The most interesting developments in interventional radiology at this moment are: the expanding role for interventional radiologists in acute stroke care, the opportunities afforded by miniaturised EVAR devices and potential services that can be offered in chronic cerebrospinal venous insufficiency, says Timothy P Murphy, incoming president of the Society of Interventional Radiology.
What drew you to interventional radiology?
When I was a second year medical student at Boston University, I was planning to go into surgery when in a pathophysiology course I attended a lecture by a noted interventional radiologist, Dr Alan Greenfield. At that lecture in 1984, he discussed some interventional radiology procedures including infusion of vasopressin for gastrointestinal haemorrhage, and renal artery embolisation for renal cell carcinoma. At that time, it was like a light bulb went off. I thought that those techniques were less invasive, less expensive and very elegant solutions to mechanical problems in the body. I immediately shifted focus from a career in surgery to a career in interventional radiology. I began to spend time in the interventional radiology section and took a rotation in interventional radiology with Dr Greenfield. It is a decision I have never altered or looked back on.
Who are the people who have influenced you the most?
After I did a rotation at Boston University, I was advised by Dr Greenfield to look at Brown University Medical School, and I did a rotation as a medical student in 1986 with Drs Gary Dorfman and John Cronan. I matched there for residency, and have been in Rhode Island ever since.
At the time of that rotation in Rhode Island in 1986, there was a case of a complication of an iliac artery angioplasty, iliac artery rupture. In October 1986 as a 23-year-old medical student I was encouraged to write it up as a case report. It was published in the Journal of Vascular Surgery in 1987. Based on that experience I was taken into the programme at Brown University and taken under the wing of Dr Dorfman. He and Dr Cronan encouraged and fostered my development academically. I was also influenced by articles that I read and presentations that I heard, mostly by leaders in the field at the time such as Drs Barry Katzen, Gary Becker, Arina Van Breda, and Bob White. They strongly influenced my development and philosophy about medicine and interventional radiology, and I continue to push through with my career along those lines clinically and academically since then.
Which innovations shaped your career?
Probably the one that had the most impact on my career was the development of intravascular stents. When I was a fellow in 1992–93, stents were just beginning to be approved. The large Palmaz stent was approved in 1981 and as a fellow, I researched the literature and gave a presentation on what was out there on stents. At that time, they were being used mostly for failed angioplasty. But it was apparent to me that stents were going to revolutionise the entire field of revascularisation therapy and I pursued procedures with stents vigourously. Time has shown that that was the right thing to do.
During my fellowship, I placed over 100 intra-arterial stents—that was an unusual volume at time but it gave us experience in what the stents could do, not just in cases of failed angioplasty but even for lesions not considered to be amenable to angioplasty like very long stenoses or chronic occlusions.
It was probably the development of stents and stent grafts that took interventional radiology from what was regarded as a boutique or niche service to something that was really mainstream, which has transformed medicine, surgery in particular. I think interventional radiologists were the leaders who have been instrumental in heralding the change from open surgery to minimally invasive procedures, and this has rippled throughout all of healthcare.
What do you hope to achieve as president of the SIR?
I have often distilled down the strategic objectives of this professional society into four things:
- To develop or adapt new procedures so that we can better serve patients.
- To validate those procedures so that we can show their value.
- To ensure/obtain reimbursement for the new procedures and
- To ensure that interventional radiologists are well-placed to provide those services.
In terms of the changing landscape of healthcare and the potential changes coming down the pipeline in reimbursement, we want to gather the data that validates interventional radiology services as better, faster, safer and less expensive than the alternatives. We have been doing that and will continue to do that, so that in a more risk-sharing type of reimbursement system, a capitated system or a global payment-based system, services which are less costly with a good outcome are supported and able to grow.
