Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

I think we are live. Hello and um good evening everybody. I'm Bushra and um I welcome you all to another session in the radiology teaching series for junior doctors. And today we have got um Doctor Na Khan with us who is an ST six and interventional radiology. And we are incredibly excited for him to share um his day to day work and experience as an interventional radiology trainee and shed some light on the career way as well. So without much further ado I will let him take over. Ok. Thank you for the introduction. My name is Nadir Khan. I am a ST six trainee in interventional radiology in Glasgow. Um So um I would love to have this uh session as relatively interactive. Um If you have any questions or things you want to ask me, just put them in the chat box and I'll be happy to answer. Um So um what's the outline of today's talk? I'm going to try and discuss um the role of interventional radiology in management of a, a wide array of conditions. Um Kind of talk a little bit about what sort of devices we use, what sort of kit we use. Um And then I will center some of the talk around um some of the cases I've been recently involved in and that will I think give a good kind of um framework for everybody to kind of relate to how IR is relevant. Um And then I'm going to finish off by talking a little bit about the IR training pathways and also sort of what's on the horizon uh in terms of future of interventional radiology. So to begin with, um I would say interventional radiology is a very um vast special subspecialty of radiology. Um And you really do get involved in many different body systems. Um I would say majority of the work interventional radiologists do is related to vascular uh diseases and that includes things like peripheral arterial disease, um management of aneurysms, um management of thromboembolic disease and also uh a lot of uh embolization type procedures. We also do quite a lot of nonvascular interventional radiology procedures and that's something which uh general radiologists or radiologist with other subspecialty interests also do. And this ranges from doing image guided biopsies or drainages to interventions of the biliary system or the urological system. For example, another subspecialty of IR is neurointerventional radiology. And these are folk who just fo focus on the cerebral and neurological uh interventions and they are mainly involved in management of intracranial aneurysms uh doing treatments for stroke and also management of AVMs. So really um it's a very wide ranging uh field and you do get involved in, you know, literally from head to toe. So in terms of the modalities, we use uh one of the nice things about interventional radiology is that we use a wide range of uh tools. And if you're really interested in technology and uh innovation, it's one of the best specialties to be involved in. So we use ultrasound ct uh fluoroscopy uh as our kind of um you know, work course for doing image guided procedures. And one of the most common definitions of interventional radiology is, you know, image guided, minimally invasive surgery. And using these modalities allows us to do that. So just a little bit of history of interventional radiology compared to other fields, it's relatively new. And uh this chap, his name is Charles daughter. He's considered sort of the father of interventional radiology. So back in the sixties, he, he was asked to take pictures of, of a lady by the vascular surgeons of the vessels in her, in her leg. And this lady had presented with really bad uh ulcers of her, of her in her feet. Um So traditionally, radiologists would just take images uh of, of patients, uh they wouldn't really do any kind of treatment. So he, you know, he, this was his motto. If a plumber can do it to pipes, we can do it to blood vessels. So what he did? Well, this is the first ever angioplasty procedure um described. And this patient, he took uh an image and this is a femoral artery. And you can see here that there's a, a tight narrowing here on, on the right side of the screen. Uh and he treated that with a uh dilator and that was the first angioplasty procedure done. And that led to remarkable results in this lady and uh led to much improvement of her ulcer and it led to complete healing after amputation, amputation. So this this led to the start of interventional radiology. And now we do a lot more complex procedures than that. So, one of the main starting points of any interventional radiology procedure is uh something called the Seldinger technique. Um This is where we access uh part of our body using a very minimally invasive approach, a very safe approach. Um And this is used to access blood vessels, the biliary system, the urology, uh any kind of renal system variety, any system really you can access using this technique. So this is where we insert a needle, a very fine needle, usually under image guidance, usually ultrasound. And this allows us to pass a very skinny guide wire into the blood vessel. And this allows introduction of further devices such as catheters sheets or even big stents, for example, into the blood vessel. And then we can navigate our way to where we want the treatment uh to be delivered. So these are some of the basic tools we used in interventional radiology. We use wires which are made of a variety of materials. They come in different sizes. They come in different uh degrees of stiffness, some are very floppy, some are very stiff just to allow us to do different tasks during the procedure. And his catheters uh which also come in various shapes um which allows us to cannulate different uh blood vessels which come off at different angles of the uh aorta, for example. And what we can also do is put micro catheters through these main catheters. And uh that allows uh to get into a very super selective position in a, in an organ, for example, the liver