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									                                                                                                                                                                                                                                                                                                                                                                                                                                                 ISSUE 27 Autumn 2009


                                                                                                                                                                                                                                                                                                                                                                                                  newsletter
.... . .R. . . 9 8 .2.4.. 0 3.. 9 5. 9 9 K V...................... /// ........... > / . . . . . . . . . . . . . . . . . . . . . . . . > . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .......... ...... ............ ..... .. ............. . // ....... / ........... .... .. .......




                                                                                                                                                                                                                                                                                                                                                                                                                                                                             .... . . . . . . . . . . . . . . .... ...................... /// ........... > / . . . . . . . . . . . . . . . . . . . . . . . . > . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .......... ...... ............ ..... .. ............. . // ....... / ........... .... .. .......
                                                                                                                                                                                                                                                                                                                                                                                                                                                                     www.bsir.org
                                                                                                                                                                                                                                                                                                              editor’s column
                                                                                                                                                                                                                                                                                                                                                                 Ian Francis really does bring us up to date       Jonathon Richenberg for his eye opening
                                                                                                                                                                                                                                                                                                                                                                 with the education subcommittee’s doings          piece on the perfect AE department.
                                                                                                                                                                                                                                                                                                                                                                 this issue since I’ve remembered to include       Apologies to Susan Jaffe, your article will
                                                                                                                                                                                                                                                                                                                                                                 it this time! Thanks and apologies for the        appear next issue.
                                                                                                                                                                                                                                                                                                                                                                 oversight last time. The Chinese burns are           Technology encroaches further into our
                                                                                                                                                                                                                                                                                                                                                                 settling down now.                                lives daily. Quite how far is exemplified by
                                                                                                                                                                                                                                                                                                                                                                     Stephen Thomas continues to impress me        the mobile phone specialist I met on holiday.
                                                                                                                                                                                                                                                                                                                                                                 with the developments within BSIR registries      He tells me the nations current favourite
                                                                                                                                                                                                                                                                                                                                                                 many of which will allow those who                mobile phone provider now analyses the
                                                                                                                                                                                                                                                                                                                                                                 contribute to generate their own personal         position of it’s customers every 5 seconds,
                                                                                                                                                                                                                                                                                                                                                                 data suitable for revalidation purposes. David    allegedly so it can feed the information onto
                                                                                                                                                                                                                                                                                                                                                                 West also brings us up to date with               sat-nav suppliers thus allowing us all to avoid
                                                                                                                                                                                                                                                                                                                                                                 wholesale changes in the website which            traffic jams. Other uses aren’t too hard to
                                                                                                                                                                                                                                                                                                                                                                 should substantially improve the sites utility,   think of.
                                                                                                                                                                                                                                                                                                                                                                 whilst hopefully eliminating those with              I shall return to the cath-lab now. As you
                                                                                                                                                                                                                                                                                                                                                                 excessively white teeth on the front page!        all know it’s the best room in the hospital.
                                                                                                                                                                                                                                                                                                                                                                     Junior matters are attended to by Sam         No email, no phone, and a door you can




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .......... ...... ............ ..... .. ............. . // ....... / ........... .... .. .......
                                                                                                                                                                                                                                                                                                                                                                                                                                                                     registered charity no. 1084852
                                                                                                                                                                                                                                                                                                                                                                 Stuart, and Prof Buckenham wants one of you       lock. Best of all it’s lead shielded, so the
                                                                                                                                                                                                                                                                                                                   As the annual meeting approaches a            as a fellow in NZ so get applying, I hear the     mobile company don’t know I’m there.
                                                                                                                                                                                                                                                                                                                                                                 mountain biking is good.
                                                                                                                                                                                                                                                                                                               foretaste of what is in store is included             Thanks also to Kurian Mylankal for his        Paul Scott
                                                                                                                                                                                                                                                                                                              in this Autumn’s newsletter, by scientific         piece on Surgical Endovascular fellowships,       Hull Royal Infirmary                         <
                                                                                                                                                                                                                                                                                                                  programme committee chairman Phil              to Alexander Mclaren for his on the
                                                                                                                                                                                                                                                                                                                                                                 function of the MHRA, to Abdul Razack for
                                                                                                                                                                                                                                                                                                                      Haslam. It promises to be a great          his on setting up a new IR service and
                                                                                                                                                                                                                                                                                                                  meeting which I shall enjoy from the
                                                                                                                                                                                                                                                                                                                safety of the angiography suite in Hull.
                                                                                       . / ........... .... .. .......




                                                                                                                                                                                                                                                                                                              Contents

                                                                                                                                                                                                                                                                                                              1     editor’s column                         5       communications committee
        .......... ...... ............ ..... .. ............. . // ......




                                                                                                                                                                                                                                                                                                              2     president’s column                      6       planning for trauma: the role of imaging

                                                                                                                                                                                                                                                                                                              2     how about an interventional radiology   8       imaging in trauma
                                                                                                                                                                                                                                                                                                                    felowship in new zealand?
                                                                                                                                                                                                                                                                                                                                                            8       initial results: patient experiences with
                                                                                                                                                                                                                                                                                                                                                                                                                          send all contributions to
                                                                                                                                                                                                                                                                                                              3     notes from the BSIR office                      vascular interventional radiology
        JM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .




                                                                                                                                                                                                                                                                                                                                                                    procedures – a multi-site prospective                 Dr Paul Scott
                                                                                                                                                                                                                                                                                                              3     BSIR junior section                                                                                   Department of Radiology
                                                                                                                                                                                                                                                                                                                                                                    cohort study
                                                                                                                                                                                                                                                                                                                                                                                                                          Hull Royal Infirmary
                          . . .... 0 7 m A L - 0 5




                                                                                                                                                                                                                                                                                                              4     update: BSIR registries and audit
                                                                                                                                                                                                                                                                                                                                                            9       MHRA who?                                             Anlaby Road
                                                                                                                                                                                                                                                                                                                    committee                                                                                             Hull
                                                                                                                                                                                                                                                                                                                                                            10      a measure of ovarian reserve following                HU3 2JZ
                                                                                                                                                                                                                                                                                                              4     the education sub-committee
                                                                                                                                                                                                                                                                                                                                                                    fibroid uterine artery embolization with
                                                                                                                                                                                                                                                                                                                                                                                                                          Phone: 01273 627013
                                                                                                                                                                                                                                                                                                              5     is it worth setting up a new service?           two different embolic materials: early six            E-mail: paul.scott@hey.nhs.uk
                                                                                                                                                                                                                                                                                                                                                                    month results
                                                                                                                                                                                                                                                                                                              5     scientific programme committee
                                                                                                                                                                                                                                                                                                                                                            12      views of an endovascular trainee
           12. .
president’s column
                                                         considerable achievements of my predecessors            PbR team, without consultation with the IT team,
                                                         and raising the political profile of the society.       decide not to us them. That decision has now been
                                                            For some time now the membership have asked          reversed but the result is that we are some years
                                                         for a website that serves their needs. The BSIR         behind achieving what I had hoped for. The lack of
                                                         have invested a considerable amount of time and         recognition of IR as a serious medical specialty is
                                                         money into the new site which David West will be        one that has concerned me. In the next few
                                                         unveiling at the Annual Scientific Congress. David      months you will see two documents that highlight
                                                         informs me that the site is both exciting and           that concern and are directed towards addressing
                                                         revolutionary in the way that we interact with it.      some of the issues. Trevor Cleveland is working
                                                         Members will have their own 'wicki' style area for      with the BSIR and RCR to develop 'The Provision of
                                                         uploading information, and there is a patient site      Endovascular Services'; a paper that documents the
                                                         and a find-a-doctor function. Already we have           need and requirements for a comprehensive
                                                         many new patient information leaflets and several       service. In addition, we have been fortunate in the
                                                         patient management pathways. We will continue           last 4 months in being able to work collaboratively
    This is my final column as the BSIR                  to contact members and undertake financial              with the excellent National Imaging Board. That
                                                         transactions through the web-site, and soon there       process will see the publication of a document
       President. Whatever success the                   will be the facility to easily upload and download      that discusses the inequalities in provision of a
       BSIR has enjoyed during the last                  data from the registries. The eventual life and         comprehensive IR service across the UK. This is
                                                         success will, of course, be down to the enthusiasm      aimed at the NHS executive and will eventually be
     2 years is completely down to the                   which members embrace this new facility.                made available to doctors and management.
    individuals that members chose to                       The registries have long been an important              Better news is the story of subspecialisation.
                                                         function of our society and I have written              Those who attended the Congress last year may
        run the society on their behalf.                 previously regarding the reasons for this. In the       remember that I asked for support to work with
I would particularly like to thank the officers and      last 2 years we have focussed upon having               the College to develop IR as a subspecialty of
chairmen of the committees, for it is they who           registries that serve a specific purpose. To that       Radiology. Such recognition is very important for
have co-ordinated the work and slaved into the           end we embarked upon a period of                        the future viability of IR. We have successfully
late night to serve the BSIR. And so: Maria              rationalisation to reduce the burden and focus          made that case and the College is in the process of
Sheridan, Duncan Ettles, Ian Francis, Phil Haslam,       upon the important. A number of registries will         submitting to PMETB. Behind that work lays the
David Kessel, Matt Matson, Richard McWilliams,           wound up and all will be published with reports         work of David Kessel, Ian Francis and the Education
Rob Morgan, Allan Odurney, Iain Robertson, John          sent to contributing centres.                           Committee in developing the IR subspecialty
Rose, Tarun Sabharwal, Steve Thomas, Raman                  I have been keen to raise our profile politically.   curriculum. A huge thank you goes to them.
Uberoi, David West, on behalf of the BSIR many,          We now have a very good profile with NICE,                 I leave the BSIR in the very good hands of
many thanks for all your selfless hard work.             NCEPOD etc. The story of PbR is less happy. Many        David Kessel and a wonderful Council. I wish you
   And has it been a successful 2 years? That is not     of you will know that I feel strongly that we need      all well for the future.
for me to judge but what I can do is relate what         to not only ensure that PbR works for IR, but also
the Council has been working on during that time.        that we are in charge of our own destiny. Despite       Prof Peter Gaines
My focus has been two-fold; consolidating the            spending some years developing HRGs for IR, the         President BSIR                                     <




