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[Disclosure: I am a radiology resident going into interventional radiology]

There was a thought provoking thread intiated by a surgery resident on the new Interventional radiology sub forum about recent trends in IR and how it may affect surgery. I'm curious what other surgery-minded individuals may think about this.

Given recent trends in interventional radiology (IR) towards a more clinically-oriented practice with clinics and admitting privileges at increasingly more institutions, the practice of IR is evolving to be more like the surgical fields and less like “radiology.” What are your thoughts about IR becoming more clinically oriented? Is this welcomed or threatening to surgeons? Are there turf issues between surgery and IR?

I was also wondering if any of the surgical residents out there considered doing radiology with the intent of doing IR or if having to spend 4 years doing diagnostic radiology scarred people away. If you did consider IR were you aware of the Clinical or DIRECT pathways?

I'd be interested on hearing any of your thoughts. I think having cross-specialty discussions in these types of forums can be fruitful and beneficial to those participating to better understand another perspective/field.
 

beaverfetus

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IR is losing ground in peripheral vascular interventions from the data I've seen presented at conferences. They seem to be losing their slice of the pie to vascular surgery, while cardiology has remained about the same (controlling the biggest slice). Cards of course is gaining in some specific areas e.g. carotid stenting. IR has lots of procedures though, and I only have read about their market share in vascular.

The reason as a medical student I discounted IR is two fold.

1) They're referral dependent, and they've seen their referrals dip as more people are doing the cases (e.g. vascular surgery). Furthermore, I think they have a theoretical disadvantage to the traditionally patient care oriented fields e.g. surgery, medicine. First off, these fields have ample training in patient care (admitting privileges doesnt make up for years of patient care training during residency). Second, the patient care fields like cards and vascular surgery, have established referral bases e.g. surgery consult will call vascular for a cold foot. Cardiologists will call up their buddies in interventional when they find peripheral disease.

2) The training paradigms that I know about in IR seem circuitous at best. It seems like the vast majority of what IR does on a day to day basis is learned in a few years during fellowship. I can't imagine intensive training in reading knee MRIs is that helpful to your average IR. That being said I haven't read about the more clinical paradigms you refer to.

p.s. I'd appreciate any info you can give about the clinical/ direct IR routes
 

filter07

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I think in general, people who do interventions on patients should be involved in post-procedural care. So the change is good. But that raises some questions. Is one year of internship and one year of IR sufficient to learn patient care in such a wide variety of clinical cases that IR handles? How do you fit in care of the vasculopath, with the cirrhotic, the cancer patient, etc in one year? Does this trend reduce the number of radiologists that want to go into IR? I don't see this trend as a threat to surgeons; the radiologists will do these procedures anyway, so having them be more involved in patient care is not going to threaten our turf any further. If anything, the rounding and clinics will slow down the number of procedures that IR can pump out.

I was interested in IR but I just cannot stomach reading radiology books. It reminded me of everything I disliked about medical school, just reading about obscure diseases, endless differentials... just too much minutia for me. The focus is so different than surgery literature.
 
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IR has lost quite a bit of ground in vascular interventions, however there are still a good number of interventional radiologists in private practice that do peripheral vascular work. I agree the reason IR lost the cardiac work to the cardiologists and has lost ground to the vascualr surgeons is due to their traditional dependance on referrals from other specialties and because they were not involved in the care of their patients beyond the procedure. Many interventionalists have recognized the need to develop clinical skills and provide care for their patients both before and after the procedure. This is the new paradigm being taught by an increasing number of fellowships and encouraged by the Society of Interventional Radiology (SIR). Furthermore, cooperative clinical practices that include both vascular surgeons and Interventional radiologists are becoming more common and are quite successful.

Neuroradiologists and now neurosurgeons do most of the head/neck stuff. They should probably be the ones doing htat anyhow. Many radiologists do a lot of vertebroplasties and some do interventional pain work, even though there is competition in these areas as well.

Beyond that, IR has seen significant developments in its interventional oncology work with ablations, chemoembolizations and radioembolizations. Further inovation in this area continues to develop.

Other areas in IR that have a lot of potential to grow is vein work and uterine artery embolizations. There is a large population of underserved patients with varicose veins etc that can benefit from IR procedures. Uterine artery embolization for the treatment of fibroids can gained considerable ground verses hysterectomy.

In summary I guess I'd argue that although IR has lost some ground (cardiology and vascular surgery) there is still alot of work and demand for them. IR is undergoing a bit of a revolution towards a more clinical practice and training is evolving and will evolve more in the coming years to accomodate this. The procedures are realtively short (no epic 10 hour surgeries), the tools available are pretty cool, the imaging is great and it often results in a less invasive solution than would be available otherwise. I think most of hte procedures are good for patients and that it can be very rewarding.

Regarding diagnostifc residencies and fellowship. 1 year is not enough time to learn IR skills and clincial skills. Many of us are seeking out more clinical experience during residency with our elective time. The SIR recognizes this and has devleoped non-traditional pathways for IR trainees. I understand there is talk at high levels calling for further and more significant changes that would better prepare IR -trainees for more clinical responsibilities.

