to choose from among thousands of them. I had just returned to Brazil after my US fellowship. My “welcome” was scheduled on 19 December 1997 at the Children’s Hospital at the University of Sao Paulo Medical School: a transcaval TIPS in a five-year-old girl with Budd-Chiari syndrome. The procedure was performed by me and a “neurointerventional assistant”. After the procedure, my assistant reached the conclusion: “The liver is the strongest organ in the body”. I do agree with that statement and that child is still alive without liver transplantation with a patent TIPS.
What are the three most interesting findings from your research in prostatic artery embolization?
The opportunity to perform pre-clinical studies gave me the confidence necessary to beging performing the procedure and have good clinical results. Science must be developed step by step and under serious and rigid protocols.
Prostatic artery embolization is an amazing procedure. We have to identify and cross tiny and atherosclerotic arteries, place a microcatheter into the prostate and inject spheres that make the prostate shrink. A refined technique and patience are key to a good embolization; patients’ symptoms improve in more than 90%, without retrograde ejaculation, sexual disorders or urinary incontinence, from a procedure done under local anaesthesia, which, if necessary, can be repeated in the future to avoid surgery; interdisciplinary cooperation with a urologist is essential for patient selection and follow-up.
Could you identify three areas to improve in interventional radiology in Brazil?
Paediatric interventional radiology would be one of them. There are neither interventional radiologists nor companies interested in this field. This means that children are treated with old-fashioned techniques and hospitals are losing a great chance to become leaders in this field. Interventional oncology is another area. Brazilians have achieved better social and economic conditions during the last 10 years. Consequently, patients have a longer life expectancy. They are also aware of new therapies but some of them are not available, or these therapies are too expensive.
Interventional Radiology in Emergency and Trauma is another field that needs to be explored in my country. There are a large number of patients that could be treated by minimally invasive interventional radiology procedures.
Which interventional radiology procedures are popular in Brazil?
The majority of procedures like transarterial chemoembolization, biliary drainage with stent placement, arterial and venous angioplasties, TIPS, embolizations, and inferior vena cava filter placement are performed in Brazil. Nevertheless, only procedures with codes and devices approved by the government or health care system are offered to patients. Doctors face challenges with the health care systems (public and private). Nevertheless, interventional radiology has a huge growth potential in Brazil.
As director of the Interventional Radiology Fellowship Programme at the University of São Paulo, Brazil, how is the programme set-up?
For 11 years I have tried to train interventional radiologists with a multidisciplinary view in a university hospital with 2,500 beds. Interventional radiology staff and residents represent our department during meetings for case discussion with several specialties. We also have a weekly interventional radiology meeting. The fellowship programme has two years where fellows are fully dedicated to vascular and non-vascular interventional radiology after finishing radiology, general surgery or vascular surgery as a prerequisite. Our interventional radiology society (SoBRICE) is a branch of the Brazilian College of Radiology and certifies these physicians. We give our fellows opportunities to visit international centres and get more experience overseas.
To build a department that is strong in research and teaching with pre-clinical and clinical studies is another challenging project. Having built a solid relationship over the last six years with the Urology Department, several investigational projects have been started in the field of prostate embolization. It will be a great opportunity for companies’ investments and physicians’ research. We have been looking for agreements with international hospitals and universities for collaborative projects. The “know how” has been achieved.
As a postgraduate teacher of interventional radiology, what do you emphasise to young people who wish to pursue a career in the field?
We have given interventional radiology classes to third and fourth year medical students as an alternative discipline during medical graduation. They also have watched our daily practice in the interventional suite and the feedback has been positive. The University of Sao Paulo Medical School is the most recognised in Brazil. Residents and fellows also have the chance to participate in pre-clinical and clinical studies, getting Master’s and Doctoral degrees to build their academic careers. We have tried to show that assistance, teaching and research are our three areas of focus.
What are your interests outside of medicine?
I love to travel with my family to our country house and enjoy spending time with my children, Marina and Rafael, and my wife Ana. I delight in moments spent in playing with my kids, taking care of the garden, and climbing fruit trees. I also enjoy cooking a delicious barbecue and making pizza while drinking my own “caipirinha”. Going for a morning run is one of the most peaceful times of my day.
Faculty of Medicine of the University of Mogi das Cruzes, São Paulo, Brazil (1990)
1994 Hospital das Clínicas at the University of São Paulo Medical School
PhD in Interventional Radiology, Faculty of Medicine of the University of São Paulo (1999)
Membership of professional societies
- Brazilian College of Radiology.
- Member of the Brazilian Society of Interventional Radiology and Endovascular Surgery (SoBRICE).
- Former President of the of Brazilian Society of Interventional Radiology and Endovascular Surgery (SoBRICE, 2009–2010).
- Member of the Society of Interventional Radiology (SIR).
- Member of the Cardiovascular and Interventional Radiological Society of Europe (CIRSE).
- Radiologia Brasileira (Brazilian College of Radiology)
- Intervencionismo (Sociedad Iberoamericana de Intervencionismo, SIDI).
CardioVascular and Interventional Radiology (CVIR)
- Journal of Vascular and Interventional Radiology (JVIR)
- CardioVascular and Interventional Radiology (CVIR)
- Journal of Urology
- Liver Transplantation
- Pediatric Liver Transplantation
Editor and author of the book: Interventional Radiology and Endovascular Surgery.( Revinter, First edition 2006 and second edition 2014 [in press]).
More than 50 published papers