Paediatric interventional radiologist Alex Barnacle (Great Ormond Street Hospital, London, UK) gave the Josef Roesch Lecture at the Cardiovascular and Interventional Radiological Society of Europe 2022 meeting (CIRSE; 10–14 September, Barcelona, Spain), choosing to present on the subject of ‘Developing excellence in interventional radiology (IR) for our youngest patients’.
The presenter used various case examples to demonstrate to non-paediatric interventionalists that they “still need to think about [paediatric IR]—children grow up and graduate into adult practice”. A take-home message from Barnacle was how cross-specialty collaboration on issues such as establishing standards of practice, especially with the wider IR community, will help paediatric IR grow and “[change lives]”.
Barnacle’s presentation began with the story of a patient of hers, who was the first to receive orbital sclerotherapy at Great Ormond Street Hospital. Highlighting the life-changing impact of the treatment on her patient, Barnacle also underlined the importance of her network in providing the care her patient required—“[David Lord] talked me through [the procedure] over the telephone and we did [it].” This success is proof of the value of tapping into “the very small pool of expertise around the world”—Lord is based in Sydney, Australia—however “if we do not know each other, we cannot share our expertise and data,” Barnacle acknowledged.
How crucial cultivating a network within paediatric IR is, is complemented by the need to communicate and work together with other specialties so that they better recognise where paediatric IR can play a key role in patient care. “Just as with IR […] paediatric IR is massively under-recognised by other specialties,” Barnacle stated, going on to explain the impact this has—”we get late referrals because other teams do not know what we can do”. An example of where increased awareness and implementation of paediatric IR expertise could make a difference to current practice is, as illustrated by Barnacle, central venous access. “We all know that children should not need to be going through repeated painful, distressing cannulations […] that will mentally and physically scar them and their families for the rest of their lives.” What is a “bread and butter” procedure for a paediatric interventional radiologist will enable their patients to “get on with dealing with [everything else] that they need to, without having to think about those repeated cannulations.”
In contrast to the day-to-day roles paediatric interventional radiologists can play, such as by providing central venous access, Barnacle touched on the “supportive care” that they can give patients with rarer conditions, including those with rapidly involuting congenital haemangioma, and those who have swallowed button batteries, and may require dozens of interventions to “get through”.
Protocols and guidelines are also a factor in limiting the extent to which paediatric IR can fulfil its potential in such cases, as Barnacle also flagged. The presenter illustrated her point with a trauma case example, which saw the 15-year-old patient requiring a partial splenic embolization bypass a major trauma centre, as protocol would not allow (non-paediatric) interventional radiologists to carry out the treatment. “[It] just feels wrong”, Barnacle admitted, before suggesting that, as with the “limited” existing standards of practice for paediatric IR, “we need more”. As a potential solution to the paucity of paediatric IR-specific practice guidelines, the presenter offered the approach of adding paragraphs to existing guidelines on how to nuance well established adult practice for children.
A further barrier to widespread recourse to paediatric IR that Barnacle brought to the audience’s attention was the increase in paediatric contraindications for some devices—“we have had to change the inferior vena cava [IVC] filter we use,” the presenter lamented. This is symptomatic of a “small toolbox that is being emptied very quickly,” which, in addition to affecting paediatric IR practice, also has a knock-on effect for training, as device companies feel obliged to pull out of events such as the hands-on device training offered at meetings.
Nevertheless, Barnacle rounded off her presentation on a positive note, taking stock of the increasing interest in paediatric IR, of which there is ample evidence. The scope of the paediatric IR programme at CIRSE was one example Barnacle drew upon, including a sell-out hands-on session in spite of one company pulling out for the aforementioned reason of contraindications. “Things are changing,” according to the presenter, proceeding to celebrate the fact that CVIR Endovascular’s most downloaded paper of the past year was on paediatric IR, and how the remote Society of Paediatric Interventional Radiology annual meeting in 2020 saw attendees from 43 different countries.
Key now, Barnacle believes, is to “build on this interest”, which, she believes, extends to trainees looking for more of a “human side” to their work and “greater job satisfaction”—requirements that, she opines, being a paediatric IR can meet. As relayed throughout her presentation, efforts to grow paediatric IR, and interest and awareness of it, can take the form of establishing clearer guidelines and protocols, drawing on professional networks to aid innovation and optimal patient care, and working with colleagues in other specialties “so that children get referred to us sooner—this is better than picking up the pieces,” Barnacle concluded. “[After all], we are all here because we believe that minimally invasive procedures are the way to go” was the presenter’s salient final remark.