Here is a link to the alternative pathways:
http://www.sirweb.org/fellows-residents-students/pathway-options.shtml

The dark rooms and endless differentials have been hard at times and some of what I have learned will not be relevant to my future practice. BUt I will have the additional knowledge needed to read CTAs, MRAs, and vascular ultrasound. Many also like having the option of moving more into diagnostic radiology later in their careers.
 

irwarrior

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I think that it is the natural history of IR to become a clinical specialty. Radiation oncology was part of radiology and then utimately it separated to become its own specialty.

IR is becoming much too complex to be in the house of radiology.

For example when I see a liver cancer patient. I need to be able to deal with the complications of liver disease. Ascites, SBP (lasix, aldactone). Paracentesis/TIPS. Varices (EGDs, nadolol). Encephalopathy (lactulose etc). I also have to know the role of transplant (milan criteria, UcSF criteria). At the same time I need to know the role of resection and the randomized trials of ablative therapy vs resection. I also need to know the SHARP daa for nexavar and what the complications of nexavar are including (hand and foot syndrome, fatigue, anorexia, gi etc). Also doing IO we need to be able to refer a patient for palliative care/hospice and to be able to candidly talk to patients about their prognosis.

For the IR doing vascular interventions. It is important to know the natual history of AAA and the main trials. UKSAT, ADAM, DREAM, OVER,EVAR 1 and II, PIVOTAL, CESAR trial etc. Now with percutaneous closure devices many of these cases can be done with local anesthesia and conscious sedation. Follow up is mostly CT based and looking for sac growth and endoleaks etc. The other key is to make sure the patients are on appropriate post procedure regimen including statins (ldl<100), smoking cessation, +/- acei, bblockers in pts with CAD,bp control, hba1c<7 etc. The IR or any physician treating these patients is obligated to prevent cerebrovascular or CV events which is what these patients often succomb to.

Other IRs treat fibroids,CRC, pain, brain avms, stroke etc.

The reason I chose IR rather than surgery was to do something less invasive and see faster recovery times. I hated to see the postop paient with long recovery times in the ICU.

We have a busy practice where we admit about 10-15 patients to the hospital weekly. More and more of my IR colleagues are practicing in this fashion. Unfortunately, many of the academic programs are still practicing the old fashioned IR.

I enjoy working with my surgical colleagues and learn an awful lot from them. Our skills are quite complementary and allow us to offer the gamut of treatment options including medical treatments.
 

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Having trained in the day when IR did not admit or manage any of their post-procedure complications/issues, I am all for an increase in such duties.

However, I respectfully ask: where and when are you getting this training? I understand that everyone is doing a Prelim Med or Surg year but I don't know anyone who thinks that sufficient to be able to truly medically and surgically manage your patients. There is a reason why being BE/BC in IM or Surgery requires more than a year of training.

Irwarrior mentions treating varices, including the use of dx/tx EGDs. GI already tries to tightly control those from surgeons, I can't imagine they will take lightly to someone else coming in. Are you really prepared to manage the complications of doing those procedures? GI can't manage all their complications and they do hundreds of scopes during residency; when in IR training would you get the procedural as well as the medical training?

Is the plan to lengthen training as it currently stands or really to make IR a separate specialty and if so, will DR cease to do all percutaneous interventions?
 
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irwarrior

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IR is not necessarily involved in variceal treatment outside of TIPS, BRTO and nadolol. THey should understand the role of EGD and banding/sclerotherapy grading of varices and when to refer a cirrhotic for EGD etc.

1 year of clinical is definitely not enough. More and more IR are learning the clinical management during fellowship at the national meetings and simply by being involved in the global care of patients.

There certainly are 3 components to a good IR.
1. clinical
2. technical
3. imaging

The imaging component is very challenging to grasp and does take a full 4 years and then some. The field of imaging is rapidly changing and is becoming more accurate.

If you look at breast cancer it is really an imaging diagnostic algorith with the workup being based on mammo, us, mri and biopsies etc.

The most recent guidelines for the AASLD for diagnosis of hepatoma has taken afp out of the picture and it is based on imaging with little role for biopsy.

Most recently the NLST (very large RCT looking at screening for lung cancer shows a great reduction in lung cancer mortality. this is again based on imaging and then often image guided biopsy. currently lobectomy/segmentectomy is the preferred treatment for st 1, but cybeknife/cryoablation/rfa are showing some promising results.

So , the imaging component is becoming critical for diagnostic and therapeutic standpoint.

Granted, it has been tough to learn the critical from a Diagnostic backgroud but not impossible. I had a busy internship and a strong clinical fellowship and continue to learn a ton on the job by seeing patients.

Medicine is an art and sometimes there is not a single right answer. But,it is important that I weigh all the options and I know all the options and I have referred patients who I feel would benefit more from ercp placed stent than me doing a transhepatic intervention. i also defer to open surgery when i feel that is best for the patient. we do need more level 1 evidence and many of the rcts are being done now.

clever for claudication.
coral for renovascular disease.
crest done for carotids.
attract for dvts.
 

irwarrior

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typically I am not worried about SBP, unless they are presenting with fevers or abdominal pain with documented ascites. Patients with significant hepatoma may present with right upper quadrant pain and I thnk this is likely the cancer causing some distension of the liver capsule.

We do send ascitic fluid for other labs especially SAAG to confirm portal hypertension. Sometimes we will do balloon occlusion hepatic pressure measurements to get a corrected sinusoidal pressure to confirm portal hypertension.