or the pro or near the prostate to, to deliver treatment. We use balloons which uh are used to treat sort of stenosis or narrowings. We also use stents which gives us a more of a permanent solution to, to a narrowing. You also do uh we sort of considered it kind of the kind of the ultimate or the more most definitive kind of vascular access people in a hospital. So you can put in things like devices such as sports. Again, th this is a vascular access device where the catheter sits in the superior Vena cava and the rest of the catheter sits underneath the skin. And this port is a device which is connected to this catheter and also sits underneath the skin. So it's a completely internal device to the patient's body. But uh you can palpate it, attach a needle, uh get vascular access, inject drugs and very useful for patients who need longterm treatments such as chemotherapy treatments or antibiotics for like long term long term infections. For example, we also have different pieces of kit which we use to block blood vessels. Um These are some examples of the kit we use. So coils, uh we can insert into blood vessels or plugs and they, they work by occluding the blood vessel through thrombosis. We can also use small particles which we can inject and they can go really distally into the really small blood vessels and cause ischemia to uh area of the body where, you know, which is abnormal, such as a tumor in the liver. And here is an example of a lipiodol and glue, which is another. So literally, we can put glue in patients as well after uh it's another way we can uh block off blood vessels. So I'll move on to sort of discussing some of the cases. Uh And hopefully, that will highlight um uh some of the common places where we use interventional radiology uh skills. So the first case is of a patient with a central venous occlusion. Um So I'll put up this picture and I'll open the floor. Anyone wants to have it a guess what this picture shows. Uh If you can put it in the messages, uh give you guys, maybe a 20 seconds or so. So just hazard a guess, you know, if, if, if you, what do you think this might represent? Um So what, what you're seeing here is, is the chest and this is the uh uh Aveno gram. And what we have here is we've injected some x-ray dye contrast into the vein. And this, in this particular patient, he, she presented with uh arm swelling, uh quite significant arm swelling and one of the reas and that this, this was her only complaint. Um So got one answer of thoracic outlet syndrome, which is a really good thought. Um and it can, this could be that. So what we have here is actually a patient uh who has occlusion of their uh central vein. So here, the subclavian vein is occluded. And what we can see here is a lot of collaterals which have formed around the subclavian vein. In this particular patient. It wasn't a thoracic Calculate syndrome, which is a very good uh thought where in this case, patient had an underlying uh uh requirement for dialysis. So she has had previous line insertions in her jugular vein and subclavian veins. And that's traumatized that subclavian vein and caused a fibrotic stricture almost to develop. So, um we, we treated it using again very minimally invasive technique. So we punctured the vein in our arm using the Seldinger technique and we cross the blockage with a guidewire and catheter. We initially treated this with a balloon, but the balloon wasn't really strong enough to open up the stricture. So then we decided to put in a stent. So this is an example of a stent, very commonly used. It's called a vivan stent. And it's a stent with a covering of PTFE. And it's also coated with heparin. And that allows an a really tight stricture to stay open uh for longer. And this is our final results, you can see nice in line flow down to the superior vena cava. So coming up the ancillary vein, then the subclavian vein then into the brachiocephalic vein and into the S PC. And that led to significant improvement in her arm swelling. Another common procedure we do in IR is treatment of aneurysms. And here is an example of a patient who presented with abdominal pain and this is AC T scan and what this shows is a, an infrarenal abdominal aortic aneurysm. Hopefully you can appreciate on the screen that it's this iota and then around that this kind of dark looking rounded uh bulge, which is the aneurysm. So traditionally, and even to this day, uh some people would advocate that aneurysms of the aorta should be treated using an open repair. But uh endovascular repair is also very popular a lot safer for patients in the short term. And uh this case, we did under local anesthetic. So here's an example of a stent graft we can use to exclude the aneurysm and basically stop risk of rupturing. So what we do is again, using cell dier technique, gain access in the femoral arteries. And one of the key things when we're doing an uh er procedure is to place the stent accurately, not cover any unwanted arteries. And we do pictures during the procedure to make sure that's the case. Uh So here is the picture, it shows us uh cannulated one of the contralateral gates. And that's the final result after the stent has been deployed. So you can see here, the contrast is now flowing through the stent graft rather than through the i of the patient and therefore not pressurizing the aorta anymore and negating the risk of rupture in this patient. So, taking a slightly different tact, um another common place where I get involved is in urology. So a lot of patients with problems of the kidneys and ureters or the bladder uh often require interventional radiology techniques to treat them. This is an example of a patient who had a very large fibroid uterus which was compressing on the ureter and causing obstruction of the kidney. And here we can see the right kidney and the left kidney. You see the right kidney, the chalices in the pelvis is much more dilated compared