Interventional radiology (IR), also known as vascular interventional radiology (VIR), is a medical sub-specialty of radiology which uses techniques that relies on highly specialized radiological image guidance (computed tomography [CT], magnetic resonance imaging [MRI], and ultrasound) to precisely target the treatment. Their expertise with the imaging techniques allows them to use small catheters (tubes) and guidewires through blood vessels and other pathways to a specific organ to deliver treatment. These techniques and procedures used by the interventional radiologists to diagnose and treat are often minimally invasive in order to minimize the risk to the patient.
EducationalRequirements
Bachelor’s Degree
Just like any other medical specialty, an aspiring interventional radiologist must first complete a pre-medical bachelor’s degree. In the United States, it is important that aspiring medical students has completed a bachelor’s degree from an accredited college or university. Even though college accreditation is not covered by the United States Department of education, the law states that the U.S. Secretary of Education is required to oversee accreditation as well as publish a list of colleges and universities which have been accredited. It is the aspiring doctor’s responsibility to make sure that their chosen college for their bachelor’s program will be acceptable to any medical school or to the specific medical school of their choice.
The chosen degree should at least cover the basics of medical laboratory and instrumentation. This will serve as the initial foundation of scientific knowledge and experience. It is also recommended that the degree chosen provides emphasis on the theoretical and practical science pre-requisites that can be used for medical school admissions as well as to pass the Medical College Admissions Test (MCAT). Doing extracurricular activities that is related to the medical field and patient care is also recommended to gain experience and develop long term strategies that they can use to advance their knowledge for their future medical education. A student’s Grade Point Average (GPA) is also an important factor to ensure their entry to a good medical school. An aspiring medical school student should monitor their GPA and should obtain at least a 3.0 cumulative GPA and a 3.0 or higher for all science and laboratory work. Some medical schools require a higher cumulative GPA than others, so it is imperative that the aspiring medical school student has checked the requirements of the school that they are applying to before submitting their application.
Establishing good working relationships with their teachers and mentors is also highly recommended. These authority figures can guide the student and remark them about their ability, work ethic, overall professionalism, and potential to be a successful physician. These remarks can be used for the required letter of recommendation to be submitted to the institution/s that the student is planning to apply to.
Medical College Admissions Test (MCAT)
The Medical Admissions Test or MCAT is a required four-and-a-half-hour multiple choice test for aspiring medical school students. According to the Association of American Colleges (AAMC), applicants taking the MCAT will be tested in the following areas:
Biological and biochemical foundations of living systems
Chemical and physical foundations of biological systems
Critical analysis and reasoning skills
Psychological, social, and biological foundations of behaviour
Medical school requires that the MCAT score should be submitted along with the other application requirements of the selected school. Each medical school has their own range of acceptable MCAT score and most of the schools in the United States accept MCAT scores from up to three years, giving the students’ time to gain additional training or experience between the times they finish their bachelor’s degree and starting their medical school.
Medical School
There are three different pathways that aspiring interventional radiologists can choose from when deciding upon their medical degree program. The first option is getting a medical degree (M.D.). This degree focuses on the traditional methods of diagnosis, treatment, and medicinal therapies. The second pathway is taking the Doctor of Osteopathic Medicine (D.O.) degree where the student can focus more on patient care and the study of the musculoskeletal system. The last pathway to be discussed is the combined program of Doctor of Philosophy (Ph.D.) and Medical Degree (M.D.). This combined program is offered by a significant number of medical schools in the United States due to its high demand and gratification.
The combined degree (M.D. along with Ph.D.) provides a wide range of benefits for future IR specialists. It allows the graduate of the dual degree to be proficient in being a physician and a scientist at the same time. The doctor from this field will be able to participate in both the healing of patients as well as participating in researches that may lead to a breakthrough in their field. As the doctor continues to amass expertise regarding the mechanisms underlying the diseases, he or she can also continuously engage in applying the knowledge in a clinical setting. Another known benefit of the combined degree is that it provides a fast track in acquiring two degrees. Some medical schools offer a 3-year medical degree program to Ph.D. graduates saving them time and money. Combined degrees are also known to offer scholarship programs that would provide participants tuition and stipend.