how about an interventional radiology
fellowship in new zealand?
The life of the Interventional Radiological Fellow in Christchurch,
                                                                                     with all antipodean organisations, the Vascular Radiologist and Neuro-
New Zealand, is characterised by skiing, sunbathing, writing papers,
                                                                                     Radiologist are required to perform a wide range of interventions outside
gaining a wide variety of endovascular experience, waterskiing, climbing,
                                                                                     these constraints and the Fellow is expected to step forward at all times.
and if required, a modicum of ornithology. Limited opportunity for
                                                                                         There is a combined Vascular and Radiological Surgical Ward Round on
trainspotting is available, as only a few daily trains pass through
                                                                                     Tuesday mornings, which is followed by general clinical presentations and
Christchurch. Christchurch is a city of 300,000, serving the middle and
                                                                                     multiple lamb sandwiches. The Vascular Interventional Radiologist is part of
upper South Island, and is the regional vascular centre. We have two
                                                                                     the Department of Vascular, Endovascular and Transplant Services, and the
interventional rooms, two 64-slice CT scanners, and a dedicated
                                                                                     Fellow would be expected to assume a similar clinical footprint. The
Interventional CT. The Fellow's job is to report the endless CT angiograms
                                                                                     remainder of the Radiology Department is filled with cross-sectional
(catheter angiography, along with New Zealand's World Cup rugby
                                                                                     Radiologists of all varieties, some remarkably akin to the radiological
hopes, has long since vanished in all forms). The Vascular Ultrasound
                                                                                     colossus that bestrides the Green Wing.
Service is run by the Vascular Radiologist and situated in the Radiology
                                                                                         We are currently looking for an Interventional Fellow to start in
Department. The Fellow is exposed to endless vascular ultrasounds to
                                                                                     December 2009 or January 2010. Any post-CCST Registrar is welcome to
fill their day with whistling noises, to accustom themselves for the South
                                                                                     apply. Details of remuneration, travel assistance, etc, can be obtained from
Island summer pursuit of dog trials, where canine fellows round up large
                                                                                     Jane Elms in the Human Resources Department (jane.elms@cdhb.govt.nz).
number of sheep, responding to a series of loud blasts from the
                                                                                         If you think this article is misleading in any way, or perhaps puts an overly
consultant's whistle.
                                                                                     optimistic view on the Fellowship job, please feel free to contact our most
   The Interventional Radiology Service is staffed by five Interventional            recent Fellow, Dr Chris Day, who enjoyed the experience so much he has
Radiologists – a biliary interventionalist, a neuro-interventionalist, a vascular    become a permanent member of our consultant staff (rather than returning
interventionalist, and two general interventional radiologists. The lucky            to Merthyr Tydfil). Chris would be happy to give you the truth about the job.
Fellow's job is to spend two days a week in the Interventional Suite, one day        If anyone is interested, please feel free to contact us,
with the Vascular Radiologist, and one day with Neuro-Interventionalist. As          tim.buckenham@cdhb.govt.nz or chris.day@cdhb.govt.nz.                           <




2
   notes from the BSIR office                                                                                                         Lavinia Gittins, for the BSIR




annual general meeting 2009
The 2009 Annual General Meeting of the British Society of Interventional Radiology will be held on Friday 6th November 2009 at 11.45 am at the Brighton
Hilton Metropole Hotel, in conjunction with the BSIR Annual Conference.
All BSIR members are invited to attend the Annual General Meeting.


BSIR 2009 election results
Following the elections held earlier this year the following members were elected:
  Iain Robertson, Vice President                           Jon Moss, Secretary                           Sam Chakraverty, Education committee
  Trevor Cleveland, Communications Committee               Davis Thomas, Registries & Audit Committee    Graham Robinson, Scientific Programme Committee
  Simon Girling, Registries & Audit Committee              Tarun Sabharwal, Membership & Rules Committee



BSIR subscriptions
A number of BSIR members still have payment outstanding for their 2009 subscription.
We seek your co-operation in ensuring that your membership subscription is paid on time, and we would ask that you consider standing order payment if you do
not already do this. Please contact the BSIR Administrator (office@bsir.org) for a standing order authorisation form to complete to set this up for January 2010.



changes of address
Please remember to let us know if you move jobs, change your correspondence address or your email address.
Please send your new details to office@bsir.org



Transfer to full membership
When Junior members obtain a consultant or academic post they should advise BSIR office, and they will be transferred to Full membership at the
beginning of the next subscription year.                                                                                                                              <




BSIR junior section
                                                          to hear how the availability (or non-availability!) of      While the vascular surgical trainees are placing
It’s my first chance to write in the                      focussed individual training (FIT) has been.             emphasis on being trained in endovascular
newsletter since taking over the                              For those of you interested in taking a more         techniques it will be interesting to hear whether
                                                          active role in the junior committee there will also      interventional radiology trainees want or are
reins of the junior section of BSIR                       be elections.                                            indeed learning the skills our vascular surgical
and I’d like to start by thanking the                         This summer we again had a very enjoyable joint      colleagues are gaining in the clinical assessment
                                                          meeting with the vascular surgical trainees from         and treatment of vascular diseases.
previous chairs of the junior section                     the Rouleaux club. It was great to meet the BSIR            I’m very excited about the new BSIR website
(Jeremy Taylor and Chris Dey) for                         members that came along and I enjoyed hearing            that is being developed which should allow easier
                                                          your views on the junior section and how it could        contact, discussion and interaction between
their continued input and support.                        offer more for trainees. As well as talks by some        junior members. The new ‘Wikipedia’ style should
I hope you’re looking forward to                          very interesting and eminent speakers from both          allow us to update topics more easily and thus
                                                          vascular surgery and interventional radiology the        increase the usefulness of the website to junior
this years meeting as much as I am.                       meeting gave a great chance for trainees from both       members, for example with up to date
   I hope as many trainees as possible will be able       worlds to meet and share views. It was interesting       information on courses, fellowships and meetings.
to attend the junior section AGM at lunchtime on          to see just how keen the vascular surgical trainees      Thank you to those of you that have helped with
the Thursday of the meeting (lunch included!). We         are to gain experience in endovascular techniques        providing images or text for the website.
will be having an open forum and will cover as            and how important they feel these techniques will           Good luck to those of you who have entered
many topics relevant to trainees as possible to find      be for their future careers. Even though many            the scholarship competition for the annual
out your ideas, experiences and suggestions for the       seemed disappointed by the amount of exposure            meeting and congratulations to those who had
society and training. With the recent changes to          they were getting to these techniques they were          abstracts for posters or presentations accepted. I
our rotas and on-call systems brought by the              all hoping to learn these skills before their training   look forward to seeing our efforts and I look
European Working time Directive it will be                had finished. It shows that even though formal           forward to meeting you in Brighton.
interesting to see how this has impacted on your          joint training has not yet arrived the vascular
training and work patterns. It will also be interesting   surgeons already have one eye on the future.             Sam Stuart Chair Junior BSIR                       <




