Interventional Radiology: Past, Present, and Future
2023; Radiological Society of North America; Volume: 308; Issue: 1 Linguagem: Inglês
10.1148/radiol.230809
ISSN1527-1315
AutoresClifford R. Weiss, Nima Hafezi‐Nejad,
Tópico(s)Cardiac Imaging and Diagnostics
ResumoHomeRadiologyVol. 308, No. 1 PreviousNext Reviews and CommentaryFree AccessEditorial–Centennial ContentInterventional Radiology: Past, Present, and FutureClifford R. Weiss , Nima Hafezi-NejadClifford R. Weiss , Nima Hafezi-NejadAuthor AffiliationsFrom the Johns Hopkins University School of Medicine, 1800 Orleans St, Zayed Tower, Suite 7203, Baltimore, MD 21287.Address correspondence to C.R.W. (email: [email protected]).Clifford R. Weiss Nima Hafezi-NejadPublished Online:Jul 25 2023https://doi.org/10.1148/radiol.230809MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In See also the editorials by LaBerge and Marx in this issue.IntroductionIn this editorial, written for this centennial issue of Radiology, we discuss the past, present, and future of the field of interventional radiology (IR). We explore its evolution as a subspeciality of radiology to its current role and discuss where we expect the field to advance in the future.Radiology and the Evolution of IRThe field of IR began around 70 years ago with the introduction of the Seldinger technique in 1953. This technique allowed for coaxial replacement of smaller-bore needles and catheters (1). Interventionalists were now able to perform diagnostic angiography with remarkably fewer risks. Increased application of the percutaneous technique and the rapid expansion of minimally invasive procedures in the 1960s transformed medicine and resulted in the birth of modern IR (2). Diagnostic angiography became popular on the back of several pioneering articles by Baum, Gensini, Abrams, and other prominent researchers describing the clinical efficacy and feasibility of catheter-directed angiography in virtually every organ system.Since the beginning, Radiology has been the leading platform for the publication of the most critical research and innovative methods in IR. Herein, we summarize some of the landmark studies published in Radiology that pushed the boundary of IR to new frontiers. In the late 1960s, Amplatz and colleagues (3) designed and optimized some of the most critical postprocessing tools, such as automatic film rollers, injectors, and video systems, thereby streamlining catheter angiography. In the 1970s, more studies described the efficacy of catheter angiography–based intervention as a minimally invasive treatment option. Rösch and colleagues (4) described the effectiveness of catheter angiography followed by injection of vasoconstrictors or embolic agents in the treatment of acute upper gastrointestinal bleeding. However, a more sustained treatment effect was not achieved until the introduction of intraluminal stents in the 1980s (5). Almost a decade later, the journal introduced the preliminary results of endovascular stent graft placement, allowing for percutaneous treatment of aortic aneurysms (6).While most advancements in IR in the 1960s and 1970s were related to angiography, in the 1980s investigators adapted the percutaneous coaxial technique to access other organ systems. Mueller et al (7) showed the efficacy of percutaneous biliary access and stricture dilation with acceptable long-term patency. Advancements in cross-sectional imaging (also first described in Radiology) and the ability to perform percutaneous procedures with CT guidance expanded the boundaries of IR in the 1990s. CT-guided drainage of lung abscesses rose in popularity due to its high technical and clinical success and obviating surgery (8). In the late 1990s, the exponential growth of local and regional percutaneous and transarterial cancer treatment options revolutionized modern cancer care. This is most notable in the area of primary and metastatic liver malignancies (9–11). It is in this era that interventional oncology became a critical component of multidisciplinary oncology teams. Some of the earliest interventional oncology studies focused on ethanol injection for small hepatocellular carcinomas. Percutaneous ethanol injection was a safe and effective treatment option that resulted in survival rates comparable with those of surgery when accounting for perioperative complications and mortality (11). Due to a higher rate of complete necrosis and fewer treatment sessions, radiofrequency ablation gained popularity and investigators used it to treat small (9), medium, and large hepatocellular carcinomas (10) as well as hepatic metastases (12). Hepatic arterial embolization for unresectable hepatomas dates back to the 1980s, with technical and imaging success (ie, the disappearance of tumor vessels and reduction in tumor size) yet only