The first two years of medical school are designed to expand the student’s knowledge in anatomy, biology, chemistry, physiology, and other necessary sciences that will support them for the next years of medical school. In the United States, the first two years usually ends with a test to gauge the student’s capability and readiness to begin the next stage of their journey as aspiring doctors.
The third and fourth years of medical school include clinical rotations throughout the medical specialties and facilities. The students will be working with patients under direct supervision. This period will be used to apply the theories and techniques that they have learned during the first two years. There are at least six core specialties for rotations namely: surgery, psychiatry, paediatrics, internal medicine, gynecology and obstetrics, emergency medicine, and ambulatory medicine. The student can already declare their preferred specialty and/or sub-specialty during or after the clinical rounds. Aspiring IR specialists will choose radiology to be their specialty and will further specialize later on into interventional radiology. They can also take a number of advance d lecture and independent research classes in radiology in order to gain necessary knowledge and skills to further specialize in interventional radiology. The fourth year of medical school ends with the second of the series of three tests. This test is used to determine the readiness of the students to proceed to the residency program and to evaluate the knowledge and skills that they have acquired.
United States Medical Licensing Exam (USMLE) or Comprehensive Osteopathic Medical Licensing Exam (COMPLEX)
In order to be licensed and practice medicine, medical doctor candidates must past a licensing examination depending on their choice of medical programs. The Federation of State Medical Boards (FSMB) determines the standards and processes which must be adhered to regarding the exams. This medical board represents the 70 medical and osteopathic boards within United States as well as their territories.
Residency and Fellowship
The residency program is a more hands on and less supervised experience compared to the clinical rotations that the doctor has experienced during their medical school proper. The four-year radiology residency program aims to provide the students the opportunity to gain more experience and broaden their knowledge to further specialize. Listed below are the four possible pathways for aspiring IR specialists as presented in the Society of Interventional Radiology (SIR) webpage.
Traditional pathway
The traditional IR residency involves a one-year non-radiology clinical training that is approved by the Accreditation Council for Graduate Medical Education (ACGME) and a four-year diagnostic radiology residency. The residency is followed by a one-year IR fellowship training (total of six years of post-graduate training). This pathway will only be available until June 30, 2020 and will be replaced by the Independent IR Residency program.
Integrated IR Residency
The Integrated IR Residency follows a one-year non-radiology clinical training that is approved by the Accreditation Council for Graduate Medical Education (ACGME). The residency alone is five years in length and it involves a three-year diagnostic radiology training and two years of interventional radiology training.
Independent IR Residency
This residency pathway also follows the one-year non-radiology clinical training that is approved by the Accreditation Council for Graduate Medical Education (ACGME). The difference between this residency pathway and the Integrated IR pathway is that the diagnostic radiology residency is extended up to four years while the IR residency training stays the same (two years). This pathway will not be offered until July 1, 2020.
Independent IR Residency with ESIR
This pathway is offered to diagnostic radiology (DR) residents who completed the Early Specialization in Interventional Radiology (ESIR) training which involves 12 IR or IR-related rotations and at least 500 image-guided procedures within the IR domain. This program allows the DR resident to finish an Independent IR Residency program in only one year.
The IR sub-specialty was awarded by the American Board of Medical Specialties (ABMS) a primary specialty status in 2012. Current technological and scientific advancements have increased the complexity of IR procedures and made the IR specialist more involved in patient care. These procedural changes proved that a transition in teaching and training approach is necessary. As of the moment, training for IR is transitioning from a 1-4-1 pattern (one year of internship, four years of Diagnostic Radiology, and one year of IR fellowship) to a 1-3-2 pattern (one year of internship, three years of Diagnostic Radiology, and two year of IR fellowship).
