Autumn Newsletter 2024 by BSIR

Autumn Newsletter 2024

Autumn Newsletter

WELCOME FROM OUR EDITOR

As the days get shorter and leaves change colour, plans are gathering pace for the Annual Scientific Meeting in Brighton from 6th-8th November. We hear from our President, Robert Morgan, and Chair of the Scientific Programme Committee, Conrad von Stempel, about some of the highlights to look forward to. The program is comprehensive and varied. I am super excited to experience the ASM first hand and connect with as many of you as possible in person in Brighton.

The primary theme of this newsletter is around radiation protection, which is an unavoidable occupational hazard relevant to our everyday work. Hence we are lucky to have the thoughtful review of current evidence from Andy Rogers (Medical Physics Expert, Nottingham), practical advice from our ex-President Phil Haslam and an incredibly insightful article on the topic by our BSIRT team (Natasha Aghtarafi, Deevia Kotecha and Hunain Shiwani). Huge kudos to you all!

We then have a wonderful article on how to foster team working by incoming Communications committee chair Yuri Gupta. The next article reflects the importance of IR training going beyond the teaching of IR practical skills, to being equipped to circumvent the often-complex dynamics of gaining visibility within large healthcare organisations. Mihir Desai shares his experience of having completed an Executive Leadership course alongside a busy IR fellowship at Guy’s & St Thomas’, London.

Establishing and advancing a clinical service carry many challenges and we are lucky to have some incredibly practical and thoughtful advice from Kevin Fung, a real rockstar in paediatric IR! We wrap up with reflections from the IOUK and Paediatric IR UK special interest committees as well as (yet another) excellent research initiative from the UNITE collaborative.

Happy reading and as always please contact me if you wish to write or cover relevant IR news for future editions.

A feature we have added to the newsletter this time around is to embed videos with some of the articles. As always, happy to hear your feedback!

Dr Narayan Karunanithy BSIR newsletter editor Consultant Interventional Radiologist (London) office@bsir.org

WELCOME FROM THE BSIR PRESIDENT

Greetings fellow BSIR members,

As I write this, the annual BSIR meeting is almost upon us. It is a long time since the BSIR Annual Scientific Meeting (ASM) was last held in Brighton. We must go back as far as 2009 for the previous visit to the Brighton seafront and before that to 2005.

I recall that previous BSIR ASMs in Brighton were always hugely enjoyable and popular among attendees. Although the BSIR ASM has always taken place in November, many people still managed to enjoy the seafront and a hardy few even braved the waves for a swim. I anticipate that our return to Brighton will be a similar experience for those of you who join us, and I hope that there will be many of you!

Dr Conrad von Stempel and his colleagues on the Scientific Programme Committee have produced (in my opinion) a wonderful and varied scientific programme with something for everybody. Dedicated topic streams have been instituted for this year and will run until Friday afternoon.

One of the notable events this year has been the creation of the Vascular Special Interest Committee. The BSIR Vascular SIC is chaired by Professor Mo Hamady. Mo and his committee have been working very hard on several areas to promote vascular IR. Additionally, they have created the new BSIR vascular meeting – VITALS (Vascular Innovation and Technology Advanced Learning Symposium) –which will take place in Sopwell House, St Albans in March 24-25th, 2025. Everybody is welcome to attend and details on how to register are already on the BSIR website

Another event to highlight is the new IR GIRFT project that is being led by Dr Alex Barnacle. Alex will be providing an update of how things are progressing on the Friday afternoon of the BSIR ASM.

I am also looking forward to dedicated sessions during the November ASM on IR training We will welcome Drs Kath Halliday and Priya Suresh, from the Royal College of Radiologists leadership, who will participate in these sessions and will be on hand to answer any questions that you might have regarding IR training and RCR matters in general.

Finally I would like to thank Nike Alesbury Julie Ellison and Abbey Templar Phillips for running the

Robert Morgan

Consultant Interventional Radiologist, St George’s University Hospitals NHS Foundation Trust

JOIN US IN BRIGHTON FOR BSIR 2024!

The BSIR Annual Scientific Meeting (ASM) promises to be a unique event with both inaugural and revisited sessions not seen at the ASM for many years.

In addition to the fantastic poster and scientific sessions, with presentations from the ever-growing community of academic IRs producing high quality trial data, the ASM is honoured to host representatives of the Canadian, Indian and South African IR societies. The international IR session will bring together colleagues from around the world to share experiences of delivering IR services in different geographies to our comparatively tiny island but also explore topics of sustainability and training as well as common service delivery challenges and clinical conundrums.

