Interventional News speaks to Sanjiv Sharma, professor and head of the Department of Cardiac Radiology, All India Institute of Medical Sciences, New Delhi, India.
Can you give a brief outline on the situation of interventional radiology in India?
The practice of interventional radiology in India began in the early 1970s. It has grown from 19 interventional radiology specialists in nine institutions performing around 2,000 procedures in 1999, to 363 members of the Indian Society of Vascular and Interventional Radiology (ISVIR) from 56 institutions reporting over 50,000 procedures last year. This practice is still restricted to large metro cities and has tremendous potential for expansion to the interiors. Interventional radiology is at a crossroads in India today. Most products are still imported, the prices are steep and not matched to the average per capita income of the Indian households. The indigenisation of the hardware technology and their local production is essential to bridge the above gap. We face turf issues with various other subspecialties. Despite these issues, there is a tremendous scope for the practice of interventional radiology in India. Interventionists perform all state-of-the-art techniques available anywhere in the world and participate in cutting edge experimental and clinical research. Some key areas of recent individual and collaborative research include gene therapy in vascular disease, stem cell therapy in various disease states, experimental work on tagged stem cell homing by MRI and synthetic valves among others. Interventional radiology is strategically poised for growth.
ISVIR was launched in 1997 and has over 350 members. It performs many activities including monthly local, quarterly zonal and annual national scientific meetings, publishing a quarterly newsletter, engaging organising public awareness programs in different regions on locally relevant subjects, conducting short-term postgraduate training fellowships, and providing assistance to its members for participating in meetings. It also maintains an interactive website. It is the only national society in the world to conduct a web-based comprehensive annual national registry of vascular and interventional radiological procedures since 1999.
What aspects of practicing interventional radiology in India are similar to the West and what aspects are unique to India?
The disease states and devices and techniques used to treat them are similar in many ways. The devices have similar approval states, such as FDA and CE marks. The interventional radiology specialists practicing in India are often trained with similar backgrounds and share similar levels of expertise in handling devices and techniques. There are no language barriers. The specialists are well trained in research methods and in the designing and implementation of clinical and experimental projects and trials. We have the same turf issues! As elsewhere, there are many more non-radiologists practicing interventional radiology than the trained interventional radiologists in India.
Specific issues unique to the practice of interventional radiology in India include certain specific disease states that have a predilection for this subcontinent with resultant implications for interventional radiology device technology development and technique usages; issues related to device availability, mismatch of sizes and cost; cost factors that often preclude the use of interventional radiology techniques in favour of surgery as the latter turns out cheaper in the immediate term; lack of interventional radiology specialists − most practice diagnostic as well as bits of whole body interventional radiology, there are very few dedicated interventional radiology specialists and even fewer who subspecialise to specific body systems for interventional radiology practice; sparse industry support for the growth of interventional radiology in India; inadequate regular updates in knowledge and techniques; and lack of insurance cover for interventional radiology procedures.
Can you name the most influential papers on interventional radiology to come from India in the recent past?
The role of autologous stem cell therapy in the management of critical limb ischaemia; long term outcomes of interventional radiological treatment of hepatocellular carcinoma; outcomes of bronchial artery embolization in the management of hemoptysis: comparisons between those caused by inflammatory lung disease and cyanotic congenital heart diseases; chromosomal abnormalities induced by CT angiography− a multicentre study.
What should interventional radiologists in India do in order to grow the field?
What can we do to improve interventional radiology practice in India? Increase the number of centres providing interventional radiology care and induct more interventional radiology specialists for this practice. This can be implemented only if more training opportunities become available for those wanting a career in interventional radiology and can happen if interventional radiology is included as a separate subject in the undergraduate and postgraduate teaching in medicine. Exposure to interventional radiology along with training in pertinent aspects of clinical medicine as relevant to the practice of interventional radiology with postings in outpatient clinics, wards and emergency medicine must become an essential part of the medical programme of radiology.
Dedicated specialty teaching programmes in interventional radiology should be started in tertiary care teaching institutes in the form of certified courses and fellowships in this subject.
The interventional radiology society in India should create guidelines for performing and interpreting various interventional radiology techniques and device usages in various organ systems with mandated experiences in different forms of diagnostic radiology with a focus on image acquisition and diagnosis, radiation protection and rotation in clinics and wards; handling of emergencies; and the performance of minimum specified interventional radiology techniques under supervision and independently. Those who are certified should have cleared an objective examination.
There should be an implementation of a legislation to limit the practice of interventional radiology to certified trained subspecialists as per the above requirements and a creation of awareness programmes to introduce the scope of interventional radiology to the physicians, surgeons and other specialists and the public. The practice of interventional radiology must move beyond the metro cities to the interior towns and districts to make an impact on overall improvements in the delivery of healthcare to the population at large. Media resources should be utilised to spread this message to those who are the ultimate beneficiaries of interventional radiology techniques.
What is your key message to your interventional radiology colleagues in the West?
Join hands to promote interventional radiology in this subcontinent, help innovate and reduce the cost of devices and procedures and bring about better integration of societies, individuals and industry to help improve the quality of healthcare delivery. Create collaborative programmes and campaigns for qualitative and quantitative improvement in teaching and research. The opportunities for collaboration could work at various levels − individual, institutional and societal. We have similar disease states, infrastructure, trained manpower and no language barriers. There is tremendous potential to contribute in various research programmes, trials and registries which has yet to be tapped into.
Is there anything you would like to highlight regarding the integration of interventional radiology in India into the worldwide community?
The global interventional radiology community is faced with similar issues and needs to integrate and produce a calibrated and optimally designed approach to ensure judicious utilisation of interventional radiology procedures and curb the growth of non- or quasi-trained doctors without imaging backgrounds practicing interventional radiology procedures. The global interventional radiology community should also work towards creating legislations to curb this proliferation. The creation of unified guidelines for the practice of interventional radiology procedures jointly endorsed by all the societies will go a long way in doing so. We also need to join hands to bring down the costs of the devices to ensure their gainful utilisation in the wider perspective.