Board Certification IR residency graduates are qualified to take the IR/DR certification offered by the American Board of Radiology. This certification was approved by the American Board of Medical Specialties (ABMS) in 2012 and this certificate is one of the four primary certificates offered by the ABR. The first set of the certifying exams was administered on October 2017 and the candidates are required to demonstrate competency to practice in diagnostic radiology, as well as the full scope of interventional radiology.
This certifying exam has both oral and computer-based component. Diagnostic radiology certified candidates are only required to take the oral component of the exam while those who are not are required to take both the oral and the computer-based component. The computer-based component includes one Essentials of Diagnostic Radiology module and one Interventional Radiology module.
Maintenance of Certification (MOC)
The Maintenance of Certification (MOC) is a vital part of ensuring that the quality of health care is strengthened or at least maintained. It also demonstrates the support for the continuous quality improvement of medical specialties and patient care. All ABR volunteers, including governors and trustees, are required to participate in MOC.
In the 2012 Continuous Certification process implemented by the ABR, an annual review on March is used to evaluate all four MOC parts and render MOC participation status. The four parts are:
Part 1: Professionalism and Professional Standing
Part 2: Lifelong Learning and Self-Assessment
Part 3: Assessment of Knowledge, Judgement, and Skills
Part 4: Improvement in Medical Practice
All the diplomates with a sub-specialty in vascular/interventional radiology are enrolled in the MOC program automatically and required to participate immediately.
Roles and Responsibilities
For centuries, surgery was the only viable treatment option for a number of medical conditions. Being a highly invasive procedure, this practice exposes the patient to high risks. The goal of interventional radiology is to provide a less invasive and safer option in order to lessen the pain and recovery time of the patient. The techniques used by interventional radiologists allow patients to have shorter hospital stays. Their procedures are also applicable in almost every organ system and the list of the conditions that can be treated with image-guided techniques is continuously growing along with the specialty. The body parts and systems that can be diagnosed and treated using IR techniques include:
Abdomen - intestine, kidney, liver, and stomach
Central nervous system (CNS) - brain and spine
Chest - lungs and the whole respiratory system
Heart and vascular - arteries and veins (including hemodialysis access)
Musculoskeleta l - bones, joints, and spine
Genitounrinary - uterus, testes, and kidneys
Other organs and soft tissues
Interventional radiologists are historically consulted by the specialists of other fields and patients rarely have the opportunity to talk to them in person.
There are three types of interventions in IR namely: Neurovascular, Non-vascular, and Vascular. An expanding list of treatment options became available as the technology progresses and high-quality imaging equipment becomes more widely accessible. Inteventional radiologists perform both diagnostic and therapeutic procedures. List of the common treatments and procedures offered by interventional radiologists are mentioned below:
Diagnostic
Angiography - real-time imaging of the blood vessels with the use of various contrast media (mainly iodinated contrast agents) to look for abnormalities. This contrast material is delivered through a thin catheter (tube) into a particular blood vessel and it shows the inside of the vessel, making the blockages easily detectable.
Biopsy - taking a tissue sample from an area of the body for pathological examination from a percutaneous (via needle-puncture of the skin) or trans jugular approach.
Cholangiography - imaging of the bile ducts to look for areas of blockage.
Computer tomography (CT) – imaging test that provides detailed cross sections of the body’s internal tissues. Just like angiography, a contrast material is also used to aid the visualization of the arteries and veins. The series of cross sections obtained through CT scanning can be used to create a three-dimensional picture of the blood vessels called a CT angiogram (CTA).
Fluoroscopy - the use of X-rays to produce real-time moving images of the patient’s internal tissues and structure. A contrast material is also used to make the blood vessels show up more clearly under X-ray.
Magnetic resonance angiography (MRA) - the use of radio waves to create images of arteries and veins. During the procedure, the patient is placed in a magnetic field that is why any metal instruments are not allowed to be used during the procedures.
Therapeutic
Vascular
Balloon angioplasty/stent - the use of a balloon (sometimes along with metallic stents that can be self-expanding or balloon expandable) to open a narrow or blocked blood vessel.