to the left. So there are different ways you can treat this obstruction. This patient was quite unwell, was developing a urinary infection and drop in renal function because of this blockage. So what we can do is drain this percutaneously again, using very minimally invasive techniques. So this is what we can do. We can use these very fine needles to gain access into the collecting system under ultrasound and then put a pigtail drain. And this drain has a sort of uh it's called a pigtail cause it has a curve at the end which looks like a tail of a pig and that has multiple holes which allows drainage of urine externally. So what we do is puncture the kidney inject dye to make sure we are in the right part of the kidney and then pass this big tail and that allows decompression of the kidney resolves patients kidney function and over helps them overcome their sort of episode of urinary infection. Sometimes what we can also do is put in ureteric stents. The same process, what we can do is puncture the kidney and then pass a guide wire down into the ureter. And this patient, there was a stricture. This patient had a stricture connecting from the ureter into their bladder. And we passed a guide wire into the bladder from beyond the stricture. We used a balloon to stretch that stricture. And then we were able to put a ureteric stent, which is also a double J stent where this is a completely internal to the patient, internal drainage for the patient, bypassing that blockage and uh helps deal with uh re uh obstruction or the obstruction the patient is experiencing and here's the final image where there's one end of the stent at the bottom and the other at the top. So kind of more kind of, um exciting stuff which usually happens in the middle of the night. You can probably see the timings on the scans as we've done it half past one early hours of the morning. Would anyone hazard a guess? What's the abnormality here? I'm trying to show there's an arrow pointing at it as well. Um If you want to put it in the chart, what the uh pathology here is. So, just to give a bit of background, patient is quite unstable, very low BP, high heart rate and they're having profuse bleeding uh uh through their back passage. Um So what might be the underlying abnormality here? Yeah. So this is a, an example of a lower G I bleed and the ones we as interventional radiologist get involved in are the ones which are arterial bleeds. Often these bleeds can be, you know, from hemorrhoids or from tumors and can be venous for which there's not much we can offer. Um But if it's an arterial bleed, which this it was, and this is a branch of the superior rectal artery which was bleeding into the rectum, we can go in and try and uh embolize it. So the first part of the procedure again, we gained access in the femoral artery. We did a pic tail angiogram which basically delineates the vascular anatomy. And we can see here inferior mesenteric artery coming off. Then we catheterize the inferior mesenteric artery. And then we using a microcatheter, which is a very small catheter. We uh basically went supers selected into the rectal artery and this is an angiogram and it shows kind of normal blood vessels should be straight I and kind of tubular in structure. Here, you can see near about where the rectum is. There is this kind of abnormal conglomerate of blood vessels and ization. So patients actively bleeding into the rectum. So in this case, we used glue to embolize the artery and immediately there's no flow in in that region and patient immediately stabilized and uh went on to have a uneventful recovery. So, embolization is uh you know, one of the more exciting procedures we do in IR here is an example of a patient in which we, as I caused a patient to bleed. This patient had a lymphoma which we biopsied um lymphoma involving the spleen. And here we can see that these kind of two linear lines kind of to the left of the screen, uh which is the site of the biopsy tract. And the patient was basically hosing out of those uh biopsy uh region in the spleen. And fortunately, you know, we can also treat that. So we went in super selectively into the splenic artery and we deployed some coils, we initially put some coils in the upper pole branch, still ongoing bleeding. So we also embolized a lower pole branch and that led to, you know, um good hemostasis in this patient and uh avoided them, you know, ending up needing a splenectomy. So these are coils. Some of the coils you use, the coils come in different shapes which can, you know fit in the blood vessel, you're trying to target. So if it's an aneurysm, you're trying to coil, for example, like in the brain, you want it to be very a bendy kind of coil. Uh but if it's just a, you know, big blood vessel, you want to coil, you want nice helical structure with loads of fibers on it to promote uh thrombosis. So um moving on to the next case. Um so there this patient uh we've done a CT scan and hopefully you can appreciate that there is, this is the liver and the liver is quite nodular and irregular in appearance. Um and there's a lot of fluid around the liver as well and you can hopefully appreciate that there's also some dioceses. Um So a patient with nodular liver and free fluid in the abdomen with viruses, what would be sort of the underlying pathology in such a patient? Um want to put it in the chat function. What might be the underlying disease process here? OK. Portal hypertension. Yep. Perfect. So this is a case of a patient with portal hypertension and who was uh unfortunately suffering from sequela, which was recurrent ascites. Uh One of the other issues they can have is um variceal bleeding, which this patient didn't actually have, but he was having requiring kind of, you know, liters of acidic drainage every week. So what we can do as interventional radiologist is uh try and bypass this um way we can do that is do a tips procedure which stands