Following on from previous years’ successes we have a packed masterclass itinerary with ranging topics from, nerve blocks to lymphatic intervention, portal venous to paediatric access and advanced imaging to radiation protection. This last topic is a crucially important focus for our community to protect ourselves, our colleagues and our patients.

The Scientific Programme Committee are also grateful for the quality of scientific studies and case reports submitted to the ASM and we have created a bespoke IR morbidity and mortality meeting on Friday morning: this will be an unmissable event, we encourage everyone from all disciplines to come with an open mind, and use this as a time to reflect, learn and discuss the most difficult cases submitted this year.

Finally, the social programme is brimming with great networking, relaxation and wellness events!

We would like to thank the BSIR and CIRSE teams for all their support in putting the programme together. Have a wonderful ASM and see you in Brighton!

Conrad von Stempel Consultant Interventional Radiologist, UCLH/Royal Free Hospital

OCCUPATIONAL RADIATION HAZARDS CHALLENGES & SOLUTIONS (MAYBE)

The basics of radiation protection in practice [shielding, distance and time] are well known to radiologists and radiographers practicing in interventional radiology (IR). These basics may be less well known to our nursing colleagues and other health professionals within IR who will, in the main, rely upon Local Rules training and sometimes instructions from a radiographer or radiologist regarding the behaviours in the lab. Furthermore, the effects of radiation exposure are also generally well accepted [1] being stochastic effects (mainly cancer induction) and tissue reactions (almost exclusively patient skin and epilation effects). However, with the advent of emerging clinical data on radiation effects and a plethora of novel protective garments and devices, the situation in many ways has never been so unclear.

One set of emerging health data has been to reinforce the Linear No-Threshold concept that states that even at low doses there will be an excess risk. Until recently this had not been empirically demonstrated but two recent papers [2,3] have demonstrated excess leukaemia and brain cancer risks from paediatric Head CT. These data emphasise the need to keep IR doses as low as reasonably practicable. The most controversial data recently emerging was in a paper by Roguin [4] that published case reports and, mainly, self-reported brain tumours in radiation-exposed physicians. His conclusion, whilst admitting the biases contained within his paper, was that his data provided the ‘basis for speculation regarding a causal relation between chronic radiation exposure and brain tumours of the cell types associated with such exposure’! A more systematic approach was taken by Lopes [5] in her rather more scientific review and meta-analysis of occupationally exposed workers. She collated data from various sources (medical, nuclear workers and uranium miners, Chernobyl clean-up workers and nuclear test participants) that amounted to over 20 publications. Her pooled data showed a statistically significant excess relative risk for both incidence and mortality due to cerebrovascular disease (i.e. non-cancer effects) and Parkinson’s disease (Table 1). There are many other publications also showing excess risk of both cancer and non-cancerous effects in the brain that also may be of interest [e.g. 6].

This emerging health data has led to (or maybe it’s a coincidence?) a plethora of protective devices for interventional procedures. These developments are also driven by the search for a Pb-apron free lab environment because of the well-documented MSK risk of wearing Pb PPE during one’s career. In the limited space available I shall concentrate on the emergence of Pb caps to protect the brain. The literature for these is variable, both in reported dose reduction and in quality of scientific methodology [see for instance, 7,8,9,10,11].

Table 1 – Excess CNS risks due to radiation exposure: Lopes et. al.

The difficulty with many of these papers is that they do not estimate brain dose The doses reported by some of these works report results from passive dosimeters placed on the inside and outside of various devices and therefore is measuring the device attenuation directly rather than a brain dose protective effect This is borne out by Figure 1 from Ramos-Avasola et al [10]

This all goes to show that we really don’t yet know with any degree of confidence what to do but if you do want to reduce brain dose then you require a Pb-hood as a significant element of brain dose comes from radiation entering the head from the front and lower LHS and then being scattered upwards into the brain

In summary, this is most definitely a live field for emerging data/evidence and my best advice at present would be to properly utilise a good ceiling suspended shield of 2mm Pb-equivalence and minimise patient dose as the less the patient gets, the less you get!