modest survival benefit. While the incorporation of iodized oil and chemotherapy was later found to improve survival rates (13), the long-term benefit from chemoembolization remained limited for decades. Later investigations showed that combined transcatheter arterial chemoembolization and radiofrequency ablation can result in an overall survival rate similar to that of surgery when patients were within the Milan criteria. Most recent studies advocate for the optimization of patient selection using quantitative biomarkers for the preprocedural identification of patients with a survival benefit (14).Most Cited IR Articles in RadiologyLooking back at the most cited Radiology articles in IR (Table), the dominant role of interventional oncology studies in the past 3 decades is noticeable. Eight of the 10 most cited IR articles in Radiology were on the application of percutaneous and transarterial treatments for primary and secondary liver malignancies, including notable studies by Livraghi et al (9–11) on the safety and efficacy of ethanol injection and radiofrequency ablation for hepatocellular carcinoma. Outside of interventional oncology, two instrumental studies changed the landscape of IR practice in the 1990s. These included the introduction of gadolinium-based MR aortography (15) and the report of the first national multicenter registry on the effectiveness of catheter-directed thrombolysis for acute lower extremity deep vein thrombosis (16).List of the Top 10 Most Cited Interventional Radiology Articles in RadiologyThe Past Decade and the Increased Online Presence of IRContinuous advancements in IR in the past decade have highlighted the need for data-driven, clinical, and experimental expansion of scientific evidence. Radiology has continued to be the frontline medium for landmark studies that have led to evidence-based growth of IR globally. The persistent growth of social media enhanced the online presence of Radiology, leading to increased dissemination and improved access to IR literature. In contrast to conventional citation metrics, online viewership may be more sensitive in the detection of more recent influential articles. Similar to conventional citation metrics, interventional oncology studies attracted more online views than other IR subspecialties. Using conventional citation metrics, a multisociety statement on standardization of terminology and reporting criteria for image-guided ablations was the most cited IR article in Radiology in the past decade (17). In terms of online viewership, the two most viewed Radiology IR articles were a report of the Radiation-Emitting SIR-Spheres in Non-Resectable, or RESIN, registry on survival and toxicities after yttrium 90 (90Y) radioembolization (18) and the Transarterial Radioembolization versus Chemoembolization for the Treatment of Hepatocellular Carcinoma, or TRACE, randomized phase 2 trial comparing 90Y radioembolization with drug-eluting bead chemoembolization for unresectable hepatocellular carcinomas (19), both published in 2022. Aside from interventional oncology studies, two other studies published in 2022 were popular among the readership of Radiology. The first was the introduction of the PEARL approach for CT-guided lung biopsy (20). PEARL stands for patient positioning biopsy-side down, needle removal during expiration, autologous blood patch sealing, rapid rollover, and pleural patching. The other popular article was on the reversal of sarcopenia after transjugular intrahepatic portosystemic shunt placement in patients with cirrhosis (21).Future of IR as a New SpecialtyUpon approval by the American Board of Medical Specialties in 2012, the American Board of Radiology begin issuing specialty certification in IR/diagnostic radiology. The American Board of Radiology issued the last vascular and interventional radiology subspecialty certificates in 2016 (22). Since then, the educational structure for IR has undergone a major overhaul, with three major pathways including an IR/diagnostic radiology residency, independent IR residency, and residency with early specialization in IR. The new framework has resulted in enhanced exposure to vascular radiology and IR and greater dedicated time to procedural training. It is not surprising that IR's clinical and research frontiers have changed in the past decade to resemble a new independent specialty. On the clinical front, novel image-guided vascular and nonvascular procedures are introduced every year (2). Specialized services by interventional radiologists are being increasingly used throughout the United States, in every state, and in inpatient and outpatient settings (23). We expect this exponential growth to continue in the coming decades with increasing access to IR in every zip code in the United States and enhanced