Thoughts on IR programs?

[Smoking Jay Cutler]

"Can you touch upon the benefit of doing IR training versus going into vascular surgery if we are just looking at PAD and aortic work?"

If we are just looking at PAD and aortic work, going into vascular surgery is the way to go. The reason I brought up those specifically is because they are considered a part of IR training as per the IR residency GME guidelines (2 of the 12 case log domains) and may be only a small part of training in many programs.

"Can you also touch upon the difficulty of getting into multi-disciplinary groups?"

My n=1 and this person attended a lesser known program with strong IR and stated at that time that his case log was very impressive to practices where he applied. He ultimately joined a VS and IR group.

"In the study you quoted, over 60% respondent did not feel PAD training correlate to their first job. This is what I’ve seen with my trainee as well."

The reason i included the study was to provide some data.

The questionnaire of Grads revealed:
48.5% were in a private practice and 45.3% were in academic
practice.
In 60.2%, the practice was >75% VIR.
During fellowship training, 60.7% performed relatively few (0-25)
first operator PADi and 49.5% described their training quality as
weak or barely adequate.
63.7% felt that PADi training had no influence on the choice of first
job after training while 7.6% avoided jobs with PADi.
First job PADi case load per year was 0-10 (36.5%), 11-50 (38.9%),
and >50 (20.9%).
35.4% of Grads felt their training prepared them very well or excellent for first job PADi.
36.9% of Grads currently feel very comfortable with managing
acute limb ischemia.
Factors that facilitated/improved PAD skills in their first job were:
practice member instruction 43.9%, non-PADi VIR skills 43.2% and "self-taught" 25%.
43.6% perceived PADi as a rewarding aspect of their first job, compared to 18.6% as a distressing aspect.

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[IRattending2021]

"Can you touch upon the benefit of doing IR training versus going into vascular surgery if we are just looking at PAD and aortic work?"

If we are just looking at PAD and aortic work, going into vascular surgery is the way to go. The reason I brought up those specifically is because they are considered a part of IR training as per the IR residency GME guidelines (2 of the 12 case log domains) and may be only a small part of training in many programs.

"Can you also touch upon the difficulty of getting into multi-disciplinary groups?"

My n=1 and this person attended a lesser known program with strong IR and stated at that time that his case log was very impressive to practices where he applied. He ultimately joined a VS and IR group.

"In the study you quoted, over 60% respondent did not feel PAD training correlate to their first job. This is what I’ve seen with my trainee as well."

The reason i included the study was to provide some data.

The questionnaire of Grads revealed:
48.5% were in a private practice and 45.3% were in academic
practice.
In 60.2%, the practice was >75% VIR.
During fellowship training, 60.7% performed relatively few (0-25)
first operator PADi and 49.5% described their training quality as
weak or barely adequate.
63.7% felt that PADi training had no influence on the choice of first
job after training while 7.6% avoided jobs with PADi.
First job PADi case load per year was 0-10 (36.5%), 11-50 (38.9%),
and >50 (20.9%).
35.4% of Grads felt their training prepared them very well or excellent for first job PADi.
36.9% of Grads currently feel very comfortable with managing
acute limb ischemia.
Factors that facilitated/improved PAD skills in their first job were:
practice member instruction 43.9%, non-PADi VIR skills 43.2% and "self-taught" 25%.
43.6% perceived PADi as a rewarding aspect of their first job, compared to 18.6% as a distressing aspect.

So 50% of IR grad described their PAD training as weak, yet 60% of new grad do more than 11 case of PAD a year. Only 35% felt they had strong training.

From what I’ve seen, the reality is that the IR jobs that require a new grad to do PAD are NOT competitive and usually PAD are required because there aren’t enough VS and cards to provide PAD care in a rural region. Those jobs would be happy with (Almost) any IR grad. It certainly is helpful to have more experience in PAD or other service lines prior to signing up but it certainly isn’t a requirement for those jobs. More over, with appropriate mentoring or even just plain “know-your-limitation” I believe most IRs can safely treat PAD. Maybe they aren’t doing pedal recans or venous arterlization but I do not believe they are hurting people inappropriately. Above the knee PAD is relatively straight forward compared to some of the more complex things we do.