Endovascular aneurysm repair - treatment used to prevent the expansion or progression of the defective vessel by placing an endovascular stent-graft across an aneurysm.
Embolization - blocking abnormal blood vessels and/or organs to stop bleeding or stop the extra function of the organ. Examples are: embolization of the spleen for hypersplenism and uterine artery embolization for percutaneous treatment of uterine fibroids.
Uterine artery embolization (UAE) or uterine fibroid embolization (UFE)
Prostate artery embolization (PAE)
Thrombolysis - destroying blood clots (such as pulmonary embolism or deep venous thrombosis) using a catheter-directed technique. This is accomplished with the use of either pharmaceutical (TPA) or mechanical means.
Inferior vena cava (IVC) filters - these are metallic filters placed temporarily or permanently in the inferior vena cava to prevent the accumulation of deep venous thrombus (blood clot).
Dialysis related interventions - range of treatments including placement of peritoneal dialysis catheters, tunneled hemodialysis catheters, and revision/thrombolysis of poorly functioning surgically placed AV fistulas and grafts.
Transjugular Intrahepatic Porto-systemic Shunt (TIPS) placement for patients with critical end-stage liver disease and portal hypertension.
Endovenous laser treatment - placement of thin laser fiber in varicose veins for non-surgical treatment of venous insufficiency.
Biliary Intervention
Biliary catheter placement to bypass biliary obstructions and decompress the biliary system.
Permanent indwelling biliary stents placement.
Cholecystostomy - the removal of infected bile by placing a tube into the gallbladder. This is used to treat patients with cholecystitis (inflammation of the gallbladder) who are too weak or too sick to undergo surgery.
Catheter Placement
Central venous catheter (CVC) placement - vascular access and management of intravenous devices (IVs). This treatment includes both tunneled and non-tunneled catheters like PIC, Hickman, port catheters, translumbar and transhepatic venous lines, and hemodialysis catheters.
Drain insertions - the use of tubes placed in strategic parts of the body to drain pathologic fluids (e.g. abscesses drain to remove pus, nephrostomy, pleural drains). This technique may use percutaneous, trans-rectal, or trans-vaginal approach. The placement and/or repositioning if the catheters is achieved over a guidewire under image guidance.
Gastrostomy/ gastrojejunostomy tube placement - the placement of a feeding tube percutaneously into the stomach and/or jejunum.
Ablative
Chemoembolization - the use of the tumor’s blood supply for delivering a specific cancer treatment directly then using clot-inducing substances to block the artery, making sure that the chemotherapy will not be “washed out” by the continuous blood flow.
Radioembolization - injecting radioactive glass or plastic beads and embolic agents into the arterial blood supply of a tumor, this is used for local administration of chemotherapy, slowing “washout” of the radioactive substance, and decreasing tumor arterial supply.
Radiofrequency ablation (RF/RFA) - the use of a special catheter to destroy tissue by using heat generated by medium frequency alternating currents for local treatment.
Cryoablation - unlike RFA, this local treatment uses a special catheter to destroy tissues by using cold temperature generated by rapid expansion of compressed argon gas. This is generally used for treating small renal cancers and for the palliation fo painful bone lesions.
Microwave ablation - the use of heat generated microwaves via a special catheter to destroy tissues during local treatment.
Genitourinary
Percutaneous nephrostomy/ nephroureteral stent (NUS) placement - a treatment typically done to treat a downstream obstruction of urine by placing a catheter through the skin, directly into the kidneys, in order to drain from the collecting system.
Ureteral stent exchange - placement of indwelling double-J type ureteral stents using cystoscopy. The exchange for a new stent can be accomplished over a guidewire after partially extracting the distalmost stent.
Pain Management
Vertebroplasty - the placement of biocompatible bone cement inside a fractured spinal vertebra via needle-puncture of the skin in order to restore vertebral body height and relieve pain.