Figure 1 – Radiation dose reduction (%) according to dosimeter position

References

1.International Commission on Radiological Protection. 2007. The 2007 Recommendations of the ICRP. ICRP Publication 103. Ann ICRP, 37 (2-4)

2.Pearce MS et. al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet 2012. 380 499-505

3.Matthews JD et. al. Cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ 2013. 346 f2360

4.Roguin A et. al. Brain and Neck Tumors Among Physicians Performing Interventional Procedures. American Journal of Cardiology 2013. 111 1368-72

5.Lopes J et. al. Risk if Developing Non-Cancerous Central Nervous System Diseases Due to Ionizing Radiation Exposure during Adulthood: Systematic Review and Meta-Analyses. Brain Sciences 2022. 12 984

6.Reeves R et. al. Invasive Cardiologists Are Exposed to Greater Left Sided Cranial Radiation (The BRAIN Study). JACC: Cardiovascular Interventions 2015. 8 1197-1206

7.Kirkwood M et. al. Radiation Brain Dose to Vascular Surgeons During Fluoroscopically Guided Interventions is Not Effectively Reduced by Wearing Lead Equivalent Surgical Caps. 2017 Abstract from the Western Vascular Society Annual Meeting

8.Barenfanger et. al. Clinical evaluation of a novel head protection system for interventional radiologists. European Journal of Radiology 2022. 147 110114

9.Qazi E et. al. Operator Intracranial Dose Protection During Fluoroscopic-Guided Interventions. Cardiovascular and Interventional Radiology 2023. 46 943-52

10. Ramos-Avasola S et. al. Efficacy of radiation attenuating caps in reducing radiation doses received at the cerebral level in interventional physicians: a systematic review. Journal of Radiological Protection 2024 44 031001

11. Larsson M et. al. Evaluation of novel radiation protection devices during radiologically guided interventions. CVIR Endovascular 2024. 7 18

Andy Rogers

Lead Interventional Medical Physics Expert, Nottingham University Hospitals NHS Trust

ECTION: PECTIVE

ional radiology (IR) trainee.

H sessments, being in the IR suite

b s to radiation protection. Our IR tr ess to adequate radiation p gal obligation and a potential b the field. T

in a recent Royal College of R addressing these concerns to a dive into the key findings from a n ntional Radiology (BSIR) trainee c ty for our trainees.

ing PPE

If finding a lead apron that fits properly is a weekly, if not daily, struggle - you're not alone. This isn't just an inconvenience—it's a health risk. According to our survey, 58% of trainees have difficulty finding appropriately sized lead aprons at least once a week. The implications are severe, with 56% of trainees reporting back pain from ill-fitting personal protective equipment (PPE).

The survey highlighted health concerns among trainees who are only just starting out in what is hopefully a long career. Musculoskeletal pain, including back and neck pain, is alarmingly common. Specifically:

• 56% of trainees reported back pain

• 23% experienced neck pain

• 11% had hip pain

• 6% dealt with knee pain

• 6% reported foot or ankle pain

Eye Protection: A Critical Concern

The provision of appropriate eye protection is mandated by the Ionising Radiations Regulations 2017 and is the responsibility of the employer. However, nearly a quarter of those trainees wearing personal eye protection had still been required to fund acquisition of lead goggles at a significant cost of around £300-£500. For trainees requiring prescription glasses, a staggering 77% felt that overfit goggles compromised their ability to perform procedures.

IR trainees have encountered difficulties with funding, as some trusts are reluctant to pay for prescription glasses for trainees who will inevitably rotate placements. It is essential that local training schemes work with individual NHS trusts and Health Education England (HEE) to provide the appropriate PPE for trainees to ensure their work, training, and health are not compromised.

Dosimetry: Inconsistent Practices

While compliance with body dosimetry is high, with 99% of trainees using it regularly, the use of eye dosimeters is inconsistent. Only 50% of trainees reported using eye dosimeters, exposing them to unnecessary risks. Given the well-documented risks of radiation to the eyes, including the potential for cataracts, this gap in monitoring needs to be addressed urgently.

Gender-Specific Concerns

As the number of female trainees entering IR increases, it is essential we consider the link between exposure to ionising radiation at work and breast cancer Alarmingly, a study in the USA by Chou et al. showed that female orthopaedic surgeons were four times more likely to develop breast cancer due to inadequate shielding of the axillary tail. Furthermore, no occupational dose limits exist for breast tissue despite it being highly radiation sensitive

Use of axillary coverage or sleeves has been shown to decrease intra-procedural irradiation to the upper outer quadrant by 99%, and the European Society for Vascular Surgery has already recommended female operators consider adopting this extra protection.

Recommendations for Improvement

The results of this survey are concerning and highlight the variation in trainee radiation protection across the UK. It is essential for training schemes across the UK to address these radiation concerns and ensure current and future IR trainees are properly protected. Here are some recommendations:

• Personalised PPE: All IR trainees should feel empowered to advocate for themselves regarding radiation protection by familiarising themselves with the relevant legislation. On commencing IR training, an assessment of eye protection, lead apron, and thyroid shield availability should be performed at induction, with a dedicated set of leads and eye protection assigned to each IR trainee. If there is no suitably fitting lead, a new personalised lead should be purchased by the employer. This should also include specialised prescription goggles.