Meanwhile, the OBL and unicorn IR jobs with PAD in competitive locations typically go to an experienced rad.

I still personally think it maybe misguided to recommend med students IR/DR program just based on how much PAD a program does and disregard everything else. For a medical student, the most important thing remains location, location and location (where they like to live), reputation and size of the program being the next most important thing as alumni network can help them with jobs.

Hell, it probably is far more important for a student to go to an IR/DR program with top notch diagnostic radiology component as an average med student has a much higher chance of practicing some DR along with their IR than practicing PAD service line. I think some posters here are very vocal about what they want IR to become but in doing so we forget where we came from...we are radiologists. We differentiate ourself by being the imaging experts. A medicore DR will be a medicore IR.

 

[irwarrior]

The variability in imaging is really not as great between the various programs as the DR curriculum is fairly standardized and the scope and breadth of DR is so broad that no individual will see all of the pathology that the radiology boards has tested one on. Almost all DR programs are supposed to cover MSK, Neuro/ Head and Neck , Peds, Thoracic, Cardiac, Nucs, GI, GU, US. Many trainees are sent to a Peds hospital if their training can't cover that segment. A lot of the advanced imaging that is done is because of the surgical and medical subspecialties that bring patients to the facility ie transplant surgery, Gyneonc, uro-onc , hepatobiliary surgery, neurosurgery, ortho ons etc. So, the local training experience will be based on that component. But, the ABR over the course of time has made it such that the average graduate is able to see and cover the needed material to pass the boards and be competent radiologists. I haven't read DR formally in quite some time, but I personally don't think I am a weaker "IR " because of that. In fact, I spend more time seeing patients and performing procedures so I feel like I continue to improve clinically and technically.

Currently, in VIR the average graduate is capable of vascular access, abscess drainage, chemoembolization , ablations, TIPS/BRTO . There is a great deal of variability in the remainder of what a graduate may see and much of this may be due to the surgical or medical specialists providing such services. Kyphoplasty may be done by neurosurgery, PAD by IC or VS, stroke interventions maybe neurology or neurosurgery. Imaging can potentially be learned in a book and by seeing, but for interventions you have to do (until simulators get really good). So, I would advocate go to the place with the broadest clinical and technical skill set where you are going to work super hard. If you are looking for a mixed practice, I agree you can go pretty much to any IR training program and you will be more than fine.

 

[IRattending2021]

The variability in imaging is really not as great between the various programs as the DR curriculum is fairly standardized and the scope and breadth of DR is so broad that no individual will see all of the pathology that the radiology boards has tested one on. Almost all DR programs are supposed to cover MSK, Neuro/ Head and Neck , Peds, Thoracic, Cardiac, Nucs, GI, GU, US. Many trainees are sent to a Peds hospital if their training can't cover that segment. A lot of the advanced imaging that is done is because of the surgical and medical subspecialties that bring patients to the facility ie transplant surgery, Gyneonc, uro-onc , hepatobiliary surgery, neurosurgery, ortho ons etc. So, the local training experience will be based on that component. But, the ABR over the course of time has made it such that the average graduate is able to see and cover the needed material to pass the boards and be competent radiologists. I haven't read DR formally in quite some time, but I personally don't think I am a weaker "IR " because of that. In fact, I spend more time seeing patients and performing procedures so I feel like I continue to improve clinically and technically.

Currently, in VIR the average graduate is capable of vascular access, abscess drainage, chemoembolization , ablations, TIPS/BRTO . There is a great deal of variability in the remainder of what a graduate may see and much of this may be due to the surgical or medical specialists providing such services. Kyphoplasty may be done by neurosurgery, PAD by IC or VS, stroke interventions maybe neurology or neurosurgery. Imaging can potentially be learned in a book and by seeing, but for interventions you have to do (until simulators get really good). So, I would advocate go to the place with the broadest clinical and technical skill set where you are going to work super hard. If you are looking for a mixed practice, I agree you can go pretty much to any IR training program and you will be more than fine.