coverage in other regions of the world. With the amplified presence of interventional radiologists in the clinical environment and participation in direct patient care, they will become an indispensable part of multidisciplinary care units. Naturally, we expect a more prominent role in leadership, administrative, and policy-setting positions for interventional radiologists on local, national, and international levels. Continuing to foster diversity and inclusion will ensure a more collaborative and inclusive workforce that is better positioned to overcome the barriers to health care disparities in IR (24).Future of IR and Evidence SynthesisOn the research front, the biggest dilemma in IR is that of any rapidly growing and branching domain: evidence synthesis. We are seeing the initial phases of a paradigm shift from describing what can be technically done to objectively proving how image-guided interventions can improve patient outcomes (24). Well-designed and meticulously carried out peer-reviewed investigations will be the foundation of this process, with the ultimate goal of demonstrating the safety, efficacy, and effectiveness of IR interventions.The abundance of innovation, ideas, and newfound designs was the hallmark of IR in the past 3 decades. Nevertheless, the majority of research evaluating the usefulness of IR procedures was traditionally determined from quasi-experimental studies. In this regard, the need for randomized clinical trials (RCTs) and comparative effectiveness research in IR is paramount. Thus, the next phase in the life cycle of the IR literature will belong to the establishment of high-level evidence through well-designed RCTs that can serve as the backbone of evidence-based practice building in IR (25). Even a single well-designed RCT can provide an objective evaluation that is superior to several quasi-experimental studies. In the absence of RCTs, comparative effectiveness studies of existing large, observational data sets using validated statistical methods to simulate controlled trials may provide the best alternative to inform clinicians and patients about the potential value of image-guided treatment approaches (26). Finally, the design and implementation of registries will result in the development of niches of evidence not often revealed in RCTs. With a large sample size, standardized collection of data, accreditation of outcomes, and an ambitious enrollment plan, VIRTEX by the Society of Interventional Radiology is set to become the reference standard data registry of common image-guided interventions (27). The growth of registries in IR will highlight the real-world effectiveness of image-guided intervention and set the standards for value, quality, and safety in IR.Future of IR Practice and Evidence-based TrajectoriesThe expansion of clinical IR in the coming decades rides on the shoulders of meticulously crafted studies that will shape the evidence supporting various image-guided interventions. Several studies will launch in the coming years and have the potential to change the practice of IR for years to come.For venous interventions, the results of the Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) trial (28), published in 2017, defined the role of catheter-based thrombolytic therapy in acute venous thrombosis. The ATTRACT trial was a phase 3, multicenter, randomized, open-label, assessor-blinded, controlled clinical trial supported by the National Institutes of Health that showed that the addition of pharmacomechanical therapy (combination of catheter‐based thrombectomy and catheter‐directed delivery of thrombolytic medications) to anticoagulation may result in a higher risk of major bleeding without significant improvement in postthrombotic syndrome. However, a subset of patients with iliac deep venous thrombosis was more likely to benefit from catheter-directed thrombolysis. In the coming years, the Pulmonary Embolism-Thrombus Removal with Catheter-Directed Therapy (PE-TRACT) study is an open-label, assessor-blinded, randomized trial (ClinicalTrials.gov identifier: NCT05591118) aiming to compare catheter-directed therapy and anticoagulation. The PE-TRACT study is designed to overcome the shortcomings of prior experiments, including the Ultrasound Accelerated Thrombolysis of Pulmonary Embolism, or ULTIMA, randomized trial (29) and other single-arm prospective clinical trials (30). We expect the results to specify the patient population that is more likely to benefit from catheter-directed thrombolysis in a head-to-head comparison with anticoagulation.In interventional oncology, most RCTs published in Radiology in the past decade focused on hepatocellular carcinoma treatments, including transarterial chemoembolization and transarterial radioembolization in combination with established