                                                                                                                                                                      3
update: BSIR registries and audit committee.
Current Registries                                                                           soon, and details of how to register and submit cases will be available on the
The main focus of activity in the last year has been the production of reports from all      website, and I hope to have more details by the time of the Annual meeting in
the registries following on as part of the strategy to review each registry and ensure       November. Analysis of RETA data performed by Ramita Dey, with me, for the R&A
that data collection is useful to the submitting clinicians, i.e. you the BSIR membership.   committee will be presented to the membership and a report made available via
   BIAS III reported at the end of last year following which the society adopted this        the BSIR website. There are preliminary plans to set up a similar web-based
as its first index procedure. The main focus for the BIAS registry since has been to         dataset for collection of data into the UK Thoracic stent graft registry, and
look at rationalising the dataset and addressing issues highlighted during analysis of       Graham Munneke is looking at ways to achieve this as soon as possible.
the data, to improve the quality of data submission by matching the dictionary of
terms that is present within the BIAS III report. Funnel plots for the BIAS data are         The future:
now available on line and should prove useful to BSIR members who are submitting                The process of sending regular reminders to members submitting cases to the
cases. This facility will allow members to demonstrate their participation in national          Dendrite registries is now about to go live. This should act as a means to
audit, which should be useful during appraisal, and for revalidation in the future. The         encourage data submission to many of our registries and help with ongoing
report is available to download from the registries section of the BSIR website.                data submission and collection of follow up data.
   The Uterine Fibroid Registry report is nearing completion, with Liz O’Grady,                 The extension of the funnel plot facility to other data sets, including those
John Moss and Anna Belli working with ScHARR in Sheffield to get this                           hosted on the NVD will broaden the ability of those submitting cases to BSIR
completed. Liz O’Grady has been leading on this for some time and she and all                   registries to gauge their performance across a range of procedures.
those who have contributed to running and submitting data to this registry are                  The outlier policy has been published in the BIAS III report and is available on
to be congratulated for their efforts. NICE are awaiting this registry report, and              the BSIR website, and outlines a process to identify if there are trends in
will then be looking at uterine artery embolisation again with a view to                        outcomes for members that may be a cause for concern. The exact
providing up to date guidance , which should be available by the new year.                      mechanisms for implementing the outlier policy are being looked at and will
   The Biliary registry data is being analysed and will be presented at the BSIR                be communicated to the BSIR membership as soon as it is available.
meeting in Novermber. The hardcopy report is being produced in collaboration                    There are plans to recruit a data manager to help oversee the day to day
with Dendrite will be available at the Annual meeting, and I thank Iain                         management of the BSIR registries, with recruitment of an appropriately
Robertson and Raman Uberoi for their efforts. The results will form the basis for               skilled person to work with the R&A committee in maintaining the datasets,
an assessment of whether the Biliary registry can act as a non-vascular index                   producing regular updates and help members, where possible, to make
procedure for society members. If this is not the case then consideration will be               submission of data to the registries as easy and simple as possible.
given to looking at other non-vascular procedures, such as nephrostomy.                         The Registry section of the BSIR website will remain an important focus for
   The Carotid registry is now hosted as part of the Carotid intervention audit                 getting information to members, as well as a providing links and contact details
on the National Vascular Database (NVD), and as such all cases of endovascular                  to allow easy data submission. If possible a single login facility to make linkage to
carotid intervention should now be entered via the NVD. Details of whom to                      the registry datasets simpler will be set up.
contact to register and start entering data and are on the BSIR website. The                    I welcome the election of 2 new members to the BSIR R&A committee, Simon
previous carotid data is being analysed in Sheffield, and there will be a                       Girling and Davies Thomas, and will be welcoming them to the committee in
presentation of these results by Stephen Goode in the scientific programme at                   November. I would like to thank Raman Uberoi and Suresh Babu for all their
the annual meeting. A formal report will follow in the new year.                                efforts on behalf of the BSIR over the last few years.
   ROST is no longer collecting new cases, and the dataset, including follow up,                Please try to get to the Registry sessions at the BSIR annual meeting in
is being analysed and a report will be produced by Hans-Ulrich Laasch with the                  November. There are 2 sessions planned, and brief results will be given from
help of Dendrite. This report should also be available by the time of the annual                the reports that are coming this year. Paper copies of the BSIR reports that
meeting in November.                                                                            have been finalised at that time should be available at the Annual meeting,
   The IVC registry is nearing the end of its second year, and collection of follow             and the plan is that pdf versions will be on the website.
up data will continue to the end of 2010. Please continue to submit cases, but a                 Finally, thank you for continuing to support the registries by submitting data, and if
major push will be to achieve follow up on cases submitted to November of this               you have comments or suggestions then contact any of the committee, or have a chat
year. Registration of cases to the dataset is likely to continue, though cases               at the BSIR annual meeting and the committee will take these forward on your behalf.
submitted after November will not be subject to full one year follow up analysis.
Nick Chalmers will be giving a brief update from this registry at the Annual meeting.        Steve Thomas
   With the move of the Endovascular Stent graft registry for AAA to the NVD                 Chair R&A committee, On behalf of the R&A committee: Suresh Babu,
data submission to RETA will cease. This web based facility should be available              Graham Munneke and Raman Uberoi.                                                        <




the education sub-committee
The work of the sub-committee continues                       undertaken to produce sub-speciality status for IR.              With regards educational bursaries, the sub-
unabated. Many of the projects initiated last year            The advent of a new curriculum, assessment                    committee has endeavoured to identify UK sites that
are coming to fruition and will be of interest to a           methods and change in education delivery at the               would support individuals undertaking structured
large number of members of the society.                       RCR is of significant advantage to IR. In the                 episodes of training within their units – the technical
                                                              Autumn, a separate IR curriculum will be presented            areas we have looked at and gained support on
Patient care pathways – a series of common acute
                                                              to PMETB for consideration. There is continuing               include EVAR, RF ablation and AVM management. If
vascular and non-vascular IR presentations have been
                                                              collaboration between the BSIR and the Vascular               these areas are of interest application for educational
studied and peer-reviewed in order to produce concise
                                                              society with regards to common high level                     bursaries can if required be supported through the
and informative pathways. The areas reviewed include
                                                              assessments, although progress remains slow.                  links with these expert sites
acute limb ischaemia, gastrointestinal and post partum
                                                                                                                               I enclose within this newsletter updates from
haemorrhage, urinary and biliary obstruction. These will      Bursaries – talking of future. The opportunity to
                                                                                                                            grant recipients in 2008. Perhaps this will spur
be made available via the website and it is hoped will be     gain the financial support of the society through
                                                                                                                            some of you on to think about the possibilities of
of use to many of in planning the optimal management          educational and research bursaries is again
                                                                                                                            utilising the bursary system (space issues prevented
of their patient care. If there any other areas members       available. The 2009 awards have been made and
                                                                                                                            inclusion of all 4 summaries, but two are published
feel would be of use, please do contact us.                   will be announced on the website. Surprisingly,
                                                                                                                            now and the remaining 2 will be in the spring-ed.).
                                                              there were no applicants for educational bursaries
Training – the discussions over the future of
                                                              and only a few entries for the research awards.
training continue both within the society and the
                                                              Please do not forget bursaries are not limited to             Ian Francis Chairman Education Sub-committee
RCR. There is a large amount of work being
                                                              trainees but are applicable to all members.                   ian.francis@bsuh.nhs.uk
                                                                                                                                                                                     <


4
is it worth setting up a new service?
Nothing prepares one adequately to                         Four years ago, a medical representative                Two weeks later, I persuaded my surgical
                                                        showed me a Pleurex drain which was used to            colleague and his anesthetist, to allow me to use
becoming a Consultant. Overnight                        achieve long term drainage in patients with            his theatre slot, to perform this procedure under
one becomes independent and has                         recurrent pleural effusions. This seemed the ideal     general anesthesia. The general anesthesia
                                                        solution for patients with recurrent malignant         certainly calmed my nerves as I felt more under
to take complete responsibility not                     ascites and after discussion with the oncologist,      control and the procedure went smoothly. I
only for one’s action but also for                      decided to perform this on a patient with              subsequently performed two more procedures in
                                                        recurrent ascites who was having repeated              the theatre, before regaining my confidence and
one’s team. It is both exhilarating                     drainages every two to three weeks. I soon found       now perform this procedure in ultrasound
and scary at the same time.                             out that I could not arrange this without              department under local anesthesia.
                                                        adequate funding for this “new procedure”. I now           I soon realized that performing the procedure
A lot of responsibility is thrust upon you by
                                                        realized that I had received no training in this       was the easy bit. I had to make sure that the
stealth even when you rigorously try to
                                                        aspect of consultant work and this would soon          patient or the carer understood the procedure
implement the mantra you had learnt on the
                                                        form a significant part of my job. I had to            and was able to look after the catheter at home. I
management course for new consultants – “How
                                                        research the management of malignant ascites           had to involve the district nurses and train them
to say No”. It seems I still haven’t learnt or I
                                                        and had to write to the Primary Care Trust to          as well and I was starting to wonder if it was
would not be writing this article on a glorious
                                                        obtain funding. After a brief period of time, the      worth it. This is when I learnt the art of delegation
sunny afternoon, a rarity in March, instead of
                                                        powers that be in the PCT realized that in             and I am thankful for the radiology sister who
biking with my daughter.
                                                        addition to improving patient care, this procedure     subsequently has performed such a brilliant job,
   As a registrar, I performed a lot of challenging
                                                        saved money by preventing repeated                     that nowadays I merely perform the procedure.
interventional work. One of the simplest types of
                                                        hospitalization and agreed to fund the procedure.      And before I knew it, I had set up a service !!!
interventional work I performed was drainage of
                                                           I performed the first procedure in the                  Although my team won a Service Improvement
malignant ascites in patients with advanced ovarian
                                                        ultrasound department under local anesthesia.          Award and a Health and Social Care Award for
carcinoma. However this was difficult for me, as I
                                                        However after entering the abdominal cavity            this service in 2008, I cherish the card from my
encountered a large number of patients who were
                                                        using a large trocar and a peel away sheath, I was     patient which said “Thank you for helping me to
nearing the end of their life, but had to come into
                                                        unable to introduce the blind catheter through         get on with the precious time I had left in life
hospital on a fortnightly basis to have their ascites
                                                        the sheath. This meant that the ascetic fluid was      with my family and friends without spending
drained for palliation. They had to stay in the
                                                        pouring out like a fountain and even though the        it in pain or in hospital”.
hospital for 24 to 72 hours and so would reluctantly
                                                        patient had confidence in me, I was nervous and
attend the hospital only when their abdomen was
                                                        so abandoned the procedure and converted it to         Abdul Razack, Consultant Radiologist,
so distended that it caused difficulty in breathing.
                                                        a standard drain.                                      Hull and East Yorkshire NHS Trust                  <