• Routine Assessments: Implement regular assessments of PPE fit and condition, as well as periodic reviews of dosimetry results. This could include annual fit checks and quarterly reviews of dosimeter readings to identify any trends or concerns early.

• Standardized Monitoring Protocols: Establish consistent protocols for radiation monitoring across all training sites. This should include the use of body, eye, and finger dosimeters for all trainees, regardless of their rotation site.

• Education and Training: Provide comprehensive radiation safety training at the start of IR rotations and offer refresher courses annually. This should cover proper use of PPE, understanding dosimetry reports, and strategies for minimising radiation exposure.

• Gender-Specific Considerations: Implement additional protective measures for female trainees, such as providing axillary shields and considering breast-specific dosimetry.

The radiation protection supervisors in your department are likely to be responsible for ensuring appropriate PPE is available and are usually in charge of the provision and collection of dosimetry badges for assessment. In addition to body dosimetry, all IR trainees should be provided with eye and finger dose monitors to assess exposure levels and ensure they remain within safe limits. Without this, it's difficult to identify whether additional protective measures are required.

Conclusion

Radiation protection in interventional radiology is essential to safeguard not only patients but also staff from the harmful effects of ionising radiation. Improving radiation protection for our trainees isn't just about meeting regulatory requirements it's about protecting the safety of our trainees and the interventionalists of the future. By addressing these concerns, we can ensure a safer, more sustainable future for the field of interventional radiology.

Natasha Aghtarafi, Deevia Kotecha, Hunain Shiwani

Interventional Radiology Trainees

R 2024 this year, we ct ourselves as ent.

ws in real time how hen performing

Phil Haslam Consultant Interventional Radiologist, Freeman Hospital, Newcastle

Andre Agassi. Sampras win the championship.

nt, Pete?”. mind at that time. I don't know how I do it, to be honest with you. I really don't”

In sport, music, and other creative pursuits, the highest levels of performance often come when the mind is quiet and still. This is something I have also experienced when hitting a tennis ball and when playing the piano. What about the art of interventional radiology?

In IR you may have experienced moments, and sometimes whole procedures, when your attention is completely focussed in the moment, on the subtle haptic feedback from the tip of the wire, on the tiniest movement of a catheter tip in the aorta and, like a sportsman, you know you ’ re “in the zone ” . Everything flows smoothly, you innately know whether a tortuous artery can be traversed, and absolutely nothing is going on your mind. Thoughts and emotions can often get in the way, and while planning and thinking has its place, perhaps there is also a place for a silent mind.

In psychology, they refer to the “flow state”, or being in the zone: the mental state in which a person performing an activity is fully immersed in a feeling of energized focus, full involvement, and enjoyment in the process of the activity. Flow is described as the complete absorption in what one does, and a resulting transformation in one's sense of time. Flow is the melting together of action and consciousness; the state of finding a balance between a skill and how challenging that task is. This is a highly efficient state: 80% effort produces 100% outcome.

References: Csikszentmihalyi, M. (1997). Finding flow: The psychology of engagement with everyday life. New York: Basic Books. Mulligan MS. Achieving flow in surgery. J Thorac Cardiovasc Surg. 2016 Jun;151(6):1435-9. doi: 10.1016/j.jtcvs.2016.03.051. Epub 2016 Apr 1. PMID: 27207116. Warr, M., Henriksen, D., Mishra, P. et al. Creativity and Flow in Surgery, Music, and Cooking: An Interview with Neuroscientist Charles Limb. TechTrends 62, 137–142 (2018). https://doi.org/10.1007/s11528-018-0251-3

(Mulligan MS Achieving flow in surgery J Thorac Cardiovasc Surg 2016)

This chart shows skill on the horizontal and challenge on the vertical, and the experience of the task is shown in the pie chart in the middle. If your skill is high and the challenge is low, you feel relaxed, in control. If your skill is low and the challenge is high, you feel anxiety. But if there is the right balance between high skill and high challenge, you can experience flow

If a flow state can be helpful in tennis and in IR, what can you do to help foster this state of mind? I would like to mention a few tools that I have found helpful, adopted not just from sport but also from courses in philosophy and leadership.

