What’s better, what’s not, and what’s next

Editor-in-chief Brian Stainken, author of this letter

Interventional News began more than 20 years ago as an effort to better cover the global interventional space, selecting news stories and other content that is not the province of peer-reported journals, but still important to the practising interventionalist. We focus on content that is relevant and on conversations that you might not hear on other channels. 

I am a newly retired, USA-based interventional radiologist. I finished fellowship training in 1992 and enjoyed a practice in both clinical and academic environments. It has been a privilege and an education to watch our profession evolve over the past half-century (yes, the Society of Interventional Radiology [SIR] turns 50 this year!) As a past leader in SIR, with a leadership focus on international interventional radiology (IR), I have had a front row seat for at least half of that time, so I thought I would offer one man’s perspective on what’s better, what’s not, and what’s next. When you read this, understand my focus is our global IR community and that my opinions are not necessarily Prof Adam’s (my co-editor-in-chief), Interventional News’, or those of our representative societies. Let us start with the good news:

What’s better:

  1. Our tools. Frankly, IR is a lot easier now because the random stent migrations, wire fractures, ‘stuck’ devices and oversized introducers are mostly a thing of the past. We even have devices for haemostasis! As a fellow, after a long lytic case, I still remember holding groins for days…This evolution in equipment has allowed our field to advance into progressively more novel and technically demanding approaches, solving more problems with less risk compared with the alternatives. But we should never fall for the fallacy that there is any relationship between introducer size and risk. As many of us know based on first-hand experience, one disadvantage of IR access approaches when compared with predicate open procedures is potential for loss of control. A poorly trained provider can do a lot of harm through a small hole. As IR becomes ever more complicated, we need to accept that our training and certification systems must evolve in parallel, on a global scale.
  2. Our culture. Dotter’s vision has arrived. IR is for patients, not procedures. This culture becomes a progressively important bedrock as our techniques mature and tools improve. It is all too easy to apply low- or no-risk solutions. It is not just risk/benefit that matters, it is also about alternatives. Like any surgeon, when we can avoid a procedure, we must. A great example is supervised exercise for claudication. Many patients do not want it over a simple percutaneous transluminal angioplasty [PTA], but unless and until there is a proven benefit for superficial femoral artery interventions over no intervention for claudicants, we must stand down. Yes, the data may say others do it more and we will lose market share, yes the patient may go to the ‘competition’, but our culture must be about standards of practice, clinical integrity, rigorous training and professional certification. Our superpower is a cautious culture that maximises the public benefit of our tools because we put our patients first.
  3. Imaging. Am I the only one who remembers Dr McCoy solving problems on Star Trek with his ‘wand’ thing? Look like an ultrasound probe to anyone else? I bet that McCoy had at least four years of training and demonstrated clinical imaging competency before they let him apply it to the crew of the Enterprise. In the USA, IR is the primary specialty that delivers image-guided care. As the imaging tools used to guide our solutions evolve, the fundamental need for demonstrable core imaging competency among IR providers will grow. Advances in imaging have made IR better, for sure, but that is only evident and possible if you understand what you are looking at. Excellence in IR requires excellence in imaging.

What’s not:

  1. We can’t do it all. It was amazing to learn IR in a time when the specialty had no boundaries other than solving a problem in a better way. I am not sure what I will do with the skill sets like building endografts, cannulating pedal lymphatics, freezing prostates with five 24Fr probes, or mounting stents on balloons—by hand. At the time, it was what we had to work with. For the future, we must accept that core IR requires advanced training and certification. Subspecialised IR requires even more to establish clinical equipoise and meet our specialty’s culture of excellence. You cannot do it all. When it is outside your wheelhouse, refer. Embrace subspecialised practice. Be the best.
  2. We are no longer alone. We should do a better job looking at the macroeconomics of disease state management. What are the least expensive, most efficacious solutions? In the USA, our payment structures and departmental hospital structures can interfere with closer collaboration among professional peers. Globally, regulators and payors or hospitals often restrict less invasive advances in care because of bias, or overly simplistic/outdated thinking. The result is that far too many open procedures are done around the world simply because the local system favours sutures over devices! We need to work together to educate stakeholders about the economics of the solutions we bring. IR is more flexible, and it is cheaper and safer when delivered by well-trained providers. We need to make our case and champion a right of access to IR care around the world.

What’s next:

  1. Grow global training. Our existing national societies are busy working on the needs of their members as they should. But we need to accept that the ultimate success of IR as a specialty, to some degree, rests in the development of skilled providers worldwide. There are not enough interventional radiologists, and far too few training options for most young doctors interested in the field. This is not insurmountable, but our strategy must change. Rather than funnelling trainees through a few excellent centres located far from home, we must build our in-country ‘national’ training centres. Training concepts and best practice strategies should be shared among centres. Other national groups should mentor, endorse, and provide needed faculty. To do this we need money! This is where our major societies need to join with industry to create a fund/ foundation focused on improving access to quality IR worldwide through the development of in-country training centres.
  2. Demand recognition/access/payment. Show me a country that does not recognise our peers in cardiology or vascular surgery. IR is a primary specialty with a unique competency that must be recognised. We need to focus and drive this message home, worldwide. It is time to collaborate to achieve the global goal of professional recognition.


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