I wonder if more and more people are identifying patients with NASH . Alot of the previously described cryptogenic cirrhosis patients I note are either obese or have a history of diabetes. These patients are unfortunately succombing to many of the same things that HBV,HCV, ETOH patients get.

Curious to what others think of nexavar? I have had many patients who just couldn't tolerate it and refused continued treatment with it .
 

SLUser11

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I think that it is the natural history of IR to become a clinical specialty.

For the IR doing vascular interventions. It is important to know the natual history of AAA and the main trials. UKSAT, ADAM, DREAM, OVER,EVAR 1 and II, PIVOTAL, CESAR trial etc. Now with percutaneous closure devices many of these cases can be done with local anesthesia and conscious sedation.
I think your work is innovative, and I like that you are so interested in improving your clinical skills. However, it just seems like a medico-legal nightmare if one of the patients you are medically managing has a complication, given your overall lack of training in that area.

Also, in my experience, those percutaneous closure devices suck, and I'm not sure that they should be used to close an arteriotomy big enough to facilitate a endovascular AAA stent. The pseudoaneurysm rate has got to be unacceptably high.

As far as Nexavar goes, I'm unsure about the severity of side effects. As surgeons, we typically see people with resectable liver and kidney cancers, whereas nexavar seems to have a role primarily in unresectable disease, so the medical oncologist would have infinitely more experience than we would.
 

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...when I see a liver cancer patient. I need to be able to deal with the complications of liver disease. Ascites, SBP (lasix, aldactone)....
typically I am not worried about SBP, unless they are presenting with fevers or abdominal pain with documented ascites...
Nice dance, but you are the one that listed it as one of the things you need to know how to deal with/treat and I guess you listed what your treatments would be in parenthesis. Now, you are not typically worried about it.....

It is no matter. We have heard the arguments from numerous folks in other specialties. Everyone going on about grandiose ideas of very broad scope of knowledge and clinical practice, etc.... that argument usually comes with little to no demonstratable broad based clinical training. It usually comes from folks planning on certain finite scopes of practice but trying to argue their ability to actually manage the over-all patient. Then, they get into real life practice, do their procedures, and manage little to nothing. The fact that they manage little to nothing is probably better for the patient/s.

However, these grandiose claims of scope and knowledge are quite intellectually dishonest. I would much rather an honest answer in the traditions of orthopedics that makes no bones about not planning to do clinical/medical management then the dishonest claims of large sweeping knowledge and scope.
 

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I wonder if more and more people are identifying patients with NASH . Alot of the previously described cryptogenic cirrhosis patients I note are either obese or have a history of diabetes. These patients are unfortunately succombing to many of the same things that HBV,HCV, ETOH patients get.

Curious to what others think of nexavar? I have had many patients who just couldn't tolerate it and refused continued treatment with it .
As SLUser notes, I think you are overestimating the role that surgeons play in both diagnosing liver disease such as NASH and management of Stage IV RCC or HCC. Nexavar is not a first line drug for either per NCCN guidelines and as he notes, we don't see patients with unresectable disease unless its for port placement (which is increasingly done by IR anyway outside of academic medical centers).

However, the fact is that even if the SE profile of Nexavar were tolerable, the medication does not provide much in the way of *clinical* improvement or OS. Most patients stop because the SEs are intolerable and the increase in OS is about 2 months for Stage IV HCC when Nexavar has been used as last ditch effort.
 

irwarrior

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It used to be that the bulk of patients I saw with hepatoma had HCV or HBV but now I am seeing more and more of these possible NASH cases.

As far as nexavar, I used to refer those who were non transplantable or unresectable who progressed through TACE with multiocal bilobar disease and those with extrahepatic disease and major vascular invasion. But, there is a high risk of recurrence that I have seen in patients who are either resected or ablated and I see them a few years later with new tumors. This is frustrating and I wonder if we could put these patients on nexavar and prevent future tumor development . The Bayer company has many trials ongoing including TACE with nexavar and SPACE (Drug eluting bead and nexavar). I have not had great results on patients I referred for this medication and was curious what others experience has been. The theoretical benefit of anti-proliferative and anti-angiogenic benefits are promising. It is very difficult to assess our treatment results with current imaging and alot of our tumors are AFP negative. I do think that diffusion /perfusion has promise especially with EASL criteria . I think using classic RECIST is not of benefit with IO options or biologics.


As far as RCC, IR has a possible role in Nephron sparing treatment of T1a stage 1 rcc but not much of a role in anything beyond that. Even those small tumors they have a probability of being benign such as oncocytoma or fat spared AML. See Stu Silverman's articles (up to 30 % were benign). It used to be all these lesions would get partial nephs but more and more people are performing biopsies or contnued follow up as pathologists get more comfortable with typing the lesions.

Thanks for your responses.
 

JackADeli

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...As far as nexavar, I used to refer those who were non transplantable or unresectable who progressed through TACE with multiocal bilobar disease and those with extrahepatic disease and major vascular invasion. But, there is a high risk of recurrence that I have seen in patients who are either resected or ablated and I see them a few years later with new tumors. This is frustrating and I wonder if we could put these patients on nexavar and prevent future tumor development...
I guess I am a little confused as to where you are positioned in this treatment paradigm. Are primary care physicians just directly referring to you and then you "refer those who were non transplantable or unresectable" ?