Before my IR list starts, I go through the cases and confirm that we are doing the right thing, for the right patient - this is the time for thinking and planning. I then start my lists with a check in: a five minute huddle with all the team for that day, and each person is asked “how are you feeling, and is there anything distracting you from being present for work today?”. Some people may say they feel fine and completely ready for work, another might say that they have been up all night with a sick child, or someone may disclose that they are nervously awaiting FRCR results at midday. Whatever it is, it allows that person and the whole team to acknowledge the individual’s physical and emotional state.

This allows others to accommodate someone who might be having a bad day, and gives that person a better chance of letting it go. The feedback that I’ve got from colleagues is that it: "Provides some calm at the start of the day", "Puts a smile on my face", "Let's you accommodate any issues people are dealing with", "Acknowledges that team members are human and have lives outside work".

Then it is time to speak with the patient and go through the consent process. It can be easy to see the patient as an object upon which to practice our finely honed techniques, but it is important to first connect with the patient as a human, to pay attention to how they are feeling, discuss what their expectations are, and establish a rapport before stabbing them. Then you will know if they might need extra sedation, or just some country music on the radio.

Having checked in and connected with the team and the patient, next is the ritual of prepping for the case: laying down the patient, annointing the groin, spreading out the gown and gloves I like to take the opportunity of hand washing to connect with the moment, with the sensation of the water and the scrub, become aware of my breathing, and let my mind settle down and let go of any thoughts, expectations, and ideas about the case or anything else. If there are fears, and sometimes there are, I remind myself that in that moment, I am the best placed person to do what this patient needs. A moment of calm before blood is spilt.

All of this lays the ground for a team and operator who are calm and present for the procedure. A clear state of mind allows me to operate at my best and be well placed to deal with any unexpected or critical events. In the absence of these, just like hitting an ace in tennis or finding a perfect progression in jazz, I love operating and find it energising, whether it be placing a nephrostomy or doing a complex EVAR. Much of the time, I have no thoughts, just calm, focussed attention while my hands and eyes get on with the job at hand.

I was recently discussing this with an anaesthetic colleague - she said that she knows exactly when one of my vascular surgeon colleagues goes into a flow state, by the way he clenches his jaw and focusses in on the operating field. She knows that if she sets things up just right, ensures the patient is completely ready and chooses the right music, that she can encourage that flow state, and that that will produce the best performance that surgeon can give.

To quote Dr Charles Limb (ENT surgeon, University of California): “I think there are times when you really feel like you're alive and you love something. It's important to know that it's also your brain's best functional version of itself. It's important to know that your brain has the capacity, it has peaks and valleys, and if you can time everything just right and hit one of these peaks that all of a sudden you are functioning at a much higher level than you've been previously.”

At the end, whether it has gone well or badly, I find it helpful to pause for a moment and recognise any emotional response I might have to the outcome, whether it be pride in a job well done or frustration in taking on a case that failed, and let it go Above the doors that lead the players on to Wimbledon’s Centre Court, there are these words from Kipling:

“If you can meet with Triumph and Disaster And treat those two impostors just the same.”

Yuri Gupta Consultant Interventional Radiologist, University Hospitals Sussex NHS

KING’S HEALTH PARTNERS EXECUTIVE FELLOWSHIP

I had the fortune of being selected for the 2024 King’s Health Partners (KHP) Executive Fellowship in Surgical Leadership and graduated from the program this summer. The one-year fellowship program is run by KHP Academic Surgery, the academic partnership group of King’s College London, Guy’s & St Thomas’ and King’s College Hospital NHS Foundation Trusts.

Led by the charismatic Peter Gogalniceanu, a transplant surgeon with expertise in crisis management and healthcare systems, the program bridges the gap between traditional training programs and the evolving demands of consultancy in modern healthcare. The group was formed of senior fellows or young consultants from each surgical subspecialty, and this year included IR, Anaesthetics and Perioperative Care to recognise the modernisation of surgical care. The experience was brilliant, involving engaging and often challenging conversations about what leadership looks like in contemporary surgery and intervention, using the Harvard Business School cases as central points of debate. Discussing Toto Wolff and Ernest Shackleton’s approaches to leadership in a group providing procedural care contextualises the learning points Examples of learning points included how to lead high performance teams, navigating complex interpersonal conflicts and building integrated clinical services. Particularly fascinating was a boardroom simulation to role-play power dynamics and a session led by a Captain who manages easyJet’s pilot training program to draw parallels between aviation and surgical models of training.

This was followed by immersion into MedTech and Innovation which drew upon the expertise of the newly established London Institute of Healthcare Engineering for each candidate to develop a unique product and business plan. There has been a rapid explosion in startups led by doctors with clinically relevant ideas but who often lack the knowledge and skills to navigate commercialisation. In addition, as MedTech becomes more integrated with clinical medicine, understanding the mechanics of business will become a necessity for successful high-level collaborations.

