Interventional radiology training

Hepatobiliary

Hepatobiliay work is generally higher risk than urological work and is less common, so is generally only performed at larger centres.

• Treatment of biliary obstruction:  External biliary drains and biliary stenting.
• Trans-Jugular Intrahepatic PortoSystemic Shunting (TIPSS):  Performed at specialist centres for portal hypertension causing bleeding or intractable ascites.

Gastrointestinal

• Oesophageal and colonic stenting: Usually for inoperable cancer or as a bridge to surgery. Can be performed either soley by an interventional radiologist or together with an endoscopist.
• Radiologically inserted gastrostomy: Gastrostomy tube inserted under radiological guidance either under local anaesthetic or with sedation. These can be extended as gastro-jejunostomy tubes.
• Naso-gastric (NG) and naso-jejunal (NJ) tubes: Difficult NG tubes or naso-jejunal tubes can be inserted with radiological guidance. This is particularly useful when patients have had prior surgery such as a gastro-jejunostomy and you wish to manipulate the NJ tue into the efferent limb of the jejunum. Radiologists can also exchange gastrostomies for gasto-jejunostomies or create access to the stomach when there is no route orally.

Interventional Oncology

This is a huge growth area (no pun intended) in IR.  Techniques are relatively new and indications expanding.

• Ablation:  There are several competing technologies used to ablate tumours including radiofrequency ablation, microwave ablation and cryoablation.  Tumours commonly ablated include, lung, liver, renal and bone.
• Embolisation:  Either for symptom relief (e,g bleeding renal tumour) or for therapy as in hepatocellular cancer, this can involve bland (plastic/glass beads) or with particles impregnated with chemotherapy agents allowing high doses of chemotherapy to be targeted accurately at tumours.
• Selective internal radiotherapy (SIRT):  A form of brachytherapy where either a whole organ or part of it can be targeted with radioactive particles.  Most commonly the liver for inoperable HCC or metastaic colorectal cancer.

Paediatric

Is quite specialised. In most hospitals, even large ones, this involves biopsies, drains and vascular access. In specialised children’s hospitals, there are many more procedures that may be performed, including treatment of lymphatic or venous malformations (usually with a sclerosant), treatment of renal hypertension by renal artery angioplasty or alcohol ablation of abnormally stenosed vessels, and bronchial dilatation. Any of the procedures performed in adults may be performed in children, but other conditions that may be commonly treated in adults are often rare in children.

Biopsy and drainage

Many people do not consider biopsy as interventional radiology as it is a diagnostic rather than therapeutic procedure and most clinical radiologists (diagnostic) peform these, however in many centres a significant proportion of biopsies are performed by interventional radiologists.

• Percutaneous biopsy:  Most commonly ultrasound guided, rarely CT or MRI guided.
• Trans-jugular biopsy:  Biopsy of the liver or kidneys.  Usually performed by an interventionist in patients with ascites or coagulopathy.
• Percutaneous drains using ultrasound or CT guidance.

I am an ST6 IR trainee and I am very lucky compared to other trainees.  In a typical week I will have 1 day of service (general radiology work covering CT, ultrasound or plain films) and 4 days when I can do whatever I want for my training needs!  This usually includes 1-2 morning performing EVAR in the operating theatre, 1 afternoon reporting vascular imaging or preparing for the vascular MDT, and the remaining 2.5 days in the angio suite performing a range of vascular, urological, biliary and oncology procedures. Compared to surgery or medicine the time of an IR trainee is mainly spent on training not service provision hence the ability to learn a whole range of procedures and skills in a short time (only 3 years of specific IR training).  I also take part in an on-call rota (1 week every month) and there is always a consultant on-call with me, who will supervise me for almost any procedure.