I don’t want to sound confrontational, but do you believe that the average IR grad, having had the most amount of education in endovascular and image guided techniques, would have trouble picking up the bread and butter of a service line like kyphoplasty or PAD?

Do you believe that something that can be picked up (and are picked up) by practicing cards and pain management specialist from weekend courses like PAD and Kypho would necessitate an average IR grad to go to specific fellowship to pick up?

Sentiments like this short sell our speciality and suggest that we are not as capable as the other docs. I absolutely do not think an average IR grad need to go to a specific fellowship in order to practice bread and butter PAD and kypho. I’ve done PAD in fellowship and I practice with it, some of my partners never did PAD and practices just as fine. I never did kypho during fellowship and went to the kypho course. I am doing just fine.

Frankly the sentiment of some IR can do xyz while others cannot because of where they went to fellowship is dangerous and only hurts our field. You do not see the surgical field or cards pigeonhole themselves like that.

 

[irwarrior]

Things can be picked up, but it is getting harder and harder for that to happen as credentialing is getting stricter as various disciplines set up numbers for procedures. CAST is just one example of that.

I find complex CLI cases pretty challenging despite doing this for many years and I have seen many IR graduates struggle with this coming out of most IR fellowships. There are the "talented" IR who can do just about anything without ever doing it before, but that is a small percentage.

 

[irwarrior]

Even if you can technically perform a procedure, the question I have is can you successfully compete with other endovascular specialists for these referrals from primary care, wound care and podiatry.

That takes a comfort in evaluation and management of wounds, interpreting non invasive (toe pressures, tcPo2, skin perfusion pressures)/PVR/segmentals etc. Putting on high intensity statin therapy , ace-inhibitor, antiplatelets etc.

Historically IR focused on imaging and techniques, I would argue the modern day VIR should focus on clinical evaluation and management and practice development. The latter two will enable sustainable success.

 

[IRattending2021]

Things can be picked up, but it is getting harder and harder for that to happen as credentialing is getting stricter as various disciplines set up numbers for procedures. CAST is just one example of that.

I find complex CLI cases pretty challenging despite doing this for many years and I have seen many IR graduates struggle with this coming out of most IR fellowships. There are the "talented" IR who can do just about anything without ever doing it before, but that is a small percentage.

CAST requires diagnostic neuroradiology fellowship in addition to IR training and is serving to diminish the ability of IRs to perform stroke intervention despite a significant amount of body-IR rads providing safe and competent endovascular stroke care (hell, look up how many operators in the MR CLEAN trial are IRs). RPVI certifications are essentially things that radiologists have as a part of their ABR board certification. Those are not good developments for our field.

By the way, radiology have tried to use credentialing to prevent vascular surgery from taking over PAD and EVAR and it did not work at all. Those artificial divisions only serve to hurt our field as a whole and diminish our creditability.

BTW, I've credentialed at multiple places and honestly no one really asked for my PAD numbers. I've been asked for lower extremity angio numbers which can be satisfied by trauma work as well. Frankly every groin run you do is a lower extremity angio. I don't think credentialing is a realistic barrier for many grads.

 

[irwarrior]

EVAR was primarily vascular surgery driven from the days of Juan Parodi , Veith, Okhi, Moore etc. VIR did participate at many centers including MGH and other sites, but the technical skill set was relatively easy to acquire for straight forward infrarenal repairs. The technical skill set required for fenestrated/branched EVAR/PMEG is another story and there are now some highly skilled VS who can perform such cases such as Oderich.

I do think it is wise to track all of your angiograms and interventions including lower extremity angiograms for trauma, geniculate artery embolizations, avm, etc.

Depends on who is on the credentialing board and depends on how strong your radiology group is in the hospital setting and how supportive they are of your endeavors. A forward thinking diagnostic group will support a clinical IR division and enable it to flourish without shackles and their leadership is well situated in various administrative circles including credentialing .

