The future of interventional radiology rests on the creativity and innovation that founded the discipline

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Sindhura Nirmalarajan

Described by her supervisor Glen Schlaphoff (Sydney, Australia) as “a perfect example of a young up and coming interventional radiologist”, Sindhura Nirmalarajan is a Radiology registrar at the Prince of Wales Hospital, Sydney, Australia. At the 2018 annual meeting of the Cardiovascular and Interventional Radiological Society of Europe (CIRSE; 22–25 September, Lisbon, Portugal), she was honoured with the Magna cum Laude e-poster award for her work on prostate artery embolization. Here, she discusses this research with Interventional News, as well as why she is excited for the future of interventional radiology (IR).

What is your reaction to winning the prestigious e-poster award at CIRSE?

I submitted this project through the CIRSE trainee support programme and was very excited to hear the poster was accepted for presentation alongside many high calibre projects. Receiving the Magna cum Laude award took me completely by surprise and I feel incredibly honoured by this recognition. I am grateful for the opportunity to have presented this work and for the support of my supervisor Glen Schlaphoff (South Western Sydney Clinical School, Sydney, Australia).

Would you summarise the findings of the research presented in your e-poster?

Prostate artery embolisation (PAE) is emerging as an effective treatment option for lower urinary tract symptoms caused by benign prostatic hyperplasia. One of the technical challenges of this procedure is accurately identifying variant pelvic arterial anatomy. We reviewed the angiograms of 202 pelvic sides and classified the branching pattern of the internal iliac and prostate arteries using the framework of existing angiographic classification systems. We found the incidence of anatomical variants in our series from a single Australian institution (Liverpool Hospital, Sydney) to be comparable to the incidence reported in previous studies. Despite the high degree of variability, the origin of the prostate artery could be classified into one of four types in 96% of our cases.

How will these findings influence clinical practice?

This poster serves as an educational resource that provides a systematic approach to understanding and identifying complex and variable pelvic arterial anatomy. In particular, it provides a pictorial overview of the range of arterial variants related to PAE and  potential intra/extraprostatic anastomoses. Ultimately, this awareness improves technical success, reduces fluoroscopy time and minimises the risk of non-target embolization.

Why is this an exciting time to be involved in interventional radiology?

IR is founded on creativity and innovation and this enables the specialty to meet the increasing demand for minimally invasive treatment options, which are effective, safe and have reduced recovery times. There has been a shift in the practice of IR in the modern day, with an increasing recognition that technical expertise is only one component of the larger clinical skill-set of an IR. The continued progression of IR into an increasingly integrated clinical specialty combined with the development of new technical innovations makes this an exciting time to be involved in IR.

You currently practice in Sydney, Australia. How does the Australian healthcare system help and/or hinder your work and how would you describe the IR scene in Australia for up and coming radiologists?

Australia is fortunate to have one of the world’s leading healthcare systems. The availability of universal healthcare means that IR services in public tertiary centres are highly accessible.

IR is embedded in the multidisciplinary healthcare system and there is constant collaboration with other specialties, such as in the settings of oncology, trauma, paediatrics, and many others. As an Australian trainee, this provides a diverse and robust mix of cases and exposure to the breadth of interventional radiology.

There is a widespread recognition of the importance of achieving subspecialty status for IR in Australia. An essential step in this complex process is increasing the clinical focus of IR. This has seen a shift towards the establishment of outpatient clinics, primary clinical responsibility for patients, and collaboration with other disciplines to provide care for a larger number of increasingly complex patients. Furthermore, the need for standardisation of training is recognised and has resulted in many Australian IRs undertaking the EBIR [European Board of Interventional Radiology] certification. For trainees in Australia, this is a great time to be involved in helping to shape the future of this dynamic specialty.

There still exists a gender imbalance in this field, with more male IRs than female. Why do you think this is and what do you think should be done to address/change this?

There is a growing focus on the disproportionately small number of female IRs compared to the numbers of female medical graduates and trainees in other traditionally male-dominated specialties. Several studies have explored the reasons for this disparity and have highlighted multiple contributing and inter-related factors including: the relatively few women in leadership roles, an entry pathway via diagnostic radiology, and the misconceptions surrounding radiation exposure.

Personally, I feel that a potential avenue to address this gender disparity and also recruit individuals (both male and female) who are motivated to pursue a career in IR would be to increase the profile of IR in medical schools and set out a clearly structured IR training programme that builds clinical and procedural expertise alongside diagnostic training. I believe that cultivating an interest in IR at the medical school level could result in a more balanced proportion of female IRs that is more reflective of the numbers of female medical graduates.

I hold this belief because I found that an early exposure to IR in medical school was pivotal in forming my interest in this field. I completed a diagnostic Radiology term at Johns Hopkins Hospital in my third year of Medicine and returned for an IR elective in my sixth year. The elegant solutions to tricky scenarios, the broad scope of practice and the effective, precise treatments that IR could provide were a revelation to me. There were several female IRs working in the department at the time and, looking back, I believe it was this early exposure to IR and the diversity of the team that helped me to see this field as a future career path.

What do you think the next generation of IRs will bring to the discipline?

I think the strength of the next generation of IRs will be to enter the training programme directly from our clinical foundation years and to maintain and build our clinical acumen throughout our training.

I believe that bringing in new perspectives with a steady influx of young trainees and increasing collaboration between IRs and other disciplines will keep the specialty progressing at the cutting edge of medicine.

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