scientific programme committee
The Programme for this years 22nd annual meeting is finally complete and            your own scientific research and find out what’s new at the cutting edge of
we hope to see you all in Brighton this autumn. It’s great to return once           IR (I hope that doesn’t sound too surgical).
again to this excellent venue. The Metropole provides an ideal venue where             Of course it’s not all about work. There will be a drinks reception on the
it’s possible to roll out of bed in the morning (bright and early) and get to a     Wednesday evening after the workshops finish, followed by the dinner on
lecture without having to sample our great British weather!                         Thursday night in the Brighton Metropole.
    The programme committee have been working hard and we hope that we                 This year’s trade exhibition is one of our largest and provides a great
have put together a varied and stimulating programme covering many areas            opportunity for delegates to meet up with our industry partners and see
of both vascular and non vascular IR. The programme includes intervention           what new equipment is out there.
in panceatitis, radioembolisation, TEVAR, drugs in IR, head and neck IR,               We’re all looking forward to seeing you in Brighton on the 4th November!
aortoiliac disease, GI haemorrhage, venous intervention, thoracic IR, debates,
                                                                                    Dr. Phil Haslam Chair BSIR Scientific Programme Committee 2009
tips and tricks and of course-complex cases.
    This meeting will provide you with the opportunity meet up with your            Programme Committee members:
peers (possibly over some beers), learn from our invited speakers, present          Dr. Tarun Sabharwal, Dr. Jane Phillips Hughes and Dr Raman Uberoi             <




communications committee
The communications subcommittee has been                   Many members have kindly offered support in         Much of this will be available to all members and
working hard to launch the new BSIR website at          producing content for the patient information pages    the accuracy and attractiveness of the
the annual conference in November. Key                  so vital for communicating our messages about the      information will be absolutely dependant on the
improvements include use of a UK based website          role of interventional radiology in modern medical     input from members. If you think you have
provider, WIKI style content management,                practice to GP referrers and patients and their        additional information, more accurate
electronic booking and payment systems for              relatives. Please keep these coming on new topics so   information, more readable information, better
membership and conference facilities, a series of       we can develop a comprehensive portfolio of all our    images, more relevant references and links don't
patient information miniwebsites on individual          procedures and soon achieve our aim of providing       just moan... upload them! A new platform has
interventional radiology procedures, an urgent          the most respected and up to date information          now been produced but the success of the site is
ask the expert facility and a find a doctor facility    about Interventional Radiology for all users.          now a community effort and down to you.
to guide patients and GPs to local experts in the          The site has been totally redesigned to enable
management of their condition.                          immediate simple online updating of information.       David West                                         <



                                                                                                                                                                  5
planning for trauma: the role of imaging
Trauma is sudden – devastating accidents come out of                                the orthopaedic team access to the pelvis for external fixation. The
                                                                                    neurosurgeons meanwhile prepare to drain the extra-dural haematoma.
the blue, with no respect to age. Planning the delivery                                Justin is in luck: the craniotomy releases the pressure before any
of a trauma service, therefore, needs to be meticulous,                             significant neurological sequelae; the embolization coils stem the internal
                                                                                    bleeding, without laparotomy, and the Ex-Fix staunches the pelvic bleeding.
compensating for the random violence that smites                                       ITU provision – carefully modelled in the planning phase, based on
down those it is designed to help.                                                  network usage, HDU and ITU usage – is such that a bed is available as soon
                                                                                    as surgery is complete (and not at the expense of an equally needy patient).
   The UK is beginning to appreciate this juxtaposition, realising that
                                                                                    Justin has survived the first 6 hours after extreme multi-trauma; his recovery
improved outcomes for trauma require investment in a series of well
                                                                                    will be long because of his need for a series of planned pelvic orthopaedic
placed grade 1 trauma centres. Just such a centre is planned for the South
                                                                                    procedures, but it is safeguarded because he can remain at St Saviour’s
East: the project team comprises amongst others, senior clinicians, architects,
                                                                                    throughout, his journey to recovery assisted by an excellent imaging
health planners from the SHA, and the ambulance service. The 1:200 drawings
                                                                                    department, and any complications including pulmonary embolism,
for the 13 level build have been agreed, and the 1:50 scale drawings are being
                                                                                    secondary bleed, formation of intra-abdominal collection or deterioration
prepared, concentrating on detailed room design. The imaging floors (yes, we
                                                                                    due to traumatic injury missed at the initial CT (diaphragmatic rupture or
have 2 floors of xx square metres each) have pre-occupied a disproportionate
                                                                                    mesenteric injury can crop up as a nasty surprise), identified and if necessary
amount of resource, with the acknowledgement that a superlative imaging
                                                                                    treated percutaneously.
service – diagnostic, interventional and neuro-imaging – is a sine qua non
for trauma management.                                                              Ivor Nolack’s story:
   All this has taken three years of meticulous industry, and the diggers           The Western County’s paramedic team is dispatched by road ambulance,
will not be on site for at least another 18 months. The justification for           arriving shortly after the helicopter. Ivor is placed on a spinal board and taken
this amount of resource and time may be better understood with the aid              17 miles to Dolor District General Hospital. His journey takes him through the
of a short parable.                                                                 very market town where he had been heading – ironically arriving in the town
                                                                                    unconscious rather than as he had hoped, leaving it unconscious.
A tale of two twitties
                                                                                    Unfortunately, the revellers in the town centre delay the ambulance which
    A normal Saturday evening sees two likely lads jump into the Gti, rev
                                                                                    takes 45 minutes – most of the golden hour – to arrive at A&E. Ivor is
the motor and dash toward the drinking holes of the nearby town centre.
                                                                                    received by a middle grade A&E registrar, and together with the surgical F1
The surface water from a recent downpour does not put off our erstwhile
                                                                                    and anaesthetic registrar, he takes over long stabilising the pelvic fractures
heroes, at least not until the turbo charged charabang spins off the road and
                                                                                    and completing the secondary survey. At last the patient is transferred down
collides with a venerable oak, which has marked the County border since the
                                                                                    a 50 metre corridor to CT, and with some delay transferred onto the gantry.
Norman invasion. The driver, Justin Luck is thrown out of the car to the East
                                                                                    The consultant radiologist is summoned and arrives 25 minutes after the CT
side of the tree and his mate, Ivor Nolack falls to the West of the mighty
                                                                                    (performed in the portal phase) has been completed. By this time, the patient
trunk. This dispersal has more than geographical interest, for Justin has
                                                                                    is back in A&E being seen by the surgical registrar who, with the benefit of
landed within the catchment area of St Saviour’s [a brand new teaching
                                                                                    the CT (no active bleeding point identified because no arterial phase images)
hospital, just appointed Level 1 trauma centre], while Ivor’s senseless body
                                                                                    decides that the extradural is more important than a laparotomy. However,
is to be taken to Dolor District General Hospital. By chance, both boys
                                                                                    while making contact with the neurosurgeons at St Saviours, the patient
have sustained identical injuries: splenic laceration, complex pelvic
                                                                                    deteriorates. The consultant general surgeon arrives and commences
fractures and an extradural haematoma.
                                                                                    emergency splenectomy, with subsequent improvement in blood pressure.
Justin Luck’s story:                                                                Ironically, with this systemic improvement, the extradural extends: with no on
The wreckage is quickly spotted and the ambulance service for the Eastern           site neurosurgeon, the consultant general surgeon makes the courageous
County contacted. They have strict pick up and delivery protocols, the pre-         decision to form a burr hole and drain the haematoma. The patient is saved
hospital care pathway carefully thought through in the planning stages. The         by the have a go hero, and the pelvic fractures cobbled together by external
network has agreed that major trauma be collected when possible by the              fixation. Ivor has been in theatre for 6 hours by now but youth and vigour are
emergency helicopter, and the patient transferred directly to the level 1 trauma    on his side. By day 9, he is alive, albeit with questionable ability to weight
centre, leapfrogging smaller (and very competent) district general hospitals        bear on the right because of the pelvic fractures. In any case, he is
within the county.                                                                  hemiparetic from the extradural. As he mentally adjusts to a life in a wheel-
   Vigorous resuscitation commences as soon as Justin is on board, and the          chair, tragedy strikes in the form of overwhelming and fatal pneumococcal
receiving hospital is alerted with a full primary survey. The helicopter            septicaemia following his splenectomy!
transfer, free from Saturday night traffic, takes 12 minutes before landing on
                                                                                      A corny tale, but one that tries to highlight several of the advantages of
the helipad on top of the 13 storey tower block at St Saviour’s. Justin is taken
                                                                                    concentrating resources in to a major trauma centre.
on the same trolley (avoiding critical delays in transfer) in a dedicated lift to
the major resuscitation room on level 5 of the tower.                               Definition of a Major Trauma Centre
   As soon as the A&E consultant and the anaesthetic consultant (senior               The Royal College of Surgeons’ recommendation of at least 250 cases per
staff are resident for major trauma) are happy, the patient is taken to the CT        annum, as set out in its Provision of Trauma Care: Policy Briefing (2007).
scanner that is in A&E. A gantry system has been built (tip: make sure the            Neurosciences burns, plastic and reconstructive surgery to compliment
ceilings are high enough) so that the trolley and anaesthetic machines move           the full range of clinical services set out in NCEPOD’s Trauma: Who
through the lead lined doors into the CT room, with rails directly to the             Cares? (2007) and the Healthcare for London standards for Major Trauma
heart of the CT. Once again, unnecessary transfers are avoided. A full body           Centres (2008).
CT (head, C-spine, chest to perineum) is acquired in the arterial phase on the        Full support of the regional Trauma Network and its constituent NHS
64 slice scanner in 15 seconds. Consultant radiology review is provided               Trusts, including the regional Ambulance Service.
(suggestion: radiology included in the trauma call team for patients ISS>16).       Chapter 11 NCEPOD.
The right extradural, the splenic bleed (angio phase shows continued active
                                                                                    Incidence of Major Trauma
bleeding) and the pelvic fractures (with reformation) are documented.
                                                                                    A research study1 (2008) into the outcomes and costs of blunt trauma in
   The team congregates around workstations in CT (remember this is in A&E)
                                                                                    England and Wales provided the following assessment: Injuries are a major
and immediately it is agreed that the Polytrauma theatre should be prepared.
                                                                                    cause of morbidity and mortality in young people, representing the leading
This theatre has the dimensions of an aircraft hangar, enabling several teams
                                                                                    cause of death in those aged younger than 35 years and causing           >
to work on the patient at once. A state-of-the-art C-arm means that
                                                                                    approximately 3,500 deaths annually in England and Wales2. The number of
interventional radiology can be performed to the highest standard, and this
                                                                                    serious injuries implies approximately 640,000 hospitals admissions each
commences, using a trans-axial approach to embolism the spleen, allowing