 

[qxrt]

The most common complication I've seen amongst younger IRs is the inability to recognize what they are looking at on the fluoroscopy table and ending up doing something wonky. Just in the past couple months I've seen someone push a CAT12 through the interatrial septum into the pulmonary vein during an attempted PE thrombectomy (unrecognized by the operator, who wondered why he couldn't get any clot), and another person embolize a branch of the renal artery thinking it was a bleeding lumbar branch in a patient with retroperitoneal hemorrhage, while missing the actual bleeding lumbar artery lower down (to be fair, the renal artery was severely stenotic/atrophied and abnormal, but still did not look anything like a lumbar artery). And yet another person embolized the hepatic artery in a trauma patient, not recognizing that the actual bleeding source was a replaced right hepatic artery arising from the SMA.

These complications came from hardcore young IRs who self-professedly disliked diagnostics and avoided reading whenever possible. On the flip side, they pick up new pathologies and techniques such as PAD with relative ease.

The fundamental of IR is still diagnostic imaging. New techniques and catheter skills are easy to pick up. Having IR colleagues who neglected their DR training and thus make basic errors like the above is not as easy. I will trust the IR with a strong DR foundation more than I will the gung-ho IR who is only interested in big cases and neglects to hone their diagnostic skills during residency.

I do kyphoplasties and cerebral angiography and PAD work and treat acute limb ischemia and am pretty comfortable with them. I did not learn any of these procedures during residency or fellowship, and yet my patients have good outcomes, and I have not yet had a significant complication developing these skills as an attending. They are not difficult to pick up in a high volume practice.

 

[irwarrior]

The more angiography you do , the better you will get with it.

You need to have autonomy in decision making early on, if the faculty are always there to back you up you won't learn as quickly. The first few years out on your own is when you will clearly learn a lot , because you often don't have any attending to ask questions. The more you have autonomy and are asked to make those decisions early on the quicker you will improve.

I think these days when in doubt do a rotational angiogram for confirmation. I have a low threshold to do cone beam CT scans and look very closely at your preoperative CTA to give you guidance. You can use programs such as emboguide to target your treatment zone as well.

I personally find long segment CTO s of the tibiopedal circulation and popliteal occlusive disease challenging. We don't have great bail out stents for those locations . Can consider supera for popliteal and DES for short segment tibial, but I feel we need more strategies to attack those beds. Acute limb ischemia is ok if you are dripping, it is more the motor/sensory evaluation and worry of compartment syndrome and bleeding from the foleys, intracranially, retroperitoneal, etc that stress me out doing thrombolytic therapy in these elderly patients. I sometimes try penumbra or angiojet for those cases to minimize dwell time of lytic.

 

[IRattending2021]

The more angiography you do , the better you will get with it.

You need to have autonomy in decision making early on, if the faculty are always there to back you up you won't learn as quickly. The first few years out on your own is when you will clearly learn a lot , because you often don't have any attending to ask questions. The more you have autonomy and are asked to make those decisions early on the quicker you will improve.

I think these days when in doubt do a rotational angiogram for confirmation. I have a low threshold to do cone beam CT scans and look very closely at your preoperative CTA to give you guidance. You can use programs such as emboguide to target your treatment zone as well.

I personally find long segment CTO s of the tibiopedal circulation and popliteal occlusive disease challenging. We don't have great bail out stents for those locations . Can consider supera for popliteal and DES for short segment tibial, but I feel we need more strategies to attack those beds. Acute limb ischemia is ok if you are dripping, it is more the motor/sensory evaluation and worry of compartment syndrome and bleeding from the foleys, intracranially, retroperitoneal, etc that stress me out doing thrombolytic therapy in these elderly patients. I sometimes try penumbra or angiojet for those cases to minimize dwell time of lytic.