for transjugular intrahepatic portosystemic shunt, basically connecting the hepatic vein to the portal vein, thereby allow reducing the pressure in the portal system and therefore reducing the sequelae of portal hypertension. Um The way we do that is we cannulate the jugular vein, get into the hepatic vein. And then we use this device which is basically a cannula type device with a needle inside and we poke in the direction of the portal vein, uh pass a wire into the portal vein and then put the stent uh in between the hepatic vein and the uh portal lane, essentially creating um ex uh a a new shunt to allow bypassing the the liver for this patient. So here's some of the images from the procedure. We've punctured the portal vein from the hepatic vein. We have got an angiogram not to confirm that. So here we can see portal vein and also the hepatic vein lighting up. And we've got a catheter now connecting the two vessels and then we place a stent. And now you can see a good flow from the portal vein into the uh hepatic me and let this led to improvement in patients ascites in requirement for recurrent acidic drainage. But this can be a lifesaving procedure in patients who ha have vari bleeding. And that's more of an emergency procedure, but it would be the same steps involved. Another very rapidly growing area of IR is interventional oncology where we use minimally invasive techniques to treat cancers. So here is an example of a patient with a liver tumor and HCC and these tumors are typically, you know, very bright on our CT scans. And the ultimate treatment is liver transplant, but there's only so many livers to go around the country. And if the lesion is small enough, we can treat it using minimally invasive techniques and avoid the patient needing surgery. Also, a lot of patients are not suitable to have surgery. They have usually have core morbidities. Um So we use a, a variety of techniques. One of the techniques is called ablation where we use different techniques. So the technique I'm describing here is thermal ablation where we pass needles under CT guidance usually, but you can also use ultrasound guidance uh into the lesion, the tumor and we burn it. And the techniques most commonly used are radiofrequency ablation, which uses um oscillation of ions to generate heat. Or you can use microwave ablation which uses oscillation of water molecules to generate heat and that creates temperatures of, you know, up to 100 degrees plus in a very short area without, you know, damaging the surrounding organ too much. And uh that allows us to get almost curative treatment of the, of the tumor. So here's the example of a case I did recently where we put in two needles in from two different planes into that tumor we saw earlier. So we do this under CT guidance and uh with general anesthetic support where they can suspend patients breathing whilst we do this. And that's the result after the lesion. So you can see it's no longer enhancing. There's a bit of bright in brightness inside the lesion, but that's related to the where the needles were sighted. And we usually follow these patients up and often these patients have a curative result from this procedure. But there's other techniques used as well, you can freeze tumors. So there's a cryoablation technique which is often used for renal tumors. And uh you can also use things like uh ethanol, alcohol injections for more kind of cystic tumors. So sometimes we have patients who have multiple liver tumors. So this patient has three, at least three liver tumors and some of them are too big in size to treat using the ablation system. So what we can do is treat them through the blood vessels. And this is called a tace procedure. This is where we go trans arterial to the liver tumor and get a, a microcatheter in that position, which is supplying the tumor. And we deploy a combination of particles uh and a chemotherapy drug called DOXOrubicin commonly. And that also leads to fairly good result in treating these tumors. Often, these, this treatment is not, you know, completely curative, but it certainly, you know, reduces the spread and the growth of this tumor and can significantly improved patient survival. So, here's an example of a case I did recently, a couple of lesions, the lesions we can see at the top of the liver which we access using a microcatheter system. Uh and then also the lesion at the bottom of the liver, which we also accessed and then we treated. So here's a chest x-ray. Would anyone want to guess what this chest x-ray shows and put that in their chat function? Yeah. So it shows pleural effusion quite, quite a significant one on the left. Uh Basically, this shows pulmonary edema. So pleural feeding is one of the hallmarks of um uh pulmonary edema. And this patient, they weren't entirely sure why this patient was going into heart failure. They did an echocardiogram and actually the cardiac function wasn't, was wasn't too bad. Um And she was also very hypertensive and um hypertension and pulmonary edema. Together, pe pe people often kind of look for other causes and one of the causes is renal causes for pulmonary edema. And this patient went on to have a CT scan and what it showed was a stenosis of the renal artery. Um So again, we, this is something interventional radiologists can treat. So we did an angiogram to identify the stenosis of the right renal artery. And we crossed out with a catheter and guide wire and deployed a stent. And you can see on the image on the left side of the screen, much better flow to the right renal artery. And this patient was instantly cured. They stopped needing uh furosemide and significant diuretics and basically didn't have pulmono edema anymore. Uh So this was an example of a patient uh where there was significant improvement in their uh P edema due to renal artery stenosis and their hypertension also improved significantly. I think they were on four antihypertensive