In the past, many of us who went into interventional radiology thought that we were on the leading edge of a field that was going to transform medicine because the procedures were effective, less expensive and less invasive. So everything seemed to be moving in the positive direction and it seemed that the market forces would naturally align to foster tremendous development in the field of interventional radiology. Unfortunately, in the managed economy of healthcare in the USA, the fee for service system, where bills are submitted for services, the cost saving of interventional radiology were not highly valued. In fact, in the hospital system in which most interventional radiologists practice, there is a drive towards top-line revenues and not so much towards cost-effectiveness. So interventional radiologists have not had as much of a prominent a role in the healthcare system as we thought we would.
With the explosion in healthcare costs that the fee for service system has engendered, which has obviously gotten out of control, it is obvious that things are going to be changed sometime in the future. For example, in Clayton Christensen’s book, The Innovator’s Prescription, interventional radiology is mentioned in three separate places as a model for affordable care. It is possible that we were ahead of our time, but the concept of better, safer, and less costly is still sound and if interventional radiology can demonstrate that, we are probably going to be very successful.
Can you describe the expanding role for interventional radiologists in neurointervention?
One of the strategic initiatives of the SIR has been to expand the role of interventional radiologists, who have tremendous and multi-faceted catheter and device experience and skills, into the neurointervention arena. We have seen that stroke therapy is probably one of the most rewarding things that can be done by interventional radiologists. There are a number of life-saving procedures that we do, but the swings in outcomes between an effective interventional procedure for stroke and no interventional procedure are probably as large a swing as for any of the procedures that we do. In stroke, you can have people come into the hospital with profound disabilities which can alter their lives forever for the worse, or kill them. Often a stroke can result in the loss of speech, the loss of the ability to communicate with their families and friends, the inability to move half their body. It is an outcome that is often rated on quality of life surveys as “worse than death.”
With some of the new techniques that have been developed like the new thrombectomy devices and thrombolytic procedures for stroke patients, interventional radiologists can take people who have extensive vascular occlusions, including total carotid occlusions and middle carotid artery occlusion in the dominant hemisphere, etc, and literally within minutes, clear them out and get blood flow back into the brain. In some of these cases, the difference in outcomes is extreme. People who would have to go for months of rehabilitation and never be normal again, would be discharged into their homes with normal or near-normal levels of function. Also, one of the most expensive outcomes a person can have is a stroke. We are trying to look at how we can promote the interventional treatment of stroke, by showing the lower cost to society by managing these patients interventionally rather than medically. In terms of delivery of this care, we believe that only interventional radiologists have the skills and the numbers to make an impact, and SIR is strongly encouraging its members to get involved in this field.
Which developing techniques and technologies are you watching closely for the future?
There are three things that we think are really on the cutting edge and we are encouraging all interventional radiologists to keep involved with to try to incorporate into their practice as they see fit. We believe these are tremendous strategic areas for the specialty, tremendous opportunities to improve public health and we strongly encourage our members to try to provide these types of services.
As I said, the first is acute stroke therapy. We have over 4,000 interventional radiologists who are members in the SIR, and that is a small army which is able and willing to go out and address this public health menace. There is no other specialty, including neurointerventional radiology, neurointerventional surgery, cardiology, vascular surgery, etc, that can meet this demand. We are the only specialty that can do it and we should do it.
The second is endovascular treatment of abdominal aortic aneurysms. The devices are becoming miniaturised year by year and the capability of vascular access closure devices to close even large accesses is improving as well. This is a procedure that is moving rapidly, if it has not already, to something that is purely a percutaneous procedure. Interventional radiologists are very well-qualified to offer endovascular aneurysm repair.
The third thing which has got a lot of press and attention is chronic cerebrospinal venous insufficiency for the treatment of multiple sclerosis. There is a lot of theoretical support for the aetiology of multiple sclerosis being partly, or in some patients at least a venous outflow occlusive disease and interventional radiologists should not be shy about getting involved with the care of these patients.
Yes, there is no level one evidence, i.e. no randomised controlled trials, at this point in time, but there are a lot of very severely disabled patients who are seeking care. Anecdotally, the outcomes look good. However, there are a lot of things that we do that do not have level I evidence and we do not want to be caught blindsided on this by taking five to 10 years to do an adequately powered, methodologically sound, randomised clinical trial, and then leave 10 years of disability in that population. I think we should do the procedures for those patients who seek them out, just as we would any other service that seems to work. Even though randomised trial data are not present yet, it is certainly reasonable, the risk is low, and the patients want it.