A lot of times cone beam is not feasible, not possible, or just plain don’t have time in a trauma patient. This is where excellent diagnostic training comes in and make a difference. Not to mention shorter cases when I realized I don’t have to cone beam 5x in a TACE case but just once because I recognize the angio better than certain junior partners who may or may not paid as much attention in their diagnostic rotations.

 

[NDcienporciento100]

A lot of times cone beam is not feasible, not possible, or just plain don’t have time in a trauma patient. This is where excellent diagnostic training comes in and make a difference. Not to mention shorter cases when I realized I don’t have to cone beam 5x in a TACE case but just once because I recognize the angio better than certain junior partners who may or may not paid as much attention in their diagnostic rotations.

So a couple things in most trauma situations in which the patient is unstable there going to surgery. Example, unstable patient with hypotension and tachy grade 5 splenic lac there going to surgery if you follow best practice guidelines. So I don’t want people to have this notion that a trauma comes in and a guy is bleeding to death that IR is swooping in on all these unstable pt’s and saving the day, its false, most things in that situation go to surgery. Lastly I train in an institution that has no shortage of trauma and I can tell you it’s rare to see a cone beam ct in a trauma mostly because it’s not required. Splenic bleed? You take out the splenic A it’s pretty strait forward. GI bleed will likely have a cta and if not you better have good reason for not like an endoscopy showing a duodenal ulcer etc. All these situations almost never require a cone beam. As far as doing cone beam for tace some docs do it regardless every time Some only if they feel unsure of where they are. However 5 times in one case would be unheard and a serious case of amateur hour.

 

[irwarrior]

The more you assimilate cone beam , the faster your techs get at setting it up. In my opinion it is very valuable for certain procedures including TACE, PAE etc. It doesn't add a lot to your procedure time and it gets highly efficient. Emboguide is a slick tool and makes it almost too easy to target the tumor.

In the crashing patient , you may not have the luxury of the cone beam CT. The splenic embolization can be done with a proximal plug very quickly. Pelvic embolizations can be safely done with gel foam as can renal or hepatic artery bleeds. The lumbar arteries usually tamponade with an intact retroperitoneum. The key is to reverse coagulation factors quickly in patients on DOACs , anti platelets or in a fibrinolytic state with prothrombin complex, factor 7,9 , cryoprecipitate, platelets etc.

Agree with importance of knowing vascular arterial anatomy. But, any specialist who does a lot of angiography will be good at their organs of interest. Most vascular interventional radiologists and most vascular surgeons won't be very comfortable with coronary angiography and their special obliques. I have read a fair amount of coronary CTA but still get confused when I look at cine coronary angiography. Fewer VIR graduates are as comfortable with cerebral angiography as our neurosurgical/ neurology colleagues who do cerebral angiography.

The key is experience in angiography and knowing your vascular anatomy and variants cold no matter what bed it is. The more angiograms you do and interpret the better you will get at it so it comes down to interventional experience and getting as many cases as possible.

 

[Yhwach]

Best place to train if I want to mainly do IO??

 

[IRattending2021]

Best place to train if I want to mainly do IO??

any program will train you to do IO. Although I am not sure how you can mainly do IO in any practice outside some pretty niche one unless you include biopsy and port as IO

 

[Yhwach]

any program will train you to do IO. Although I am not sure how you can mainly do IO in any practice outside some pretty niche one unless you include biopsy and port as IO

in your opinion what is the "cream of the crop" place to train for IO?

 

[IRattending2021]

in your opinion what is the "cream of the crop" place to train for IO?

Northwestern is wellknown for Y90, but you are aware that most job will not be 100% Or even 50% IO right?

 

[Yhwach]

Northwestern is wellknown for Y90, but you are aware that most job will not be 100% Or even 50% IO right?

Based on research I been finding yes I understand that my job could possibly not be a lot of IO but I'd like to be an expert in IO hopefully, that's my goal at least. I'm ok doing other IR stuff but would like to really get familiar with IO. Like I wouldn't mind working as an IR in a cancer center.

Might not be whole possible but I'll try my best to at least contribute to IO while practicing general IR stuff.