6
year and more than 6 million attendances to accident and emergency (A&E)                 the establishment of robust clinical governance and continuous review
departments3,4.                                                                          processes for trauma care within the Trust
    The incidence of polytrauma (defined as a new injury severity score (NISS)           Discussions with the National Clinical Director for Trauma Care.
? 16) is currently 10,500 per year5. The annual cost to the NHS of treating              Planned Development: Facilities
trauma injuries is currently estimated at £1.6 billion; about 7% of the total            – a dedicated polytrauma theatre with full interventional capability, plus an
annual NHS budget6. In 1988 the Royal College of Surgeons reported                          additional interventional theatre for elective interventional radiology and to
‘significant deficiencies in the management of seriously injured patients’7; its            provide a back-up for the polytrauma theatre;
retrospective study of 1,000 trauma deaths concluded that ‘one third of all              – a polytrauma ward; and
deaths occurring after major injury were preventable in the large DGHs.’                 – a helipad, in line with NCEPOD and Royal College of Surgeons/British
Subsequent reports, including Better Care for the Severely Injured (2000)8 and              Orthopaedic Society recommendation that ‘a helicopter pad close to the
Trauma: Who Cares? (2007)9, drew similar conclusions. In its 2007 consultation              A&E department is mandatory [for Major Trauma Centres and that] there
on the establishment of a network of Major Trauma Centres for London,                       should be no additional secondary journey by road.’
Healthcare for London argued that: ‘A trauma system… should have big                     – Further enhancements of the Emergency Department to create an enlarged
benefits for patients – the establishment of a trauma system in Quebec                      resuscitation area with co-located imaging (CT) and direct access to the
resulted in mortality dropping from 52% to 19% due to treatment in specialist               polytrauma theatre
centres and direct transport from the scene to these centres. The need for               Planned development: Critical Care Beds
change has been evident for some time…but this has never been put into                   – Modelling for the number of additional general and neurosciences critical
practice… At the heart of this system would be the trauma centres.’ 10.                     care beds required for the planned increase in the number of patients with
                                                                                            severe injury and major trauma
Designing the imaging department
                                                                                         – research into the outcomes and cost of blunt trauma11 show a greater (70%)
The heart of the trauma centre must be A&E and the operating theatres,
                                                                                            use of critical care beds.
supported by imaging and ITU. Of course, the radiologists are less blinkered
                                                                                         Clinical Governance
than some of their clinical colleagues and realise that the department must
                                                                                         – The Trust Trauma Steering Committee, which is chaired by the Medical
cater for all forms of critically ill, not just the victims of trauma. And, being of
                                                                                            Director, has been established to oversee the clinical planning for the Major
renaissance mind – imagination beyond that of the bone fixers – they perceive
                                                                                            Trauma Centre.
that the department mostly will be involved with out-patient or more ‘routine’
                                                                                         – Its Trauma Delivery Subcommittee, which is chaired by the Principal Lead
in patient work (and don’t we know how the trickle has become a torrent). The
                                                                                            Clinician for the Emergency Department, ensures that there is a robust
key, then, is to look at patient flows, ensuring clear lines of access for the
                                                                                            process for continuous improvement in the care of patients with severe
critically ill, but recognising that the vast majority of patients served by the
                                                                                            injury and trauma.
department will be out patients with a further sizeable group of non-critical
                                                                                         – The Trust is currently recruiting for a Chief of Trauma, who will be
in-patients. Blocking the modalities (US rooms together, CT and MRI and so
                                                                                            responsible for the planning, organisation, supervision and systematic
forth) aids efficiency and our approach has been to have outpatients at the
                                                                                            delivery of care to patients with severe injury and trauma and for ensuring
south end of the building (benefitting from the superb sea views), in patients
                                                                                            continuous evaluation of and improvement in practice.
having dedicated lift access at the north end of the floor, and imaging rooms
                                                                                         The Trauma Network has established three workstreams
sandwiched between from west to east: cross-sectional suites , ultrasound and
                                                                                         – Pre-Hospital Care. This is focusing on the definition of major trauma; the
interventional ultrasound, plain films and fluoroscopy and interventional
                                                                                            organisation and staff that respond (road ambulance, air ambulance, BASICS
radiology suites. Anaesthetic and recovery rooms, reception areas and storage
                                                                                            doctors, Critical Care Paramedics) and how they will be tasked; and
strategically placed throughout. The east end of the building houses the
                                                                                            protocols for bypass versus secondary transfer to the Major Trauma Centre;
offices and administrative facilities. To further aid patient flows and smooth
                                                                                         – Emergency Department. This is focusing on the Emergency Department’s
running of lists, we have plumped for walk through change rooms, and
                                                                                            response to trauma arrivals, including resuscitation, identification of injuries,
reporting areas within the clinical floor space as well as space for the clinical
                                                                                            documentation and clinical protocols and the decision to undertake
modality managers on the floor. A dedicated IT committee is working on
                                                                                            secondary transfer; and
optimising modern electronic possibilities such self-registration (like BA use at
                                                                                         – Specialised Services. This is addressing the remainder of the patient pathway
the airport) paging systems, and signage.
                                                                                            from the point of leaving the Emergency Department to discharge from the
   The floor above is hared with the neurosurgery services, with additional CT
                                                                                            hospital (or transfer back to referring hospital or another facility). It includes
and MRI. Within the neurosurgery theatres suite, there are 2 interventional
                                                                                            the clinical and non-clinical support services that acute hospitals wishing to
radiology operating theatres. Hybrid OR advert. These are the ‘air craft hangars’
                                                                                            receive patients with major trauma across the network
in Justin’s tale. With 2, there is opportunity to deal with major incidents; and
there is opportunity to use them for EVARs and other more routine yet
                                                                                       Jonathan Richenberg, Consultant Radiologist, Royal Sussex County Hospital.
complex IR, whilst ensuring major trauma victims can be treated without delay.
The expectation – refreshingly radical – is that one theatre will be relatively
redundant – an asset that will not be flogged to within an inch of its life.           References
                                                                                       1) ‘Outcomes and costs of blunt trauma in England and Wales’; Christensen et al;
Service improvement
                                                                                          Critical Care, Vol12 No1 (Feb 2008)
   Looking at ways of working is at least as important as getting the physical
layout right. Indeed, the opportunity to rethink how the imaging service is            2) Mortality Statistics by Cause, Sex and Age; England and Wales 2005, Office for
                                                                                           National Statistics (2006)
delivered should drive the whole architectural process. There is a perpetual
need to avoid the tendency to duplicate current working practice: it is not            3) Hospital Episode Statistics, Department of Health (2006)
enough to recognise current physical constraints that limit the patient flows          4) Strategic Review of Research Priorities for Accidental Injury, Ward H, Christie
and processes, and design the new department to avoid these. It is beholden                N, Department of Health (2000)
on the planners to undertake the much more difficult task of deconstructing            5) ‘Improvement in trauma survival in Leeds’, Burdett-Smith P, Airey GM, Franks AJ.
current working practice and see if this can be performed to improve                       Injury. 1995;26:455–458.
efficiency, patient experience and quality. The new build can then be                  6) Saving Lives: Our Healthier Nation, Ibid
designed around the new working practice. My experience of being faced                 7) Commission on the Provision of Surgical Services: The Management of Patients
with a tabula rasa has been both liberating and daunting. Rather than getting              with Major Injuries, The Royal College of Surgeons of England (1988)
too poetical, let me provide a summary of some of the planning issues.                 8) Better Care for the Severely Injured: A Joint Report from the Royal College of
Modus Operandi: a summary of the planning of a trauma centre                               Surgeons of England and the British Orthopaedic Society, The Royal College
 the establishment of a regional Trauma Network,                                           of Surgeons of England (2000)
 partnership working with the regional Ambulance Service to model                      9) Trauma: Who Cares?, National Confidential Enquiry into Patient Outcomes and
 patient numbers,                                                                          Death (NCEPOD) (2007)
 liaison with outside region trauma projects, site visits to review the different      10) Healthcare for London: a Framework for Action, NHS London (July 2007)
 models of care,                                                                       11) ‘Outcomes and costs of blunt trauma in England and Wales’, Ibid                <