The interventional radiologists also provide patient evaluation and management to identify the most effective course of treatment. They can also take part in the post-procedural care of the patient in order to make sure that there is a continuous improvement in the patient’s condition. The practice of IR has been proven be less risky, less pain, and the recovery time of the patients are statistically faster compared to open and laparoscopic (keyhole) surgery.
Salary
In a survey conducted by doctor-salaries.com, interventional radiologist earns a hefty in come with an average pay passing six figures annually in the United States. The income of these specialists is largely influenced by amount of experience in the field and the geographic location of the practice, with the latter being a more significant factor. The metropolitan areas generally provide higher salaries for specialists, but it also comes with a greater and more demanding workload.
According to the U.S. Bureau of Labor Statistics, there is a predicted increase of 14% in the employment opportunities for all physicians and surgeons from 2014 to 2024. This demand will play a big role in the average projected salary of physicians in the future. The salary figures reported by ValueMD.com stated that the average income of a radiology specialist is generally around $354,000 a year, with the top salaries reaching $911,000 a year. In addition to their basic income, IR specialists with a certification in Vascular and Interventional Radiology from the American Board of Radiology (ABR) get $12,000 a year in bonuses according to PayScale’s data.
According to PayScale’s salary data report, interventional radiologists employed in the United States report earning salaries ranging from $180,000 to $456,069 a year inclusive of bonuses. The same report also stated that the basic annual salary of specialists in this profession is typically within the range of $175,000 to $441,990 and the yearly bonuses can amount to $51,521. The overall average for IR specialists varies from source to source. The average salary for interventional radiologists in the United States is $312,576 according to PayScale, $200,000 a year according to Indeed, $469,000 a year after six years of practice according to the recruitment agency Profiles, $478,000 a year according to the American Medical Group Association (AMGA), and $513,000 a year according to the Medical Group Management Association (MGMA).
As mentioned earlier, geographical location plays a vital role in the average salary of medical specialists. According to AMGA’s salary survey, the average annual salary of interventional radiologists in the northern part of the United States is around $511,485 while specialists employed around southern United States earns around $478,000 a year. The specialists around the western area of U.S. earns an annual salary of $464,542 while those working in the east make $407,184 a year on average.
The length of professional experience is also a significant factor in the average amount of total annual salary earned by interventional radiologists. PayScale stated in their salary information report that an IR specialist with one to four years of experience typically earns about $5,000 a year in average while those with five to nine years of experience earns around $10,000 a year in bonus money. The type of industry is also a factor in determining the amount average bonus money earned by the physician. IR specialists in the health care sector generally get around $15,000 a year while those working in the radiology sector get around $9,826 of bonus money a year on average.
The bonuses received by interventional radiologists also varies from one employer type to another. Listed below are the average amount of bonus money earned per year depending on the type of employer an IR specialist is employed by:
Office-based single specialty private practice/firm: $3,000
The discipline of radiology started when a German scientist named Wilhelm Conrad Roentgen (1845-1923) discovered a new kind of rays in 1895 while he was working with a cathode-ray tube in his Wurzburg University laboratory. Roentgen shielded the tube with heavy black paper and noticed a green colored fluorescent light generated by a material located a few feet away from the tube. He concluded that a new type of ray was being emitted from the tube and that this ray was capable of passing through the heavy covering. Upon further experiments, Roentgen found out that this ray can pass through human tissues, but not bones and metal objects. He named them X-rays due to its unknown origin and its essential features were described in his December 1895 manuscript titled “On a New Kind of Ray”. The new discovery aroused tremendous interest and due to the availability of the apparatus in most physics departments, the results of Roentgen’s experiments were easily replicated. On June 1896, X-rays were being used by physicians in the battlefield to locate bullets in wounded soldiers. 1896 was also the year when natural radioactivity caused by the decay of certain kind of atoms was discovered by a French scientist named Henri Becquerel while he was researching on the principles of fluorescence. Becquerel’s discovery paved the way for the industrial use of radiation. In 1901, Roentgen won the very first Nobel Prize for Physics for his discovery of the X-ray. The widespread use of X-ray in the field of medicine led to the publishing of the firs English book on Chest Radiography in 1905.