 

[IRattending2021]

Based on research I been finding yes I understand that my job could possibly not be a lot of IO but I'd like to be an expert in IO hopefully, that's my goal at least. I'm ok doing other IR stuff but would like to really get familiar with IO. Like I wouldn't mind working as an IR in a cancer center.

Might not be whole possible but I'll try my best to at least contribute to IO while practicing general IR stuff.

if your interest is predominantly cancer care, I highly recommend you to consider surgical oncology or medical oncology. The good news is that most academic IR practice allow you to do some IO, the bad news is that cancer center jobs are hard to come by, not because they are especially desirable but because there just aren’t that many cancer centers.

 

[Yhwach]

if your interest is predominantly cancer care, I highly recommend you to consider surgical oncology or medical oncology. The good news is that most academic IR practice allow you to do some IO, the bad news is that cancer center jobs are hard to come by, not because they are especially desirable but because there just aren’t that many cancer centers.

I think there is a misunderstanding. I like the general IR practice but would like to innovate within IO. Just like there are people interested in Neuro IR I'm interested in IO. IR in general is interesting to me. IO is an area I have a strong interest in within IR, nothing more, nothing less.

Also to be honest the rarity of a position or a job really isn't something that deters me. IDK but at a point, you might as well shoot for what you want right?

Surg Onc and Med Onc are both things I considered, especially med onc and I realized I like having a good mix of procedures and non-procedure work. Med onc barely has procedures and Surg onc is too procedure heavy. IR seems like great fit for me.

But I appreciate the advice you gave me. I will use this to guide my career.

 

[IRattending2021]

I think there is a misunderstanding. I like the general IR practice but would like to innovate within IO. Just like there are people interested in Neuro IR I'm interested in IO. IR in general is interesting to me. IO is an area I have a strong interest in within IR, nothing more, nothing less.

Also to be honest the rarity of a position or a job really isn't something that deters me. IDK but at a point, you might as well shoot for what you want right?

Surg Onc and Med Onc are both things I considered, especially med onc and I realized I like having a good mix of procedures and non-procedure work. Med onc barely has procedures and Surg onc is too procedure heavy. IR seems like great fit for me.

But I appreciate the advice you gave me. I will use this to guide my career.

if you want to innovate with cancer care the best bet is surg onc and med onc. There are a lot of innovation ahead in IO also but getting good data for our modality have been difficult. If you want IR more than wanting to do cancer care than IR is a good choice.

If you want a job that set you up for a career in IO innovation then stick with programs with fancy sounding names, big cancer centers and Northwestern as those programs tend to have better research support.

 

[irwarrior]

Agree it is challenging to develop a predominant interventional oncology practice outside of the confines of a liver transplant center / cancer center. The transplant centers are outnumbered by the general hospitals by a ratio of nearly 40 to 1. So, for most interventional physicians you will need a broad portfolio of disease expertise (fibroids, BPH, pain, varicose veins, spine interventions, PAD, dialysis, oncology ,vascular access, biopsies).


I agree that there has been an immense number of advancements in medical oncology with next generation sequencing and the advent of IO (immuno-oncology) including targeted therapy against CTLA-4, PD, PDL1 as well as Tyrosine kinase inhibitors. Surgical oncology major advancement has been arguably the conversion to robotics and perhaps HIPEC (which has limited role).

I do think interventional oncology has a lot of innovation when you look at some of the great work being done in that space. The below are just a few of the examples.

A Novel Dual-Balloon Catheter for the Treatment of Locally Advanced Pancreatic Cancer

Dr Ripal Gandhi discusses his 2020 SIR abstract, “Overcoming Limitations in the Treatment of Locally Advanced Pancreatic Cancer With Transarterial Microperfusion Utilizing a Novel Dual-Balloon Catheter."

www.interventionaloncology360.com

Y90 radioembolization: Novel use may transform prostate cancer treatment

Investigators from Chicago, USA, have successfully used Yttrium-90 radioembolization in the treatment of prostate cancer in a canine model.

interventionalnews.com

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