chemotherapy regimens. The modest survival benefits from liver-directed therapies alone and the move beyond sorafenib in clinical oncology represent paradigm shifts in hepatocellular carcinoma treatment. The effect of liver-directed therapies will now be assessed in conjunction with new immunotherapy regimens (31). Invoking the immune response will be a new focus in marking the benefit of combination therapies (32). Similarly, high-level evidence supports the safety and efficacy of ablative methods for early-stage renal cell carcinomas (33). Thus, the issue facing IR will be how to increase utilization and expand access to these curative treatment options, with the goal of reducing health care disparities across the nation.Among arterial interventions, multiple previous RCTs have shown the efficacy of uterine fibroid embolization (for leiomyomas) and prostate artery embolization (for benign prostatic hyperplasia). The randomized EMMY (Embolization versus Hysterectomy) trial, despite its limitations and the potential for bias, has shown the efficacy of uterine fibroid embolization in the short term (34) and the potential to avoid hysterectomy in a significant portion of patients with up to 10 years of follow-up (35). For prostate artery embolization, prior studies have shown the benefit over a sham procedure (36) and transurethral resection of the prostate (37). However, the available evidence is equivocal regarding functional outcomes. Several ongoing RCTs are now addressing the scarcity of long-term multiyear assessments in initial studies. We forecast that within the next decade, increased public awareness, improved access to care, and more widespread availability of IR services will result in increased utilization of these procedures, closing the gap in socioeconomic and racial inequities that exist to date.The list of ongoing innovations in IR that may revolutionize the landscape of IR practice goes on. Early evidence for the clinical effectiveness of arterial embolization has been promising for geniculate artery embolization for osteoarthritis, left gastric artery embolization for weight loss, and rectal artery embolization for hemorrhoidal disease (38). While we cannot predict the direction of evidence arising from individual ongoing trials in IR, we are certain that the implementation of evidence-based approaches to the clinical practice of IR will be the cornerstone of IR growth in the decades to come. We foresee a bright future in which the advancements in imaging and technology will expand the horizons of IR to a degree previously deemed unimaginable or impossible. Ultimately, the most persuasive argument for the existence and growth of IR remains to be the improved patient care that we provide to our patients.To celebrate the centennial year of Radiology, the reader will enjoy the editorials by Laberge (39) and Marx (40), which highlight the past, present, and future of interventional radiolog. Almansour et al (41) provide trainees' perspective on the international IR training programs. In addition, please find the state-of-the-art review articles by Brock et al (42) and Elsayed and Solomon (43) on the present and future of interventional radiology and the future of interventional oncology, respectively. We hope that these articles will provide an opportunity for the readership to review where we came from and where we are aiming to go as a subspecialty.Disclosures of conflicts of interest: C.R.W. Grants from Medtronic, Siemens Healthcare, Boston Scientific, and Guerbet; consulting fees from Medtronic and Boston Scientific; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Medtronic; support for attending meetings and/or travel from Medtronic; patents planned, issued, or pending Boston Scientific, Siemens Healthcare, and Shrunken Medical; leadership or fiduciary role in SIR Foundation; receipt of equipment, materials, drugs, medical writing, gifts, or other services from Guerbet, Boston Scientific, and Siemens Healthcare; deputy editor of Radiology. N.H.N. Radiology In Training editorial board, 2021–2023.References1. Seldinger SI. Catheter replacement of the needle in percutaneous arteriography; a new technique. Acta Radiol 1953;39(5):368–376. Crossref, Medline, Google Scholar2. Baum RA, Baum S. Interventional radiology: a half century of innovation. Radiology 2014;273(2 Suppl):S75–S9. Link, Google Scholar3. 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Link, Google ScholarArticle HistoryReceived: Feb 10 2023Revision requested: Apr 24 2023Revision received: Apr 27 2023Accepted: Apr 27 2023Published online: July 25 2023 FiguresReferencesRelatedDetailsRecommended Articles RSNA Education Exhibits RSNA Case Collection Vol. 308, No. 1 Metrics Altmetric Score PDF download
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