The radiographs were initially made into glass photographic plates but in 1918 George Eastman introduced the use of film in radiographs. The use of X-ray work was mostly performed by medical professionals at that time and the medical departments were often combined with electro-therapeutic departments. In 1903, the increase in demand for radiography called for an increase in the number of X-ray operators to be appointed from about as medical assistants and eventually the Society of Radiographers was formed in 1920.
During the 1950s, researchers developed the application of contrast agents for a better image contrast and organ visualization using special gamma cameras. The concept of tomography, the imaging by sections with the use of any kind of penetrating wave, was first introduced by a group of scientists named David E. Kuhl, Luke Chapman, and Roy Edwards in the late 1950s. Their method will later be introduced as Positron Emission Tomography (PET) and Single Positron Emission Computerized Tomography (SPECT).
The search for better diagnostic imaging techniques continued and on 1960s the principles of sonar were applied to diagnostic imaging. In this technique, quartz crystals were used to generate ultrasonic waves which will then be reflected at the interfaces between different tissues. These waves were received by the ultrasound machine and turned into pictures using computers and reconstruction software. Around 1967, the use of Magnetic Resonance Imaging (MRI), previously known as Nuclear Magnetic Resonance Imaging (NMRI), for clinical practices was conducted in England. This was followed by the development of MRI-related techniques by two physicist named Peter Mansfield and Paul Lauterbur. The first human MRI images were produced in 1977. Mansfield and Lauterbur were awarded the 2003 Nobel Prize in Physiology or Medicine for their contribution in the “discoveries concerning magnetic resonance imaging”.
The history of Computed Tomography scan, also known as CT scan, goes back to at least 1917 with the mathematical theory of Radon transform but its principles and apparatus were invented in 1972 by Godfrey Hounsfield of EMI laboratories in England. Hounsfield and a South African physicist named Allan Cormack received the 1979 Nobel Prize in Medicine for their work in computed axial tomography (CAT).
The advancement of technology catalysed the further innovation in radiopharmaceuticals and the use of computers as a necessary tool for diagnostic imaging. New techniques are now emerging to produce more vivid and useful images. Even real-time and high resolution imaging (with the use of High Resolution Electron Spectroscopy developed by Kai Siegbahn) is now possible and the processing has evolved to an automated state , producing more consistent film quality.
Interventional Radiology for Cancer Treatment
Cancer is characterized by the abnormal growth of tissue at a fast rate. These abnormal tissues are also called “malignant” tumors and they are known to invade neighboring healthy tissues. Due to its devastating effect in the body, some cancer patients are too weak to undergo surgical treatments and/or their cancer treatment drugs no longer affects the cancer cells. Below are the list of minimally invasive treatment options available for cancer patients:
Bone and Joint pain management - Variety of bone and joint injections for nerve block and fracture management. This treatment aim to provide a relief from pain.
Chemoembolization - the delivery of cancer-killing medication through a catheter directly to the affected organ. This aims to decrease blood flow in the arteries that supply the cancer.
Cryoablation - this treatment option destroys cancer calls by emitting extremely cold temperatures at the location of the tumors.
Drainage Catheters - this treatment involves the placement of catheters to drain excess fluid and relieve uncomfortable symptoms caused by fluid retention.
Irreversible Electroporation - the latest form of ablation. This creates an electrical field at the cancer cell, causing them to die.
Microwave Ablation - thermal ablation technique that uses electromagnetic waves to destroy cancer cells.
Palliative IR - provides pain relief and symptom management for patients that are in their terminal phase.
Radiofrequency Ablation - a form of thermal ablation that uses electric current, which is transformed into eat, to destroy the tumor.
Port and PICC Line Placement - the placement of temporary ports or PICC lines to minimize the number of needle punctures during chemotherapy or diagnostic blood work.
Selective Internal Radiation Therapy (SIRT) - also known as Y-90, this treatment treats cancer through the injection of small spheres of radioactive substance into the blood vessels that are supplying the tumor.
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