I suspect, these liver patients have hepatologists and/or oncologists that are doing primary referrals for chemo therapeutics... to include nexavar. Usually, the liver surgeon and/or hepatology team makes the call as to resectable or transplantable and make the appropriate referrals from there. Generally not IR. Your replies really suggest you are having a greater management role in all of this then I imagine is normal.
 

irwarrior

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So, in general we discuss the bulk of the liver cancer cases in a tumor board. Hepatology, IR and surgical oncology will bring cases to discuss. We get outpatient referrals from various physicians including PCP, oncologists, gi docs, rad oncs, surg onc etc.

The algorithm is pretty straightforward. Hepatoma is essentially an imaging diagnosis (AASLD guidelines). Once we establish the diagnosis we then determine treatment algorithm. Is it resectable ? Based on location and extent and liver disease . Most patients we see are excluded either due to severity of underlying liver disease and diminished synthetic function or portal hypertension (splenomegaly, thrombocytopenia <100k, ascites etc). If the patient has bilobar disease in general they do not resect. So, that is our version of surgical options.

The caveat is that a potentially resectable patient has an option of ablation. In fact the Chen article RCT showed 4 yr disease and overall survival similar in resection and ablation. Also a resected patient or ablated patient still has between 50-70% chance of tumor rescurrence . This is one reason we often advocate transplant. transplanted livers within milan only have a recurrence rate of 8% for up to 10 yrs. In a resected patient they lose MELD exemption points. But, if I ablate a patient within Milan and >2cm they still get 22 MELD points to boost them on the OLT list. We follow Milan and can downstage a UCSF criteria to MILAN.

We perform local regional therapy with TACE, DEB, ablative therapy for patients who are even potentially resectable if the tumor is the right size and location etc. Also, we will do it on patients who we are bridging to transplant. Also, unresectable and nontransplant candidates are treated by us to palliate/prolong survival. The problem is once it progresses through our treatments we will send them for nexavar , but my experience with these patients has not been great and many of my patients have stopped the nexavar on their own.

We admit our post TACE patients to the IR service and follow them for the course of their life until they get transplant or until they go to palliative care. We order imaging every 1-3 months with labs and see them in the office to discuss options. I worry that if you rely on the imaging report, it will either under report or over report the disease burden (affecting potential for transplantation). So, we make it a point to follow these patients oursevles. This has enabled me to gain a great experience with liver cancer and liver disease in general. I still have a lot to learn and am fascinated by the primary liver cancers as well as the function of the liver itself.
 

JackADeli

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...I wonder if we could put these patients on nexavar and prevent future tumor development...
...in general we discuss the bulk of the liver cancer cases in a tumor board. Hepatology, IR and surgical oncology will bring cases to discuss. We get outpatient referrals from various physicians including PCP, oncologists, gi docs, rad oncs, surg onc etc...
So, it is a little clearer now despite the long and somewhat round about description. You are describing a multidisciplinary conference suggestive of higher volume center that uses multiple modalities. That scenario would also suggest that the referrals go to the oncologists, hepatologists, and/or surgeons. These individuals would perform a complete, usually outpatient work-up/H&P and submit them to conference. Prior to submission they may undergo imaging and/or biopsies by IR.

At multi-discipline conference, the primary physician, onc/hep/surge would seek input and the patient may be sent to IR for some procedure. Also, oncology would discuss risk/benefits of chemotherapeutics. IR may decline the patient for procedures, etc...

In short, it is very unlikely that "you" are referring much in referance to chemotherapeutics. These patients would already be in the pipeline with onc/hep/surge. You are presumably a consulting member of the team and not a primary referring provider.

As to your question, "...if we could put these patients on nexavar and prevent future tumor development...", I suggest you ask at "your conference". You give very long thought out comments and replies in this thread. In fact, the numbers, quotes, terms, etc... suggests you maybe cutting and pasting trying to prove you are somewhat more then you are in this, IMHO, charade. However, the premise suggests your role is far lower on the ladder then you imply. :(

Thank you for the references.......
 
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youngdoc8205

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JAD why are you so down on IR. Surgeons used to complain incessantly that IR would do procedures and then not follow-up. Now that they are trying to be more clinical, to the point of even starting their own residency you and your ilk seem dead set to prevent that.

In fact one of the greatest obstacles to an IR residency is the ABS, because you need a certain amount of specialties to vote positively to get a specialty approved for a primary certificate.


Now granted, as of right now IR shouldn't be referring HCC patients for chemo, or treating SBP, at least not complicated SBP, b/c there isn't enough training, but the training paradigm is shifting. And certainly they are capable of managing lipids and BP in vascular patients. It's not exactly idiots that go into this field anyway, I'm sure they are quite capable of learning the algorithms for management.

This antagonism towards IR isn't going to benefit anybody, especially b/c some of the major medical innovations came from IR, i.e. Seldinger/Dotter, and were co-opted by surgeons.

Now while I love surgery every since I switched from rads, I don't love, and one of the major reasons I didn't do surgery from the get go, is this prevalent "holier then though" attitude among surgeons, not just towards IR, but virtually every field. And you seem to be fitting into this pigeon hole.

I find it to be a little more conducive to patient care to embrace every option that pts as critically ill as the ones IR usually treats.