                                                                                                                                                                            7
imaging in trauma
    CT in A&E dedicated to major trauma with ability to divert patients from this platform (for example colic CT patients presenting with loin pain to
    Emergency Department to CT scanners within the Imaging department). Resuscitation algorithm: A,B, CT
    Sequences: Arterial phase, delayed phase if urological trauma suspected. Proper coverage – neck as standard
    Access to read in multiple sites but better still at high quality monitors with senior clinicians
    IR – as part polytrauma. Embolise or open up vessels in cases dislocation or stent if dissection
    Follow up imaging: later complications – drainage collections, managing ARDS; DVT and PE. Reintervention


    Fabric                                              Organisation and service delivery (strategy)          Evidence base
    Proximities and adjacencies                         Network – harmonious relationship with nearby         Learning from other centres – their mistakes
                                                        smaller hospitals. Regional trauma network –          and their good points
                                                        pre-hospital care (definition of major trauma,
                                                        those involved in initial response, transfer
                                                        policies); A&E; Specialised services
                                                        Ambulance service and pick up and
                                                        delivery protocols
    Space: all specialties on site; large polytrauma    CT in A&E                                             Documents: Provision of trauma Care: policy
    theatre                                                                                                   briefing (2007); NCEPOD’s Trauma: who cares?
                                                        Infrastructure: rails and gangways
                                                                                                              (2007); Healthcare for London standards (2008)
    Senior engagement: consultant and matrons           Trauma steering group                                 TARN and national data submission
                                                        Delivery groups with regular case review and
                                                        audit. Wide representation but not too many to
                                                        make unworkable
    ITU and HDU                                         The whole process: aftercare and discharge
                                                                                                                                                                <




initial results: patient experiences with
vascular interventional radiological procedures –
a multi-site prospective cohort study
Progress so far                                                                    27 procedural explanations for this episode were given by a Radiologist, 1 by
Questionnaires have been sent out to approximately 200 patients and we             a medical doctor and 43 by vascular surgeons. Content (p=0.05), timing
have full data sets on just over 80. They have been sent to patients               (p=0.017), and the explanation (p=0.002) were considered better if explained
undergoing interventional vascular procedures in both Hull and Leeds. Prior        by radiologist than other groups. The majority of patients were satisfied with
to the deadline for the BSIR 2009 meeting we had full data sets on 62              the explanation given (Table 1).
patients and submitted an abstract for review (see below).                            50 procedural explanations allowed time for questions and 12 didn’t and
                                                                                   overall 56 participants were aware of what their procedure entailed and 6
Initial results calculated from the fist 62 patients
                                                                                   didn’t. Areas of improvements highlighted by participants included (n=14): 4 =
The age range of patients is 38-89 with a mean of 63 years. There are 36
                                                                                   more time, 3 = more detail, 1 = slower, 2 = unaware of fact having procedure
males and 26 females. 35 patients were smokers, 11 had never smoked and 16
                                                                                   at all, 3 better/clearer explanation, 1 = methods clearer.
currently smoke, both ex smokers and current smokers have more pain
(p=0.002) and more pain 1 week following the procedure (p=0.04) than               Procedural details
patients who have never smoked.                                                    The pain level experienced by patients and indicated on a visual analogue
                                                                                   scoring system decreased as a result of the treatment (Table 2).
Pre procedure satisfaction
23 patients had had the same procedure in the past, 1 didn’t know and 38
                                                                                                        Pre procedure       Immediately         1 week post
had not had the procedure done previously. 31 patients had been treated by
                                                                                                                            after the           procedure
a radiologist before, 4 didn’t know and 27 had not been previously treated.
                                                                                                                            procedure
23 had a previous angiogram, 9 had previous angioplasty or chemo
embolisation, 4 didn’t know and 27 had not been treated before.                     Pain Level          4.8                 4.23                3.38

                       Ok                  Good/Easy         Poor/Hard
                                                                                   Table 2: Visual Analogue Score (VAS): 0 = no pain to 10 = worst pain
 Content               19                  41                2                     imaginable. All values means (n=62).
 Timing                19                  38                5                        12 patients got analgesia to take home with them and 50 didn’t. Of those
                                                                                   that didn’t 11 would have liked analgesia to take home. Of the 12 that took
 Ease of               17                  34                11
                                                                                   analgesia home only 4 stated it was strong enough. Patients that were more
 Understanding
                                                                                   anxious were more likely to state they would have liked analgesia to take home
                                                                                   (p=0.045). Perhaps unsurprisingly, patients that had higher pain scores      >
Table 1: Satisfaction of treatment explanation


8
  before and immediately after the procedure were also more likely to have          High levels of pain 1 week after the procedure was associated with lower
wanted analgesia to take home (P=0.0012).                                        general health scores at 3 months (spearman’s correlation 0.383 p=0.002),
                                                                                 worse emotional health (spearman’s correlation 0.566 p<0.001), worse
Side effects of treatment
                                                                                 physical and social health (spearman’s correlation 0.473 p<0.001) and, less
The side effects of the endovascular procedures are outlined in table 3.
                                                                                 time for housework and less social time spearman’s correlation 0.414 p=0.001;
                                                                                 spearman’s correlation 0.457 p<0.001) respectively.
                     Number of            Duration of       Duration of             Smokers rated their health lower at 3 months than non smokers (p=0.007).
                     participants         side effect       side effect          They had worse initial QoL emotional problems (p=0.002) and had more
                     indicating           (mean in days)    (range in days)      emotional problems at 3 months than non smokers (p=0.044). At 3 months
                     specific side                                               smokers also showed worse physical health and social health (p=0.018).
                     effect (total: 62)
                                                                                 Future direction
 Discomfort          39                   5.3               1-28                 We aim to present these initial results at BSIR 2009. We are continuing the
                                                                                 study and are aiming for 125-150 participants. If the recruitment rate continues
 Fevers              2                    3                 3
                                                                                 at its present state we hope to have recruited all participants in the next 3
 Bleeding            13                   9                 1-28                 months and will them re-analyse the data and submit the final work to CIRCE
                                                                                 or RSNA. We also aim to write the work up as a journal article.
 Mottling            18                   9.4               3-18