agents prior to this procedure, I think uh after this procedure, they only required one significant improvement um in patients physiology from this procedure, more kind of bread and butter stuff of ir. So this is an example of a patient with a critical leg. And see there's a a long occlusion and we cross that with a guide wire. Sometimes these are very easy to cross other times they can be quite challenging to cross. And that's usually because there's either a lot of calcification in the blood vessel or because it's not always clear whether you've taken a Luminal passage or you, sometimes the wire would go in a subintimal plane and in this patient because it was so calcified, we put in a stent in the femoral artery. And here's the final result that you can see nice good flow down to the leg. You also can treat arteries below the knee. So here this is the example of the cruel arteries or infrapopliteal arteries. So, tibial artery is going to foot and this patient had a non-healing ulcer of their foot. Um So again, you can see the arteries are very poorly supplying the foot, barely any circulation reaching it. And we were able to get a gun down to the foot around the arch, the pedal arch, and we were able to improve c circulation and ultimately avoid the patient needing an extensive amputation of the foot and healing of their foot ulcer. This is an example of a patient with biliary dilatation or biliary obstruction due to a uh cholangiocarcinoma. These patients can be quite tricky to treat surgery is very high risk and um treating these patients through endoscopic means is also challenging. So often, what we can do is puncture the bile ducts under ultrasound and x-ray guidance de lineage. So here we can see the, the, the bile ducts are pacifying, but there's no contrast going into the common bile duct and then into the duodenum. So what we can do is again, use catheters and wires to cross the narrowing which is caused by the tumor and then pass stents which can open up the blockage. And here's the final result, you can see good passage of contrast and this leads to improvement in patients obstruction and alleviation of jaundice and its associated effects. Often these patients, if their bilirubin and things improve, they can then be candidates for chemotherapy as well, which prolongs survival. We can also help patients achieve uh feeding. So this is an example of a gastrostomy tube insertion where we are puncturing the stomach under x-ray guidance and then passing a feeding tube, which looks something like this. It's called a balloon in the one end. And um a flange on the outside, this allows us to administer feeds to the patient who cannot swallow or have problems, you know, with, for example, head and neck cancers or strokes and gives a good uh nutritional access for these patients. And here's a, a CT scan just showing what it looks like after insertion. Um This is a case of a patient who presented with large bowel obstruction. Here, the large bowel is dilated full of feces and there's a tumor involving the sigmoid colon. So, again, this is a procedure we do usually in conjunction with endoscopist where the endoscopist help us reach the tumor. And then we use x-rays and our guide wires and cater to cross the stricture in the tumor. And you can probably faintly see that there's a stent deployed uh across the tumor. And here's post stent CT scan which shows uh the stent in place and res resolution of patient's obstruction. It's important to say that this is not a cure for the patient. This is just a palliative procedure. And often we do this procedure for patients who are not going to survive an operation to fix their colon tumor or perhaps they're not fit enough at this time in. Uh, and this helps them, uh get a bit more fitter to allow them to have surgery. And this is what the stent looks like through the scope after we've deployed it. So next is a case. Uh I open up to the floor, the 39 year old male who presented with chest pain, tearing sensation in his chest and the difference in BP between both his arms ecg is unremarkable. So what investigation would you consider next? Um in this patient? So Antonio has got the right idea dissection. So how would you investigate that? So, yeah, CTCT A Oto gram is the right answer. Um CTP would be a good suggestion if you were thinking of pulmonary embolism, which would be in the differentials. Um But I think given the difference in BP and the history, um it's more suggestive of a dissection. So a CT aorta would be the right answer. Uh And this was the chest x-ray of this patient and anything which stands out on the chest x-ray for the for the people in the chat. What's the main abnormality on this chest x-ray? So, often what happens is, uh, you know, patient comes to A&E with chest pain. Um, usually the history is not as precise as that. Uh, and often you do kind of baseline investigations. Often they have a chest x-ray as their 1st, 1st line investigation and Antonio says enlargement of the aorta. So that's, that's right. So what this shows is a widen media stum and that's, uh, that would be quite concerning for an aortic pathology. And then you would move on to perform uh ac T aortogram to confirm your suspicion that this patient might have aortic dissection. So this is what ac T angiogram looks like. Here's an example of a dissection. This is a example of a di different types of dissection. Uh This is a type, a dissection. So type a involves the ascending aorta and you can see that there's a flap in between uh dividing the aorta. So the the more brighter aspect of the aorta is the true lumen and the less brighter aspect of the aorta is false lumen. So this can have devastating outcomes for patient depending on how far the dissection extends. So, if the dissection extends up into the carotids, for example, the patient can develop a stroke. If it extends down into the coronary arteries, patients can