Surgery is no longer the last option on the table when medical therapy fails in whatever pathologic process. That might hurt some peoples egos, but who gives a crap, as long the patient does well.
 
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So it seems the recent discussion in this thread was increased clinical responsibilities sound like a great idea, but where are the interventional radiologists going to get their clinical training from. I find that to be a very valid question. As things now stand clinical exposure during residency is varied and quite limited. Some us are making personal efforts to braoden our clinical exposure during radiology residency. I for example maintain PALS, ACLS and ATLS acredidation and moonlight in local ED's on occasion. I am also seeking elective time with Vasc surgery during my residency. As far as clinical exposure during fellowship, that also varies by fellowship. Some training programs have admitting priviledges and take care of their patients as the primary service. They then learn how to manage the disease that their patients are being treated for. I'd imagine they still get cards and IM consults as needed. Assuming people know their bounds, I think it would be improvement in patient care to have the team that did the procedure be involved in the patients manangement as it realtes to that disease process. This is a work in progress. Effrots are being made at many levels at both training programs and by the Society of Interventional Radiology to determine how to best provide this necessary training. Leaders of IR in Europe have proposed adding an additional year to fellowship heavy in clinical training with surgery and vasc surg. Here in the US some are trying to broaden exposure/training during residency. THe change or evolution of IR into a more clinical subspecialty is happening now. It is a process and will necessarily be modified and adjusted as circumstances allow. As this happens I appreciate the thoughts and support of those that are already more clinically committed to thier patients (such as you surgeons).
 

SLUser11

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The caveat is that a potentially resectable patient has an option of ablation. In fact the Chen article RCT showed 4 yr disease and overall survival similar in resection and ablation. Also a resected patient or ablated patient still has between 50-70% chance of tumor rescurrence .

.....We perform local regional therapy with TACE, DEB, ablative therapy for patients who are even potentially resectable if the tumor is the right size and location etc.
I'm relatively familiar with the literature on this subject, especially out of MSK, and the majority of studies I've read show a significantly lower recurrence rate with resection versus RFA. I cringe a little when you lump the two therapies together like they are equivalent.

I don't have a problem with RFA in general, and I think there is a role for hybrid procedures, where resectable lesions are taken out, and unresectable areas are given RFA, but I really don't think they are equivalent therapies at this point. I would hate to think that you are trying inferior therapies, be it RFA or chemoembolization, on patients that are potentially resectable.

Maybe someone on SDN with a little more free time could do a quick lit search to clear up the issue...it's not going to be me, as I'm running off to clinic now. I think D'Angelica and DeMatteo would be the authors on some of the bigger papers.
 

JackADeli

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...why are you so down on IR. ...Now that they are trying to be more clinical, to the point of even starting their own residency you and your ilk seem dead set to prevent that...
IMHO, you are completely misreading. I am NOT "dead set" to prevent or against it. That is not the issue I am pointing out. Honestly, I have no dog in this hunt and am not particular in either direction. I definately, in general, believe physicians that perform procedures should have adequate clinical skills with a clinical practice to primarily manage in that fashion.
...Now granted, as of right now IR shouldn't be referring HCC patients for chemo, or treating SBP, ...b/c there isn't enough training, but the training paradigm is shifting. And certainly they are capable of managing lipids and BP in vascular patients...
Now that is the point. Maybe the paradigm is shifting and will eventually go to where IR has outpt cinics with H&Ps and work-ups. But, that is generally not where they are. Thus, my point is the long answers and representation that at the very least imply IR is a primary referring provider as opposed to being the consultant. Chances are very unlikely that IR is arranging the surveillance scans. Rather, I suspect the primary service (i.e. onc/hep/surge) are seeing these patients in clinic follow-up and ordering the surveillance scans, represent to conference when appropriate, and referring to IR when appropriate.

As to managing lipids & BP, again, if you are not running a clinic and following, you shouldn't be managing this. It just gets to be way too many cooks in the kitchen. I would also suggest that primary care/FM are going to disagree with the generalization that suggests lipids/hypertension/?DM are simple and easy to manage without any real clinic management volume of training.
...This antagonism towards IR isn't going to benefit anybody, especially b/c some of the major medical innovations came from IR, i.e. Seldinger/Dotter, and were co-opted by surgeons...
No antagonism towards IR as a specialty. Just trying to keep the representation honest. The thread was started with the title it has. The representation in some of the replies has, IMHO, though probably not intentional, misleading. See my earlier replies if that point is not clear. As for procedures and co-opting, that is a red-herring that really means nothing. You can also say laparoscopy was co-opted, etc... That is not the relevant point.
...while I love surgery every since I switched from rads ...one of the major reasons I didn't do surgery from the get go, is this prevalent "holier then though" attitude among surgeons...
Again, not the point. If you are still hurt from some adverse experiences with surgeons in the past, I suggest you try not to let it cloud how you interpret things. It is not about "holier then though". I have no problem with qualified and trained folks providing care and managing patients. My points are fairly clear through out. I am responding to what has been said and what it infers. IMHO, much of which is innaccurate and somehow suggests IR (in this case) as the managing party referring patients for chemo.
...I find it to be a little more conducive to patient care to embrace every option that pts as critically ill as the ones IR usually treats...
Again, NOT the point. I do not believe anyone has objected to multimodality therapies or multidiscipline approaches to patient care. IR is a booming field because "we" do embrace the modalities they have to offer.
...Surgery is no longer the last option on the table when medical therapy fails in whatever pathologic process. That might hurt some peoples egos, but who gives a crap, as long the patient does well.
Who said it was??? (rhetorical). I don't believe anyone is saying not to use IR or any other specialty here.... again, If you are still hurt from some adverse experiences with surgeons in the past, I suggest you try not to let it cloud how you interpret things.
 