Balancing a busy clinical fellowship alongside this program does have its difficulties, but this has been considered in the design of the program It was offered in a hybrid format with both in-person and online options, but importantly allowed for retrospective engagement when sessions were missed

Interventional Radiology is a relatively young specialty, and our scope is rapidly evolving. As such, clinical and technical expertise needs to be balanced with our role outside of the angio-suite. Nontechnical skills are essential for young IRs as the need to advocate for resources and clinical visibility continues in our bid to expand services.

Leadership is understood as a separate skillset in industries outside of medicine which requires specific training to lead increasingly complex teams. The strength of the program lies in its teachers, individuals who can adapt these training models to the unique challenges facing us Leadership is a lifelong endeavor, and this fellowship helps lay down the foundation on which to build.

This Fellowship is taking applications from outside the KHP Academic Group this year The close of applications is the 10th December 2024. See more information and how to apply - KHP Executive Fellowship in Surgical Leadership

Mihir Desai,

Post

CCT Fellow Interventional Radiology, Guy’s & St Thomas’ NHS Foundation Trust

Narayan Karunanithy

Consultant

Interventional Radiologist, Guy’s and St Thomas NHS Foundation Trust

multidisciplinary care. The hospital is funded by the public healthcare system, which is very similar to the NHS trust.

At HKCH Radiology, we have a small team of 6 full-time radiologists. With some adult Interventional Radiology (IR) training under my belt, I took up the role as IR lead and started up a Paediatric IR service (PIR) in this new hospital. In the beginning, our service consisted of simpler procedures, such as PICCs placement for older children and teenagers. With time, we have moved on to a more comprehensive service and offered procedures to a wider age range with increasing complexity, such as interventions for neonates, ablation for oncological conditions, angioplasty for renovascular hypertension, lymphatic imaging and interventions and intra-arterial chemotherapy for retinoblastoma.

I am very privileged to have the opportunity to visit different institutions around the world where PIR is being practiced, including Great Ormond Street Hospital, Bicetre Hospital in Paris, University Hospital Strasbourg and the Hospital for Sick Children in Toronto, where I am currently completing a PIR fellowship. In addition to learning exciting new procedures, my experience with diverse IR practices in these centers was a great opportunity to reflect on my own practice back home.

Looking back, it has been a challenging yet immensely rewarding journey on this road less travelled. I would love to share my thoughts on how to overcome some of the challenges when setting up a new PIR service from scratch:

m planning to construction, until completion nd planning phases of hospitals. Once the ange things around There are some major mportant being the necessity of anaesthesia ed in the IR suite for anaesthetic equipment. ment with a dedicated recovery area This h as CT or MR. In some Children’s hospitals, heatres and share post-anaesthetic care units

Be kind, be available and never say “no”

Fig 1 – Our first MR lymphangiogram for a 2kg neonate. It was a concerted effort between IR, MR and anaesthetic teams. Contrast enhanced US is used to confirm the intranodal needle position to minimise patient transfer

When I first started at the hospital, many of our paediatric colleagues were not aware of what IR could offer to their patients. Many procedures still fall under the surgeon ’ s purview. Being a radiologist, I had the advantage of chairing MDTs and tumour boards These are perfect forums for PIRs to add value and let others know how we can help. I also went up to the ward and clinics to see the patients and parents before the procedure and to follow them up afterwards

I started with PICCs and image-guided biopsies that surgeons were not comfortable doing; and I never say, “ no ” if my paediatric colleagues want to consult me on a case – even if it’s on a Sunday. Having that rapport is extremely important. Once trust is established with the clinical teams, it makes discussions on more complex and high-risk procedures much easier

hing”

c surgeons; how to tackle young kids’ veins lymphangiogram from my MR

aediatricians … It’s a very old saying but I

Building a sustainable service

Fig 2 – Performing cryoablation in our circus-themed CT room. During the hospital planning phase, dedicated space is reserved for anaesthetic team to position their equipment, which is essential for most paediatric interventions.