What is the current status of the CORAL and CLEVER trials?
We have no data yet from CORAL that describe any unblinded outcomes. The study has completed recruitment and is currently in follow-up. So far, there have been no safety issues raised by the Data Monitoring Committee which is pleased with the quality of the data and the outcomes that they are observing.
I cannot read into the tea leaves and make any predictions. All I can say is that the data that are out there are from studies that have methodological weaknesses and that we hope that CORAL will contribute to the dialogue in a meaningful way.
With regard to CLEVER, the trial has finished recruitment and is in the follow-up phase. The quality of data is excellent, we have good protocol adherence, very few crossovers and very few missing data. We do not know what the interim results are showing, but we do know that patients in all treatment groups have been satisfied. There are anecdotal reports from our sites of very good outcomes regardless of treatment groups.
What are some of your proudest achievements?
I do not spend a lot of time dwelling on that, but probably the highlights of my career so far have been my appointment to the executive council of the Society of Interventional Radiology (2002), my appointment to the board of editors of the Journal of Vascular and Interventional Radiology (1996), and my selection to be president of SIR 2011–2012. Also, successfully getting funding for two NIH-sponsored clinical trials is a definite highlight. I was co-principle investigator for CORAL which is a US$40m study and principle investigator of CLEVER which is a US$10m study. On a personal level, it is the patients that I have treated who have had good outcomes and who have appreciated my work who stand out. My proudest achievements are my three children, Madeleine, James, and John, who never cease to amaze and amuse me!
What are your interests outside of medicine?
My hobbies are music, woodworking and boats. I have an obsession with anything that floats—rafts, barges, motorboats, sailboats, you name it. In my life, I have owned around 10 boats, most of them under 15 feet long. I like to acquire old wooden boats, restore, and sail them. Probably the type of boating I like best is a small sail boat, made of wood, close to the water, so I can really appreciate the experience of being on the water, with the wind and the waves splashing in my face!
1991–1992 Chief resident
Department of Diagnostic Imaging, Rhode Island Hospital, Brown University School of Medicine.
Vascular and Interventional Radiology, Department of Diagnostic Imaging, Rhode Island Hospital, Brown University School of Medicine.
June 2005 Full professor
Research Track, Department of Diagnostic Imaging, Brown Medical School
1996–2001 Director Division of Vascular and Interventional Radiology
Rhode Island Hospital, Providence, Rhode Island
2005 Founder and medical director
Rhode Island Hospital Vascular Disease Research Center
Honours and awards
2007 “Cambridge Who’s Who Among Executives and Professionals in Teaching and Education”, “Honors Edition”. Cambridge Whos Who, Uniondale, New York “America’s Top Radiologists”, Consumers’ Research Council of America, www.consumersresearchcncl.or www.consumersresearchcncl.org,Washington, DC
2009 Society of Interventional Radiology recognition for service on the Peripheral Artery Disease Coalition, Science Committee Chair
2010 “The Leading Physicians of The World”, International Association of HealthcCare Professionals, International Association of Radiologists New York, New York
2011 “Best Doctor’s In America”, Boston, Massachusetts
2011 Marquis Who’s Who in America, 66th Edition, Marquis Who’s Who, New Providence, New Jersey
Membership in societies
1988–present New England Roentgen Ray Society
1988–present American College of Radiology
1990–present American Roentgen Ray Society
1992–present American Heart Association
2004–present American Heart Association, Premium Professional Silver
Heart Member (recognition for continued service)
1992–present Society of Interventional Radiology
(formerly Society of Cardiovascular and Interventional Radiology)
2003 Chair, Clinical Practice Task Force
2003 SIR Executive Committee
2004 Councilor-at-large, Executive Council
2004–2005 Strategic Planning Committee