Table 3: Patients reported side effects. Discomfort, bleeding and mottling        CONTROL ID: 671856
refer to the puncture site.                                                       TITLE: Initial results: Patient Experiences with Vascular Interventional
                                                                                  Radiological Procedures – A Multi-site Prospective Cohort Study
   6 patients stated they had a mild allergic reaction post procedure (rash,      AUTHORS (FIRST NAME, LAST NAME): Charles R. Tapping1, Adam D.
tingling). There were no cases of anaphylaxis. 4 patients presented to A&E        Culverwell2, David O. Kessel2, Duncan F. Ettles1
with side effects they associated with the treatments these were: 2 episodes      INSTITUTIONS (ALL): 1) Radiology, Hull Royal Infirmary, Hull, Yorkshire,
of leg swelling (US scan confirmed DVT) and; 2 patients needed pain relief.       United Kingdom. 2) Radiology, Leeds General Infirmary, Leeds, Yorkshire,
Patients that experienced bleeding as a side effect were more likely to have      United Kingdom.
higher pain scores immediately after the procedure (p=0.011). There was           PRESENTATION TYPE: Oral Presentation and Scientific Poster
strong evidence (p<0.001) that pain immediately after the procedure and at 1-     CATEGORY: Vascular
week post procedure were associated with bruising, mottling and allergic          ABSTRACT BODY:
response. Bleeding and allergies were significantly more common for               Aims: Very little is currently known about patients’ experiences of
smokers (p=0.014). Bleeding was significantly more common for females             interventional radiological vascular procedures and also what improvement
(p=0.018). Discomfort was significantly more common in those who had not          in quality of life such procedures provide. This study explores these factors
had the procedure before (p=0.006).                                               in order that patient care can improve.
                                                                                  Materials and Methods: Questionnaires were sent to patients undergoing
Quality of life (QoL)                                                             interventional vascular procedures prior to treatment, directly after treatment
Overall quality of life improved 3 months following patients treatment. This      and 1 week following the procedure. Anxiety, understanding and pain were
was most marked in their emotional state and increased activity levels.           assessed using a visual analogue scoring system. Patient complications,
Patients consistently indicated an improvement in QoL compared to 3               analgesic preferences and satisfaction was also recorded. Changes to quality of
months earlier. However, patients indicated more emotional problems at 3          life were assessed using the validated SF36 quality of life questionnaire.
months when anxiety prior to procedure was high (spearman’s correlation           Results: So far 62 (48%) patients replied from an initial 130 questionnaires.
                                                                                  Areas for improvement included more detailed explanations of procedures
0.330: p=0.009).
                                                                                  and their complications and increased consultation times. For 69% the
   Patients with a higher level of pain before the procedure had worse initial    anticipated level of pain was greater than that experienced and patients pain
QoL general health scores (spearman’s correlation 0.403 p=0.001), more            scores were less on follow-up than prior to the procedure. The majority of
emotional problems (spearman’s correlation 0.265 (p=0.037), worse initial         patients (80%) did not get take home analgesia, however 22% of patients
physical and social health (spearman’s correlation 0.311 (p=0.014) and spent      would have liked it. The most common side effects were discomfort (63%)
less time socialising (spearman’s correlation 0.587 (p<0.001).                    which lasted for an average of 5.3 days and bruising (54%) which lasted for an
   Current level of pain was associated with more interference with home          average of 9 days. On average the quality of life scores improved.
and housework (spearman’s correlation 0.434 p<0.001).                             Conclusion: As endovascular procedures have become more complex,
                                                                                  sophisticated and readily available issues of patient information, satisfaction,
   More pain immediately after the procedure was associated with worse 3
                                                                                  anxiety and peri and post procedural analgesia have become more important.
month QoL general health scores (spearman’s correlation 0.304 p=0.016),           Results here should help interventionalists plan for day case units and
more emotional problems (spearman’s correlation 0.303 p=0.017), worse             patients care plans. Important areas include communication and follow-up
quality of life physical and social health (spearman’s correlation 0.327          and improved strategies for analgesia, sedation and aftercare.
p=0.009), less time for socialising (spearman’s correlation 0.353 p=0.005),
worse emotional health (spearman’s correlation 0.524 p<0.001), and less time
for housework (spearman’s correlation 0.373 p=0.003).                            CR Tapping, AD Culverwell, DO Kessel, DF Ettles                                 <




MHRA who?
Summary                                               but in order to limit the potential for harm to        involving medical devices each year; the majority
The Medicines & Healthcare products Regulatory        users and patients, we work in cooperation with        of these come from device manufacturers who are
Agency (MHRA) is an Executive Agency of the           clinicians and manufacturers with the mutual aim       legally obligated to inform us of any serious or
Department of Health which was formed in April        of creating a more positive benefit-to-risk ratio.     near incidents involving their devices. However we
2003 by merging the Medical Devices Agency and           We do this by investigating adverse incident        also receive reports from patients and clinicians.
Medicines Control Agency. MHRA ensures that           reports, issuing safety advice to users whenever          The information provided to MHRA by device
medicines and medical devices (healthcare             necessary, and enforcing the relevant European         users and manufacturers helps us to build up a
products) used within the UK are safe and fit for     Regulations (Medical Devices Directives). We           picture of what is happening with medical
their intended purpose. No product is risk free,      currently receive up to 9000 incident reports          devices across the UK. This is supplemented by >


                                                                                                                                                                     9
reports from overseas. Regular review of all this         closely with the Agency’s Clinical team of               we encourage all healthcare professionals to
information enables us to identify trends and take        medical and nursing experts.                             share their experiences with the MHRA when
early action on specific problems where needed.              In many cases ‘In-Depth’ investigations will          they encounter difficulties with a medical device.
                                                          require more widespread consultation with                   Reportable adverse incidents can include (but
What do we do with incident
                                                          additional professionals, such as clinicians on          are not limited to) problems with device
reports we receive?
                                                          MHRA’s Register of Experts/Committee on the              packaging (e.g. compromised sterility issues or
All adverse incidents are initially risk assessed to
                                                          Safety of Devices or the Royal Colleges and              labelling issues), inadequate IFU, device damage
decide what type of investigation should be
                                                          Societies. Our investigation may also involve            or inexplicable failure during preparation,
carried out. This assessment includes
                                                          collaboration with other UK government bodies,           complications arising during procedural use and
consideration of the type of device involved in
                                                          regulatory colleagues from Europe, the US the            implant (e.g. deployment, landing or retrieval
the incident, the severity of patient injury, the
                                                          rest of world.                                           failure) and of course patient injury or death. We
numbers of devices involved and the numbers of
                                                                                                                   are particularly interested in more recent
similar events already known to the MHRA. Many            How does all this help patients and clinicians?
                                                                                                                   developments in technology enabling
incidents are initially investigated by the device        The outcomes of these investigations can be
                                                                                                                   percutaneous/transcatheter or endovascular
manufacturer and their final reports are critically       varied. As a minimum, useful information is
                                                                                                                   implantation. For example, we would like to gain
evaluated by the relevant Medical Device                  gained by the MHRA and the manufacturer about
                                                                                                                   a clearer appreciation of the types and
Specialist. Other reports are recorded on our             device performance and user interface. However,
                                                                                                                   prevalence of difficulties being encountered
database for information and future statistical           investigations can also lead to product recalls,
                                                                                                                   when removing IVC filters labelled as retrievable.
analysis, with no immediate action being taken at         design or manufacturing changes, amendments to
this point. This may happen for example, where            instructions for use (IFU) or additional training
                                                                                                                      At the MHRA we always endeavour to
we are aware of a known complication associated           requirements. Such findings can prompt us to
                                                                                                                   investigate incidents carefully, objectively, in an
with the use of a particular device and we wish           publish a Medical Device Alert (MDA), MHRA’s
                                                                                                                   open and fair manner. We are not concerned with
to monitor over a period of time.                         main mechanism for informing healthcare
                                                                                                                   apportioning blame or liability, but with limiting the
   The remainder of reports (approximately 2500           professionals of medical device related safety
                                                                                                                   occurrence of adverse incidents as far as is possible.
each year) are assigned as ‘In-Depth’                     issues. MHRA published 88 MDA’s during 2008.
                                                                                                                   Constant effort, however, is required by all parties
investigations. As the name suggests, this type of
                                                          What else do we do?                                      involved to reduce both the rate at which adverse
examination involves more direct involvement by
                                                          In addition to investigating incidents we review         incidents occur and the severity of the outcome.
a “Medical Device Specialist” including
                                                          clinical trial or novel technology funding                  To learn more about how to report problems
correspondence with the clinician involved in the
                                                          applications, prepare Coroners reports and attend        associated with medical devices to MHRA please
incident. This interaction is often crucial to our
                                                          inquests, draft formal responses to press enquiries      see the document DB 2009(01) Reporting adverse
investigation and its ultimate outcome.
                                                          or briefing Health Ministers are only some examples      incidents and disseminating MDAs which is
   With about 55 Medical Device Specialists in
                                                          of our routine. No two days are ever the same!           available to download on the MHRA website. And
the Agency, we can bring to these investigations
                                                                                                                   to find out more about the role of the MHRA and
experience in material science, mechanical                How can you help?
                                                                                                                   make a report online, please visit
engineering, biology, medical physics, and                Whichever form of investigation is undertaken,
                                                                                                                   www.mhra.gov.uk
microbiology, to name but a few. I specialise in          the process is entirely dependent upon clinicians
cardiovascular implants such as heart valves,             bringing device-related problems to our attention
                                                                                                                   Alexander McLaren Senior Medical Device, Specialist
embolisation products, AAA devices, congenital            or reporting these to the relevant manufacturer.
                                                                                                                   & Compliance Inspector, Biosciences & Implants
heart defect appliances, IVC filters, coronary and        However, we are aware that there may be under-
                                                                                                                   Unit, Device Technology & Safety, MHRA           <
peripheral stents/grafts. In addition, we work            reporting of problems in some device areas and