develop a myocardial infarction. If it goes around the aortic Caro down the descending aorta, it can involve uh the visceral artery such as your celiac S ma or renal arteries and cause havoc there. And another reason why you might want to treat this is if patient is unstable uh secondary to this dissection. So this is what they look like uh on CT scan. And this is usually due to intimal tears in the in the lumen which uh basically allow filling of the false lumen. Uh and over time compressing the true lumen to the extent where very poor flow enters into import important end organs. Um So the management of aortic dissection for type A dissections, it's you have to manage it surgically or endovascularly because it's involving, it's probably going to involve the root of the aorta involving the coronary arteries or extending up into the carotids where type B, which is for dissections which start your Clavin artery or left subclavian artery, they can be managed medically first with BP control because often they don't involve critical uh areas of uh aortic vasculature. If they do, then you might have to treat. It is also the D bay classification, which the key one is a dissection involves the ascending arch and descending aorta. The BK two just involves the ascending and arch of the aorta and D Baki three, which is basically a type B dissection. So type B A dissections is where interventional radiologists are most commonly involved because the mainstay of treatment is either medical management of BP or uh putting in a stent graft. So here was an example of a patient I was involved in who presented with aortic dissection, uh which was causing end organ ischemia in the bowel and also the patient was fairly unstable. So we do this procedure under uh minimally invasive techniques. So here, here's an example of gaining access into the blood vessel in and the femoral artery. And then what we can do is because we need to put fairly big devices into the aorta. We have to put quite big sheets. What we can do is prec closes devices, which is this purple device which allows to form a knot again, using very minimally invasive technique uh on top of the blood vessel. So once we remove this device at the end of the procedure, it will close the hole we've made in the artery. And this is an just an example of how A T bar works, which is a thoracic endovascular uh aortic repair, pass a guide wire uh into the ascending aorta and then we deploy the stent graft you. And the key is to basically uh make sure it's precisely deployed. Uh So as to not cover any critical blood vessels. So this is the end result of the uh dissection we treated here. You can see the stent graft has been deployed and then follow up CT scan which shows the stent graft in over time, the aorta remodeled and the false lumen regressed its size. So that's some of the cases. Uh I wanted to show you and just hopefully, so there's a question here uh since I hear no sound. Um OK, I'll come back to that later. Hopefully you can still hear me. Um So the career of an IR is quite wide ranging and you can cater it to how you want it to be myself as a registrar. Um I do at my stage quite a lot of days doing procedures. Uh but some interventional radiologists would maybe spend more time doing uh seeing patients in clinics. So that's something which is uh uh quite novel about ir compared to other subspecialties of radiology where you have to see patients really in clinic settings and follow them up very much like a, a physician or a surgeon would do because a lot of the procedures we're doing, especially for liver, for tumors. Uh for example, or uh embolize prostate or fibroids. Uh We are very much the experts in those kind of uh disease states and uh the patients usually require counseling before we do the procedure and they need to be followed up to make sure the procedure has been performed well and has good results in the long term. Um And then on calls as well. It it varies as a registrar personally. I do 11 in six on calls, but my on calls are so as a resident from home. So I only have to go in when there's an emergency case to do. Um as consultants, it can vary from hospital to hospital. Some hospitals don't offer any on, on call service, others do and depends on how busy your institution is and on how busy you will be. But still a significant number of interventional radiologists do diagnostic reporting as well. Um Often vascular scans are reported by interventional radiologists or scans related to the tumors of which we are treating such as liver or renal tumors, we would be reporting as well. Uh So there's still a lot of uh diagnostic skills that you need as an interventional radiologist in terms of the pathway of uh interventional uh radiology um in the UK. So typically, uh you, you do your five or six years of med school and then your F one and fy two, some, some people do post fy two fy three S or might do additional training such as surgical or medical training or GP training and then you can apply for radiology. So when I applied for radiology, there was just one application process, a national application process and that's still the case. But from what I understand now, they are also as part of the application pro pro process. You can preference um dedicated ir training numbers. And what that, that I believe is happening in England and the application process is exactly the same as for the rest of the radiology application. Uh But there's an addition of uh you have you when you're ranking your places you can say I prefer to do an ir you know, ST one spot. And I think what it means in reality is you still have the same radiology training. You still have to do the same core radiology rotations, but probably in your first three years, you'll probably have more regular IR sessions. And then you will have a guaranteed uh training post at ST four for IR training. And with IR training, your, your, your