In resource-limited settings, the person providing the IR service may not be a dedicated PIR, but can also be an adult IR who treats children or paediatric radiologists who perform interventions. Crossskilling different team members to perform PIR procedures can help maintain a more sustainable service and prevent individual burnout. In my unit, the on-call service is covered by one additional paediatric radiologists and three other adults IRs

Meet and learn from other PIRs

Although I had some adult IR experience, it did not take me long to realise that PIR requires a different skill set and mindset In addition to a different disease spectrum, the procedures often have a smaller margin of error and require more meticulous planning than in adult cases. It’s almost nothing to flush a catheter with 10mL saline in an adult, but the 10mL saline flush constitutes 5% of a 2-kg neonate’s total blood volume

Fig 3 – We are privileged to have Dr. Alex Barnacle to speak to us on developing a PIR practice and to have Prof Afshin Gangi visit as an Honorary Visiting Professor

of a PIR fellowship. However, there is now dedicated to PIR practice The Society for webinars, PIR protocols, and an online compasses a wide variety of PIR topics A RSE, with the aim of providing a support m IR in children. Closer to home, the BSIR l meeting in Birmingham

r those who would like to setup a PIR proving Paediatric IR services in the UK” by he PIR landscape in the UK and important o ensure every child has equitable access to

Fig 4 – Blessed with this fantastic journey to experience how PIR improves care in children all around the world.

Kevin Fung Consultant Interventional Radiologist, Hong Kong Children’s Hospital

REFLECTION ON PAEDIATRIC IR UK 2024

The 6th Annual Paediatric IR UK meeting was another great success! The event took place on Monday, 20 May 2024, at Austin Court in Birmingham, UK. This picturesque venue, located adjacent to a canal, offered excellent facilities that were further enhanced by the beautiful, sunny weather. The meeting attracted nearly 100 attendees, including radiologists, trainees, nurses, and radiographers, along with several industry sponsors.

GThe day was organised into six comprehensive sessions, each designed to address various aspects of paediatric interventional radiology (PIR). The first session, "What the Adult IR Needs to Know," was aimed at encouraging adult IRs to gain confidence in extending their IR skills for some paediatric cases if and when it might be needed in their centre The session comprised four insightful talks covering vascular access, biopsy and drainage, angiography, and venous interventions.

Following this, the second session focused on "Complications in Paediatric IR," where three speakers shared their experiences dealing with challenges in sclerotherapy, gastrointestinal intervention, and hepatobiliary intervention Complications sessions are always popular, and this was no exception The talks were frank, insightful, and reflective, highlighting the importance of learning from complications to improve patient outcomes.

The third session, "How to Grow Paediatric IR," featured three talks on strategies for improving paediatric IR services, training, and overall service development in the UK. It was a chance to reflect on early progress that has come out of the recent RCR guidance on expanding PIR (Improving Paediatric Interventional Radiology (PIR) services in the UK), developments and trends in how PIR training is made workable in the UK, and included a fantastic talk from Dr Linda Watkins on the highs and lows of Glasgow Children’s Hospital service development story, with some valuable life lessons thrown in for free

A 1 5-hour hands-on and vendor spotlight session was another highlight of the day Participants engaged in practical stations on paediatric IV access and feeding tube insertion/management, while industry representatives showcased their latest equipment and innovations This interactive session provided an invaluable opportunity for hands-on learning and direct engagement with cutting-edge technology and how to adapt it for use in children.

The day concluded with "Lessons from the Coalface," the ever-popular final series of short presentations by consultant paediatric IRs who shared real-life cases and the lessons they have learned the hard way This final session allowed for a rich exchange of practical knowledge and experiences among peers. It isn’t easy to stand up and talk about the hard stuff, but these spotlights were delivered with humility, insight, and hard-won experience.

The whole day was filled with a sense of community and excitement, as people who were invested in PIR enjoyed the chance to discuss this fascinating corner of IR, meet old friends and make new ones. The event was met with excellent initial feedback, underscoring its success in fostering education, collaboration, and professional development. We would like to express our gratitude to the British Society of Interventional Radiology (BSIR) for their support in organising the meeting

With high expectations, we look forward to the next annual meeting scheduled for 19 May 2025, at the same venue, IET Birmingham.

Nasim Tahir

Chair, Paediatric IR UK, BSIR Special Interest Committee Consultant Paediatric Radiologist, The Leeds Teaching Hospitals NHS Trust.

LOOKING FORWARD TO IO

Join us at the Leonardo Royal Hotel, Tower Bridge, London on the 19th and 20th of June for IOUK 2025. We have an exciting programme in development, led by an expert International and UK faculty.

Following the success of abstract submission for presentation in the scientific and poster sessions in 2024, we will be opening for abstracts again in the New Year Please do submit for presentation and take the opportunity to access IOUK Educational Awards to support registration, travel and accommodation in 2025.