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I'm relatively familiar with the literature on this subject, especially out of MSK, and the majority of studies I've read show a significantly lower recurrence rate with resection versus RFA. I cringe a little when you lump the two therapies together like they are equivalent.

I don't have a problem with RFA in general, and I think there is a role for hybrid procedures, where resectable lesions are taken out, and unresectable areas are given RFA, but I really don't think they are equivalent therapies at this point. I would hate to think that you are trying inferior therapies, be it RFA or chemoembolization, on patients that are potentially resectable.
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I'm not going to make any sweeping claims. What it really comes down to is the patient selection from the studies where ablation and resection are compared. Even when patients with the same malignancy at the same institution are compared, one has to be careful when reading the study to ensure that appropriate measures were taken not to bias selection of patients to one group or another. If either group cherry-picks the lesions that are not adjacent to central bile ducts, vascular structures, etc then that will obviously allow them wider ablative/surgical margins. The studies I have seen pulished by surgeons usually favor resection and those published by IR show they are not significantly different. Its all about patient selection people.

I'm also familiar with Chemoembolization literature and it is not a surgical equivalent and should be considered the same.
 

irwarrior

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This is the paper I was talking about. I agree I do not yet believe RFA is ready for CRC, but in my opinion local treatment works pretty well for hepatoma. MSK had sent out a trial showing OKUDA 2 etc with solitary 7 cm hCC treated with bland embo and ablation vs resection in a retrospective large series with similar survival.

I do not do TACE as a replacement therapy for those I can ablate , but I do use it as a synergistic treatment option. combo tace and then ablate to improve the ablation zone.

I referred a number of patients a few years ago for nexavar (16 or so patients). The bulk of them 14/16 could not tolerate full dose. When I can no longer offer therapy or they are progressing through my treatments, I feel bad and want to offer them something so I will send them for referral for nexavar. But, I am still not sure that is the right thing to do.

Percutaneous local ablative therapy vs partial hepatectomy for small hepatomas
nChen et al
Analysis after post-randomization exclusion
nPLAT (71 pt) Surgical Resection (90 pt)
n1,2 ,3 , 4 yr overall survival PLAT vs resection
95.8%, 82.1 %, 71.4%, 67.9%
93.3%, 82.3 %, 73.4%, 64.0%

nDisease-free-survival rates PLAT vs resection
85.9%, 69.3%, 64.1%, 46.4%
86.6%, 76.8%, 69%, 51.6%
 

SLUser11

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This is the paper I was talking about. I agree I do not yet believe RFA is ready for CRC, but in my opinion local treatment works pretty well for hepatoma. MSK had sent out a trial showing OKUDA 2 etc with solitary 7 cm hCC treated with bland embo and ablation vs resection in a retrospective large series with similar survival.

I do not do TACE as a replacement therapy for those I can ablate , but I do use it as a synergistic treatment option. combo tace and then ablate to improve the ablation zone.

I referred a number of patients a few years ago for nexavar (16 or so patients). The bulk of them 14/16 could not tolerate full dose. When I can no longer offer therapy or they are progressing through my treatments, I feel bad and want to offer them something so I will send them for referral for nexavar. But, I am still not sure that is the right thing to do.

Percutaneous local ablative therapy vs partial hepatectomy for small hepatomas
nChen et al
Analysis after post-randomization exclusion
nPLAT (71 pt) Surgical Resection (90 pt)
n1,2 ,3 , 4 yr overall survival PLAT vs resection
95.8%, 82.1 %, 71.4%, 67.9%
93.3%, 82.3 %, 73.4%, 64.0%

nDisease-free-survival rates PLAT vs resection
85.9%, 69.3%, 64.1%, 46.4%
86.6%, 76.8%, 69%, 51.6%
That post is showing up pretty weird, but I'll read the article later today when I get some down time. I think we're in agreement here....RFA is great, but just not as good as resection at this point.
 

SLUser11

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That post is showing up pretty weird, but I'll read the article later today when I get some down time. I think we're in agreement here....RFA is great, but just not as good as resection at this point.
Here is an article from this month's Annals of Surgery that is relevant to our earlier discussion.

Resection is king when it comes to hepatic metastases, but I have to admit that I was impressed by some of the numbers for RFA....definitely a viable alternative for patients who are not candidates for surgery...but we already knew that.
 

youngdoc8205

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I can't access the whole study, but I remember reading it before. I think (please correct me if I'm wrong) that the RFA was not done percutaneously but laparoscopically or open, i.e. both performed by surgery not IR. I don't think I there are any prospective, randomized trials comparing percutaneous ablation (RFA/cryo/nanoknife) to resection, again please correct me if I'm wrong.

Also, maybe someone can answer this question for me.

How do you justify to the IRB to do a prospective, head to head trial of a proven standard of care (i.e. resection) to a novel therapy (RFA), or really in any case, aren't we condemning the experimental group to potentially worse outcomes? As the paper posted by SLU suggests, the RFA patients did worse, though the numbers were quite good for the RFA group they weren't as good as the resection group.