trainings extended by one year. Um Whereas your traditional radiology training is five years ST one to ST five, um I believe it's quite flexible still. So if after ST three, you decide that you don't want to do interventional radiology, you have the option to discontinue as a diagnostic radiology training pathway to ST five and it doesn't stop you from um you know, forcing you to do uh IR training for the rest of your career. And equally, if for example, you start at ST one as a diagnostic radiology trainee and you develop an interest in IR, then you still have the option of applying for interventional radiology training at ST three going into ST four. But that can be a competitive process if many people are interested. So it varies from place to place. Uh And some people also decide to do Subspecialty Fellowship. So within an interventional radiology, if they want to get perhaps particular expertise in oncology or they want to get particular uh expertise in aortic interventions. For example, they can do an extra year of training, which would be considered a CCT uh fellowship and often people would, would do that abroad to sort of gain a different perspective. So a little bit on, on the future of interventional radiology. Um So the question is there a run through program for IR? So that's what I was trying to say. So in England, there is uh SD one IR training posts and if you're able to get that training post, then you, what what happens is you have a guaranteed uh spot when you go from ST three to ST four. in IR training, uh your first three years will still be very much, you know, heavy on diagnostic radiology, but you will have maybe one or two regular sessions a week of interventional radiology um just to kind of build up your skill set. Um But that would be the main advantage would be that you won't have to go through another competitive process at ST three to get into ST four if you've got that run through IR training number. Um But I think the aim of this is to keep things flexible rather than uh limit people from doing dimensional radiology. So, future technologies in IR, so there's a lot of er expansion in kind of imaging techniques. Uh Not that I'm aware of in the NHS, but certainly in more kind of um uh let's uh you know, countries with more money or more hospitals with more money. They have um interventional labs with, you know, CT scanners and fluoroscopy. Both you can do more advanced interventions, quickly scan patients in between your interventions to see how it's worked. There are uh you know, image fusion systems which tell you if you've treated an area of the liver, how much of that you've uh treated adequately to achieve an adequate margin, uh which would be considered, you know, a surgical cure. It's also um robotics in IR, which is again, very much experimental and this is where you can sit behind a desk and control the robot as it does interventional procedures. But I do think that's probably AAA long way away because um often, you know, patient population we deal with uh are quite complex and you need really to use not just your radiology skills or even surgical skills, you need to use your, you know, physician skills as well to be able to communicate well with the patient during the procedure because most of the procedures we are doing it are under local anesthetic. So important to communicate well with the patient with the team as well. So it's an interesting area of research, but I wouldn't consider it as, you know, taking away our jobs or anything like that. And there's new and newer innovative treatments coming in interventional radiology. One of the exciting treatments is uh treatment for osteoarthritis, uh where there's a treatment called genicular artery embolization. Where there's growing evidence that this is quite effective in helping patient uh get pain relief. And it's really useful for patients who are young, uh who perhaps would be too young to receive uh knee replacements. And also it it can be a stepping stone, you know, delay patients getting a knee replacement is quite a big area of interventional radiology, treatment of musculoskeletal conditions such as arthritis or punishment of pain. Using these minimally invasive techniques such as embolization or imageguided uh uh uh nerve root injections and neurolysis and things like that. These are some of the resources which I would suggest uh people um uh kind of using when looking into Ir as a Subspecialty. So Ir Juniors have great resources. B SI R as well, have great videos and they have an annual conference which is, this year is in Wales, in November, which is a great place to meet other interventional radiologists and see what sort of procedures are happening. And also c which is the European society have great resources as well. So that's the end of my talk. Um If you have any questions, fire away in the chat function and I'll stick around for another um few minutes just to answer some of these questions. And um yeah, that's pretty much it. So I have a question here. Um You, you still CCT and Dr with Subspecialty Eye if you choose this. So yeah, that's a good question. So if you are on the IR training pathway, you get AC CT which says uh you have AC CT in uh uh diagnostic radiology with uh subspecialized in interventional radiology. Um So that's how it would say on your GMC. And it's a nice kind of accreditation of your training, but it's not essential. Um Many interventional radiologists uh don't have this kind of CCT in Dr and IR, they, they have just AC CT and Dr but still function as IRS. So it's not essential, but perhaps, maybe if Ir becomes more independent as a specialty, it may become a requirement. Um It's because there, there's a lot of discussion on about uh interventional radiology becoming an independent specialty. But I think there's a lot of obstacles before that happens. I think it will basically be a, a subspecialty of radiology uh selection