For the first time, in 2025 we are also able to offer doctors in training and medical students the Jean Ratcliff Prize for the best abstract on colorectal liver ablation The prizewinner will get £1500 to support attendance at ECIO in Europe or SIO in the United States

Watch this space for more details on abstract submission and registration.

Looking forward to seeing you there!

Peter Littler Consultant Interventional Radiologist, Newcastle Hospitals NHS Foundation Trust

OPTIMISE MUO

(prOsPecTIve

MultIcentre Study investigating the managemEnt of patients with Malignant Ureteric Obstruction)

OPTIMISE MUO (prOsPecTIve MultIcentre Study investigating the managemEnt of patients with Malignant Ureteric Obstruction) is a prospective multi-centre study that seeks to investigate whether the management decisions taken by clinical teams treating patients with malignant ureteric obstruction are effective. The BSIR Research Committee has approved this study, and we are looking for sites to flag their interest, along with their urology colleagues In previous work, our group has shown that there is geographical variation in interventional management for these patients, as well as demonstrating that median overall survival is 6 months (IQR 2-14), and that the majority (57%) do not go on to receive further oncological treatment(1).

We aim to undertaken a multi-centre study to investigate some of these issues further, using the UNITE (UK National Interventional Radiology Research Collaborative) and British Association of Urological Surgeons (BAUS) Oncology networks. These networks have already been successfully leveraged in the INSITE MUO study (currently ongoing) to collect data from 25 sites to investigate the incidence of malignant ureteric obstruction in patients with abdominopelvic malignancy.

In OPTIMISE MUO, study teams consisting of clinical team members from urology and interventional radiology will capture information from incoming referrals for patients with malignant ureteric obstruction (expected to be February 2025) Numbers will therefore likely be low (<10) for each centre. Some information will need to be captured contemporaneously about the outcome of the referral (decision to intervene) and the reasons for the outcome (rationale for intervention and mode of intervention). Other information (such as blood results) can be captured at a later timepoint Teams will then collect follow-up data at 3 month timepoints for up to 12 months.

The methodology will require collaboration between urological and interventional radiology study teams In some centres without interventional radiology provision, teams may solely consist of urology team members. Site set up will involve local R&D approval, which can be supported with documentation from the OPTIMISE MUO team The REDCap platform, (hosted by the Department of Clinical Surgery, University of Edinburgh) will be used by local study teams to upload pseudonymised data, keeping a local secure document to link patient identifiers to study number REDCap accounts will be provided by the OPTIMISE MUO team.

The findings will be disseminated by presentation at urology and radiology conferences and published in relevant journals. Publications resulting from the OPTIMISE MUO project will be as a collaborative. All collaborators meeting minimum required criteria of involvement will be accredited as collaborators on any publications from the study and will be Pubmed citable.

If you are interested in getting involved

Please enter your details at: HERE

Link is also available on UNITE collaborative or email MUOstudies@gmail.com for more information

Principal Investigators

Dr Oliver Llewellyn MRCS FRCR is an Interventional Radiology ST5 in Glasgow and is funded by the Royal College of Radiologists Kodak bursary to run this study as part of an MD with the University of Edinburgh.

Mr James Blackmur PhD FRCSEd(Urol) Consultant Urologist, NHS Lothian, Edinburgh

Mr Alexander Laird PhD FRCSEd(Urol) is a Consultant Urologist and Honorary Clinical Lecturer at The University of Edinburgh

Specialist Advisors

Mr Jonathan Aning FRCS(Urol) DM BM BS BMedSci is a Consultant Urologist at Bristol Urological Institute and Honorary Associate Professor at Bristol University

Dr Tristan Barrett FRCR MD is an Associate Professor of Radiology and Consultant Radiologist at Addenbrookes Hospital, Cambridge

Dr Nadeem Shaida FRCR is a Consultant Interventional Radiologist at Addenbrookes Hospital, Cambridge

Ethics & Funding

This study is sponsored by ACCORD (NHS Lothian & University of Edinburgh)

This study is funded by the Royal College of Radiologists. This study has received research ethics committee opinion (Ref 23/NRS/0070)

This study has received HRA approval in England & Wales (Protocol no AC23185)

References

1)Blackmur J; Scottish Malignant Ureteric Obstruction Study Group. Management of malignant ureteric obstruction with ureteric stenting or percutaneous nephrostomy Br J Surg 2024 Jan 31;111(2):znae035. doi: 10.1093/bjs/znae035. PMID: 38406883; PMCID: PMC10895405.

Oliver Llewellyn

Interventional Radiology ST5, NHS Lothian

Autumn Newsletter 2024