I've actually never been able to get a good answer regarding interventional (surgical, radiological, whatever) treatments, be it for cancer, stroke, carotid disease, etc. It always seemed to me that most novel therapies just kind of gained favor over time, and comparisons were done retrospectively, granted a lot of these therapies (coronary stenting) were pioneered prior to the advent of evidence-based medicine.

Additionally how do you get 2 competing groups of physicians, say IR/surge onc, or cards/CT surgeons to cooperate on research that could justify the elimination of a service that one or the other provides. Ethically it's a no-brainer, patient well being supercedes all, but economically I guess all bets are off.

Just look at uterine artery embolization, and the fighting going on there, based mostly on economic reasons.
 

BlondeDocteur

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I'm an intern-- big caveat. My sum total of experience is that I did IR as my final month of medical school, and now have two months of vascular surgery under my belt.

I found it very intriguing but, as someone stated above, a misfit in the house of radiology.

If you're drawn to the field-- the interventionalism, the patient care, the technical skills-- then I imagine 4 years of diagnostic radiology would be quite unappealing, as none of those things are in any way part of image interpretation. And, as most radiology residents select their specialty precisely because they are *not* interested in patient care, clinical responsibility, interventionalism or technical skills, your colleagues and attendings would not necessarily foster a culture conducive to the personality attributes necessary to taking clinical care of patients.

I know about the direct pathways. They're intriguing, but IMHO they just make things a lot harder. You still have to be boarded in diagnostic radiology, but you smash that training into 3 yrs versus 4. Every radiology resident I know feels that 4 years is barely enough-- you guys have some tough boards with an absolutely massive knowledge base. And psychologically the clinical base years seem tough: imagine doing two only years of surgery residency-- you've survived the least appealing parts, you're just getting to operate, and then you have to go sit in a dark room for 3 years? Not cool. Or, if you chose medicine for your clinical base, you'd be just a year away from finishing the whole residency and being board-eligible in IM.

Honestly, I think IR should divorce itself entirely from diagnostic image interpretation and change its name to "endovascular medicine" or the like.

From a personal perspective-- I enjoyed my IR month, but ultimately found it a little "small potatoes." It was fun, but didn't bring a strong sense of satisfaction like big operative cases did. Putting in ports, PICCs, dialysis catheters, drains, chemo-embo, etc... pleasant, enjoyable, but not the same thing as doing something potentially life-saving. I imagine that's where the essential divide between those who choose surgery versus IR lies: do you want the drama and responsibility of addressing high-acuity pathology in an invasive, possibly high-risk fashion or not?
 

DrBowtie

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[snipped].....I imagine that's where the essential divide between those who choose surgery versus IR lies: do you want the drama and responsibility of addressing high-acuity pathology in an invasive, possibly high-risk fashion or not?
Anyone else want to comment on this? I'm trying to decide between the two currently. I wouldn't be dead set on having a high endovascular caseload if I went the IR route either. Mix of those, drains, ablations, and some diagnostics would be fine w/me.

If I went the surgery route, I'd probably just do general surgery (maybe onc or plastics fellowship but doubtful)
 
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I’ll weigh in. I’m a 4th year who faced the same question of IR vs. a surgical subspecialty, and ultimately decided to go IR (it was really down to the wire for me!). I love surgery and thus will do a surgery prelim year.

I also love big, invasive cases…but after a few weeks on IR, something “clicked” in my head: the IR, minimally invasive way just made sense to me. It’s easier on the patient, and surgery in general is headed the minimally invasive way, undeniably. Yes, there are definitely procedures that you cannot do minimally invasively where you have to open someone up. This is why we will always need surgeons- and thank goodness for them. But, if these types of procedures can be avoided at any cost, they are.

What struck me more about IR, rather than its limitations, was everything that you COULD do: the variety of cases and practice types that are available in IR (see the IR forum for more info about this), the exciting “save a life” embolization procedures where you get your fill of adrenaline, and the ability to mix in diagnostic radiology which is challenging and stimulating in its own way. I also liked the creativity that is involved in IR. There are a lot of times where you’re in a new/tough situation and have to think on your feet and improvise (true for surgery too, but more so I think for IR). Depending on your mindset, this could be a good thing or not.

Plus, I absolutely love the research that’s going on in IR. Diverse, cutting-edge, exciting…and as I definitely want to do research in my career, this is important to me. Also, I’ve always been a techy type and felt that IR is a perfect fit in this sense, as well. There is, of course, lots of techy stuff in surgery/the surgical subspecialies- so you can find this in other places than IR.

I think you can’t go wrong with either way you go. They are both great choices, but it’s all up to what you want to do. There are ways around “spending 4 years in a dark room” such as clinical pathways and even having a supportive PD that will help you tailor your schedule to achieve your goals. Still, most of your training will be devoted to learning the imaging part well. When I had reservations about the “4 years in a dark room” concept, I opened up to several IR docs who told me that they went through the same thing- and many of them were also initially torn between IR and surgery. When I asked them, “was it worth it?” all ended up saying it was- and they’d do it again in a heartbeat.