for IR regional. So again, that is quite variable. So I've, I'm training in Glasgow and Glasgow advertise their IR training posts nationally. So they would put it on the Scottish NHS Jobs website. Um But I know in other regions, especially in England, it seems to be advertised locally first to the local trainees and if there's not enough interest, then they would advertise it nationally. Um Is it useful to go through some IR courses like Practicals on simulators? Definitely. Um There are, I think Ir Juniors uh have a list of courses you can attend. Uh There's a basics in Ir course, I believe it's happening down south in Plymouth uh uh which has kind of hands on work simulators. And equally if you attend conferences like B SI R or CC, they have a lot of simulation and CC event. Uh sorry. Um hands on workshops where you can have a go at doing these procedures, doing things on phantoms and models um compared to Neuro IR, which is more tasking in terms of consultant work. So I think looking at uh kind of the workflow of consultants, so typically you're as a registrar, I'm doing procedures, you know, 3 to 4 times, 3 to 4 days of the week, I'm probably doing one day of diagnostic reporting. But in reality, most consultants don't work like that. I think most of them have one or maybe two days of doing procedures and the rest of the time they're either seeing patients in clinics reporting scans, um uh discussing cases of MDT uh doing other, you know, educational activities, et cetera. Um And in terms of Neuro II, I think they have a similar thing. Uh they tend to do sort of less cases because their cases tend to go on for longer, more complex cases. So they would typically do maybe two cases in a day, but obviously, those two cases will be relatively, you know, more intense, more complex. Um And I would suggest probably they would do it maybe 22 days of the week, they would do that. So typically they'll be doing a lot of coil embolization for aneurysms, uh maybe one or two stroke thrombectomy a week. Um So their work load is not a volume of work is not huge, but the work they do is quite intense and requires a lot of planning and all the procedures they do, they follow up with scans. So there, there's a lot of diagnostic workload to go along with it. Uh So is there some so to get into radiology, uh there's nothing special you need to get for the IRS T one number. I don't think you need to do anything specifically for IR it's purely based on how well you do in your radiology, uh portfolio MS R A an interview. And if you score high enough and if you preference it, then you will get an IRS T one post. But if you're going from ST three to ST four, and you're going through the selection process at that stage during your ST one to ST three. And even if prior to that, if you can have experience in IR, that's great. You can do um a good place to start is doing sort of taste a weeks and then starting a log book early of doing sort of image guided procedures. So even if as a junior doctor or a medical student, if you're doing ultrasound guided venous access or putting a central line or even putting in drains or chest drains or anything like that, start a logbook early and then during your ST one to ST three years, maintain a log book as you will get to do procedures like biopsies or drainages. And that's a useful way to show that you have interest in IR and also um doing research uh in IR related topics uh is very helpful, um, audits projects essentially uh during either pre radiology training or even during radiology training, all of those will look good on your CD when you're applying for IR uh training posts uh later on. And you know, the main criteria is, you know, make sure you, you pass your exams, your FCR exams. Uh you know, you've got good feedback from your peers when you attend your, any IR session, you show enthusiasm. Um So yeah, and training is, is the training similar to surgical training or so for, I think it varies from hospital to hospital. Uh My training, uh I would say 80% of the time I've been based at sort of the tertiary university hospital because because that's where majority of IR procedures happen, but I did spend sort of six months in a AD GH type hospital, which is also a great experience because you're usually the only registrar there, you get to do more procedures and you get more, sometimes more 1 to 1 teaching as well. So it's usually a mix, but I would say it's usually more heavily towards you know, you're based in a tertiary center for your training. Um and is a separate. So yeah, once you're on the IR training pathway, there is an interventional radiology curriculum which RCR have published. And uh yeah, you just kind of do your assessments during your training. Uh and you have kind of different levels of competence you need to achieve in certain procedures by the end of your training to get signed off. Um But it's not, it's not really complicated, it's fairly intuitive once you get into training, hopefully that was useful for you guys. Um uh If there's no more questions, uh I'll finish up. Uh If that's all right. Hi, my dear. Hi. Hi, how you doing? My name is, I'm one of the doctors helping to organize the events alongside Bora. Um Yeah, thank you so much for that event. That's fantastic. Um Very useful insight into interventional radiology. And I think a lot of people are very interested in interventional radiology at the moment, um especially with it being up and coming and, you know, you saw you showed also the future of IR as well with the robotic, which is fantastic. Uh That's good. I'm, I'm glad people found it useful. Uh And where are you training? So, I'm based in Glasgow. Ok. Ok. I was just going to say if people have any um questions uh or advice they need regarding IR training, then I, I'll drop my email in the chat box and you can get in touch with me. Yeah, that would be really useful. Thank you so much. Thanks.