a measure of ovarian reserve following fibroid
uterine artery embolization with two different
embolic materials: early six month results
Purpose                                                                                the hormone blood tests. These included the uterine fibroid symptom and
To assess the difference between calibrated particles (Embozene) and non-              health-related quality of life questionnaire (UFS-QOL).
calibrated (PVA) particles for uterine artery embolisation (UAE) on ovarian reserve.
                                                                                       Results
Materials                                                                                As of the end of July 2009, 36 patients have been entered and further 21
This is a prospective, randomised, single-blind, single-centre trial to assess           patients been recruited.
the difference in the ovarian reserve following UAE with two different                   The expected completion date is early next summer
embolic materials, Embozene and PVA particles.                                           The early 6 week results will be presented as an electronic poster in CIRSE 09.
   Ethics approval was obtained from the NHS research and ethics committee.              The early results showed no significant difference in uterine maximum
   One hundred women between the ages of 18 and 45, who were seeking                     diameter between the two groups.
treatment for symptomatic fibroids, and to whom fertility is a secondary                 Pre-embolisation FSH for all patients was less than 15 u/l in keeping with
concern, were eligible for this study. A combination of clinical examination             the inclusion criteria. The pre-embolisation AMH results are available for 9
and MRI imaging was used to confirm that fibroids were the most likely                   patients with a mean of 22.1 pmol/l (range 6.1 to 57.4).
source of their symptoms.                                                                USF-QOL scores ranged between 73 and 170 with a mean of 131. There
   There are two groups, one treated with non-spherical PVA particles, and               was no significant difference between the pre-embolisation UFS-QOL
the other with Embozene. FSH, LH, estradiol and anti-Mullerian hormone                   scores in the two groups.
(AMH) levels were taken before the procedure and at 6 weeks, 6 months, and               Significantly more particles were required to embolise the embozene
12 months after the procedure. Contrast-enhanced MRI imaging was also                    group (median 7ml, range 4 to 17 ml) compared to the PVA group (median
performed 6 months after the procedure to assess fibroid perfusion and                   2.5ml, range 0.75 to 3.5ml; p<0.05).
shrinkage as a measure of radiologic success. Validated questionnaires                   Despite this the screening time was not significantly different in the two
providing a measure of quality of life and a score for menopausal symptoms               groups (p=0.9). The screening time in the PVA group ranged from 6 to 31
were also filled out prior to the procedure and then at the same intervals as            minutes (median 15 mins) and in the embozene group the range was 5 to >


10
  33 minutes (median 9 mins).                                                        patients compared to PVA.
  The USF-QOL scores showed a significant reduction, where the lower the                While at 6 weeks five patients had not resumed their menstrual cycles,
  score the less the symptoms, between the pre-embolisation and 6 week               the significance of this is uncertain as there has been shown to be a dip in
  follow-up in both the PVA and embozene groups (p<0.05).                            AMH levels at 6 weeks which returns to higher level at 6 months
  There was no significant difference in the FSH, LH and estradiol levels at 6       (Hehenkamp, Volkers et al. 2007). There was no significant difference in FSH,
  weeks between the PVA and embozene groups.                                         LH or estradiol level between the two groups at ? weeks.
  In the 6 patients with AMH results available at 6 weeks there was no significant      The 6 month and 1 year follow up of these patients will identify whether
  difference between the pre- and post-embolisation AMH (p=0.22). The post-          this improvement in quality of life is maintained, if the early amenorrhoeic
  embolisation AMH mean was 14.85 pmol/l with a range from 6.2 to 46.3 pmol/l.       patients resume their periods, what percentage of patients develop ovarian
                                                                                     failure, and if there is any difference between the PVA and embozene groups.
Conclusion
                                                                                        Early findings suggest that both embozene and PVA are successful in
This is very early data looking at the treatment of fibroids using UAE with
                                                                                     providing symptomatic relief after UAE. More Embozene particles are
either embozene or PVA.
                                                                                     required than PVA for successful UAE. However, there is no significant
   Both groups of patient showed a significant improvement in their symptoms at
                                                                                     difference between hormone levels at 6 weeks after the procedure.
6 weeks post-embolisation as determined by the USF-QOL questionnaire. There
was no significant difference in the UFS-QOL score between the two groups.           Dr Mohamad Hamady Department of Radiology,
   Significantly more volume of embozene was required to embolise                    St Mary’s Hospital, London W2 1NY                                          <




                                                                                                                                                                11
views of an endovascular trainee
It is just over three months since I took this job as a                                        then render you redundant in the future? The lessons from the cardiologists
                                                                                               are still fresh. In reality, interventional skills are not learnt by spending a few
post-CCT endovascular fellow at Hull Royal Infirmary                                           sessions in the catheter laboratory but require years of toil. Respect for these
and surely enough as expected I received an email from                                         skills which have been fine-tuned over the years should see one safe in this
                                                                                               environment. Open discussions often help clarify your stand and make your
my radiology consultant just the other day asking me                                           training a productive one.
to pen this article. From a radiology perspective, it is                                          Most interventional trainees are in competition with the radiology trainee
                                                                                               for the limited case load and angiographic sessions. The fool proof method of
educating to get the views of an outsider such as a                                            safeguarding your training is to ensure that your weekly sessions are
vascular surgeon on the interventional radiology                                               incorporated into the radiology trainee’s timetable. This way, everyone is
                                                                                               allocated to specific areas without tredding on each other’s toes. By careful
training scheme. This has since got me thinking about                                          and tactical negotiations through supportive supervisors I have secured
the radiology work ethics and how this endovascular                                            sessions in the angiography suite to suit my training needs.
                                                                                                  In addition to hands on experience in the catheter laboratory, I find the session
fellowship differs from that of a surgical job.                                                allocated to cross sectional reporting and aortic stent graft planning extremely
   To clarify, this is a Royal College of Surgeons post CCT fellowship which is                useful. It gives an insight into image reconstruction, image artefacts and
for a fixed term of one year. There are no clinical commitments to this job and                manoeuvres to eliminate these and the limitations of imaging modalities. This
hence no on-calls. Yes, you’re right in assuming that there is no additional duty              aspect is as important, if surgeons are to get involved in endovascular therapy.
hours pay either, ouch! Too much to lose for a fellowship post; especially                        As with all new jobs, there is the issue with recognition and trust. This is
when you are in your late thirties, carrying a heavy baggage and the credit                    inevitable and most registrars would have come across this at some point in
crunch is tightening its grip. However, I will over the course of this article hope            their training career. Needless to say, we as doctors are capable of dealing with
to put forward some valid argument for this small sacrifice.                                   this effectively and I believe that time and patience are good attributes here.
   On my first day at work in the radiology department, I arrived a bit late; ten                 Outside the radiology department, my training involves sessions in vascular
minutes past eight. Not an auspicious start, I thought to myself. Little did I                 ultrasound. These are supervised sessions with an average of fifteen scanning
realise that in the world of radiology, you do allow yourself some extra time in               episodes per week. I am currently working towards a post graduate certificate
bed. However, that is where the perks end. It is a hard slog once your first                   in vascular ultrasound at Leeds University. This is a skill which would be
patient has arrived in the radiology department from a “surgical ward” which is                invaluable for the day to day working of a vascular surgeon with competence
invariably 9.00 am or after. In most instances, work spills into the late evenings.            in assessing for peripheral arterial and carotid disease, venous disease and
In addition, when the surgeons are packing up for the weekend, they forget                     vascular access. I have allocated weekly sessions for minimally invasive venous
the tibial angioplasty for critical limb ischaemia that they happily handed over               surgery (endovenous laser therapy and foam sclerotherapy) which is another
to their radiology colleague on friday evening to “sort out” over the weekend.                 selling point of this job.
   One of the prerequisites of an interventional radiologist is effective                         To conclude, this is an opportunity to learn skills outside the remit of the
communication. They have respect for their surgical counterparts and critical                  current training curriculum for vascular surgeons. However these are skills that
clinical decisions are always made following discussions amongst themselves                    will be expected of the vascular specialist of the future. Although the coming
and the surgical team. This is an interesting and valuable lesson I have seen                  years will see a change in the vascular training curriculum to coincide with the
time and again and hope to have embedded in my brain by the end of this                        separation of vascular surgery from general surgery, it is early days to speculate
tenure. In addition there is a team working approach amongst the                               how effective this will be. In my personal opinion, there will be a place for
interventionists, tapping into the resources of individuals to deliver the most                fellowships such as this to deliver targeted training. My initial impressions are
effective outcome. This is interesting, as reluctantly the surgeons are realising              that a fellowship program when well structured and supervised will deliver the
the virtues of team working as opposed to individual excellence.                               most and hence I would recommend it to all trainees.
   An endovascular trainee in the radiology department does create a moral
                                                                                               KJ Mylankal Chair FRCS Edin, FRCS Gen Surg                                            <
dilemma for the radiology trainer. Does he train up a vascular surgeon who can




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