Good luck!
 

droliver

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As you've seen the vascular fellowships retool quickly to integrated programs with as much of 1/2 of that endovascular, the rationale of that there's going to be a niche for IR to do much vascular procedures (especially with cardiology, CTVS, and Neurosurgey in the mix) in the future seems like wishful thinking from a few IR partisans. While there's going to be a continued role for IR with perc-draining abdominal collections and the like, if you're interest in IR was mostly due to vascular procedures you'd be better off going the vascular surgery route.
 

youngdoc8205

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while I think the majority of ARTERIAL endovascular work i.e. stents, angioplasties may not be done by IR, it is by no means lost to vascular or cards. Furthermore IR consists of signifanctly more then drains and biopsies.

Dialsysis work: declots, temp catheters, etc. while not glamorous is highly lucrative, I've know several people to build practices solely do these procedures and make >600k in mid-size metropolitan areas, additionaly vein work: ablation, IVC filters, transjugular biopsies, thrombolysis typically goes to IR rather than VS, though these are certainly within VS scope of practice and there are areas where IR is the only one doing endoarterial work, and there are cardiology, vascular and radiology combined practices that do this as well.

And stuff exlcusively done by IR and unlikely to be taken up by other specialties in a large way due to very tightly controlled turf: image guided ablation, chemo/radioembolization, UFE, pelvic congenstion syndrome treatment, AVM treatment (body/neuro/peds), High frequence image guided ultrasound (new, not sure when it will come out)

other things (not glamorous, but necessary) thoras, paras, vascular access, image guided biopsies
AVM therapy
hepato-biliary therapy
nephrostomy tubes (i've heard urology trying to get in on these, but no IR will teach them)


my main issue with IR is it's a somewhat quaternary referall specialty, very few procedures (UFE is the only one I'm aware off) will a patient come from a PCP or on their own for evaluation, and you have to work your ass off to build a practice and get procedures out there, for me that was more of a hassle then a surgery residency, but like above people stated: IR is extremely varied in what they do, you can build a career on just UFE, dialysis care, or be a jack of all trades, but if you are only attracted it to it b/c you like stents and angioplasties and EVAR, vascular is the way to go.
 

IR_2016

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Anyone else want to comment on this? I'm trying to decide between the two currently. I wouldn't be dead set on having a high endovascular caseload if I went the IR route either. Mix of those, drains, ablations, and some diagnostics would be fine w/me.

If I went the surgery route, I'd probably just do general surgery (maybe onc or plastics fellowship but doubtful)
Sorry to unearth a fossile, but I just read through this entire thread and found it to be a great read. Just wondering, @DrBowtie, 6 years later - what did you choose? Can you provide some insight as to how and why you made your final decision and whether it was worth it?
 
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rigid

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Sort of related: The IR guys do some cool stuff no doubt about that, there is a huge difference between being a surgeon and IR doc though. IR seems to be primarily about the procedures and they have a limit to what they can achieve although their scope is ever increasing. Surgeons on the other hand treat surgical disease and surgery is just one of the tools available to treat such diseases.

IR lack the referral base and i'm not sure that they will ever be able to achieve it, they spend the majority of their training learning to be radiologists and how to perform interventional procedures rather than managing patients. They have a niche role and if you want to do what they do more power to you because what they do is awesome but be aware its very different to being a surgeon.
 

DrBowtie

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Sorry to unearth a fossile, but I just read through this entire thread and found it to be a great read. Just wondering, @DrBowtie, 6 years later - what did you choose? Can you provide some insight as to how and why you made your final decision and whether it was worth it?
Blast from the past. I ended up doing radiology and ultimately not doing an IR fellowship. Found myself totally uninterested in the vascular cases and there are plenty of non vascular procedures done by non IR radiologists to satisfy my interests in procedures. Anecdotally, ~50% of applicants/new residents express interest in IR but only ~10-15% end up applying for IR fellowship in my experience.

I think there is a very common misconception that any image guided procedure falls under IR but that is the case in a select few institutions. Aside from nuc med and ER/Nights, we do some type of procedure on each rotation.

Definitely don't regret doing radiology. I don't think I would have done well in Gen Surg. I'm skeptical of the new IR residency and predict lots of swapping in and out once people get to experience IR firsthand.
 

IR_2016

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Blast from the past. I ended up doing radiology and ultimately not doing an IR fellowship. Found myself totally uninterested in the vascular cases and there are plenty of non vascular procedures done by non IR radiologists to satisfy my interests in procedures. Anecdotally, ~50% of applicants/new residents express interest in IR but only ~10-15% end up applying for IR fellowship in my experience.

I think there is a very common misconception that any image guided procedure falls under IR but that is the case in a select few institutions. Aside from nuc med and ER/Nights, we do some type of procedure on each rotation.

Definitely don't regret doing radiology. I don't think I would have done well in Gen Surg. I'm skeptical of the new IR residency and predict lots of swapping in and out once people get to experience IR firsthand.
Would it be possible for me to contact you directly? I have some questions and it won't let me send you PMs.
 

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If you're interested in IR, I'm happy to answer any questions or concerns you may have. I went to medical school thinking surgery but I discovered IR and have not looked back since.
 

Fab5Hill33

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If you're interested in IR, I'm happy to answer any questions or concerns you may have. I went to medical school thinking surgery but I discovered IR and have not looked back since.

Would it be possible for me to contact you directly? I have some questions and it won't let me send you PMs.