2025 February Newsletter by BSIR

February Newsletter 2025

WELCOME FROM OUR EDITOR

Welcome to the latest edition of the British Society of Interventional Radiology (BSIR) newsletter!

As we look forward to another year of progress and collaboration, I felt it was also important to look back at 2024 and share the highlights of our recent Annual Scientific Meeting (ASM), an event that serves as a cornerstone for our community’s continued growth and innovation.

"Advancing Patient Care Through Interventional Radiology," remains the heart of our mission pushing the boundaries of science and clinical practice to deliver cutting-edge treatments and improve patient outcomes. The ASM brought together world-class experts, thought leaders, and practitioners from across the globe, providing a unique platform to exchange knowledge, showcase new technologies, and explore the future of our field.

Throughout this year, the BSIR events and newsletters will focus on fostering interdisciplinary collaboration, embracing new research, and strengthening our commitment to education. With a jampacked schedule of sessions, workshops, and networking opportunities, 2025 promises to be an unforgettable year for the BSIR. From pioneering techniques in minimally invasive procedures to the latest advancements in imaging, there will be something for everyone, whether you're an experienced professional or just starting in interventional radiology.

As the BSIR continues to evolve, this is a year full of promise and new opportunities. I encourage you all to engage with our vibrant community, whether by attending our ASM, contributing to our initiatives, or staying informed through our publications. Please do get in touch if you would like to contribute to this newsletter. Togeth h h f f i i l di l d continue to make a profound impac

Here’s to a year of innovation and le a look back at the highlights of the

Dr Kunal Khanna BSIR newsletter editor Deputy Chief of Radiology Consultant Interventional

office@bsir org

Radiologist, Frimley Health

WELCOME FROM THE BSIR PRESIDENT

As we kick off 2025 and planning for the year ahead, the New Year is a perfect time to reflect on the success of BSIR 2024 in Brighton. This year we attracted over 825 delegates to the BSIR Annual Scientific Meeting, an increase of 8% on the previous year. The scientific programme was very well received, with extremely positive feedback about the event received from delegates and industry partners This issue of the BSIR Newsletter is intended to share some of the highlights from the conference, including the BSIR prizes and reflections from delegates and Faculty. So if you missed out, you can find some of the most interesting content in here.

As of 1st February, BSIR Full and Trainee Members will be able to access the conference content in the CIRSE Library. We can see from the library statistics that the UK as a whole has one of the lowest levels of usage of the CIRSE Library, so I would encourage you to go and have a look around. Whilst the content on this platform is vast, it is all labelled and can be filtered to help you quickly find the most up to date and relevant content on the topic of your choice. You can log-in here, using your CIRSE log-in details: HERE

Looking forward to 2025, we have a busy year ahead of us. This year BSIR are looking forward to supporting the inaugural VITALS meeting (Vascular Innovation & Technology Advanced Learning Symposium), which is a residential conference taking place on 24-25th March at Sopwell House in St Albans. If you would like to participate, you can find out more HERE. The format focuses on expert round table discussions, hands-on workshops and video-recorded cases and is set to be a lively and interactive learning experience.

In addition for 2025, as well as BSIR's well-established events such as IOUK, Paeds IR UK and the Advanced Skills Course, there is a Nurses & Radiographers CPD meeting taking place in March and a BSIR Basics Course taking place in April. The Scientific Programme Committee is already working hard planning BSIR 2025 which will take place in Liverpool on 11-13th November You can find out more about BSIR events and webinars HERE

I look forward to seeing you at BSIR events and activities in the coming year

Professor Robert Morgan

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

BSIR 2024

November saw the long-awaited return of the BSIR ASM to Brighton, with over 800 delegates filling the lecture theatres and exhibition hall at the Brighton Centre, just a few metres from the beach. This ASM featured a reprise of sessions (and the BSIR 5km run!) that had not been seen at BSIR for many years, as well as brand new sessions highlighting the incredible growth of IR since the inception of the BSIR ASM in 1988.

Kicking off the scientific programme was the President’s welcome from Professor Robert Morgan, followed by the much-anticipated Top 3 Journal Article session. This session provided all attendees with an academic “rocket fuel” boost, covering key studies published in the last 12 months on vascular interventions, interventional oncology, non-vascular interventions, and, for the first time, hot topics in non-clinical aspects of IR, including service provision and radiation protection. Professor Tze Wah, one of the world’s most respected and revered interventional oncologists, delivered an insightful Wattie Fletcher lecture based on her personal journey in clinical academia in IR. Her poignant lecture left every delegate inspired and daring to dream.

Another first for the BSIR ASM was a dedicated international IR session, where we heard from esteemed guest speakers from the Indian Society of Vascular IR, the Canadian Association for IR, and two UK-trained IRs working in East Africa. These speakers are providing emergency IR training to burgeoning IR departments, including ultrasound access, obstetric embolisation, and the provision of robust ongoing training to radiologists, helping to support and grow this work in the years to come.

Rounding off the fantastic plenary sessions was a presentation on the “Get It Right First Time” initiative, which Dr. Alex Barnacle is leading in the UK for the first time in interventional radiology.

The scientific programme featured excellent presentations from trainees and established consultants, showcasing the innovative work we do as a specialty in virtually every organ and pathology across healthcare. All attendees, along with the Scientific Programme Committee and moderators, had the opportunity to vote for the best scientific presentation via the BSIR app. The overall winning presentation was delivered by Dr. Tim Bryant, who presented his team's impressive deep dive post-hoc analysis of post-operative menorrhagia following uterine artery embolization for fibroids. Special mentions were given to Dr. Gilbran Tim Yusuf, who presented his team’s UK-leading experience with microwave ablation for thyroid nodules, and Dr. Bahir Almazeidi, who shared an impressive series of lower limb revascularisation procedures using drug-coated balloon and stent technologies.

The junior and trainee scientific programme was seamlessly integrated into the ASM, and the quality of the winning presentations was a testament to our trainees' dedication to academic excellence. The best junior category was awarded to Dr. Euan Smyth for his presentation on the analysis of limb graft occlusion after endovascular aneurysm repair. Dr. Yiwang Xu won the best trainee presenter award for his work on the guidelines and results of SIRT in HCC treatment, while Mr. Bailey Carter won the Robert Bardsley Award for his research on the exvivo comparison of cutting needles for percutaneous core biopsy.

The ASM was generously supported by our industry partners, and the scientific programme greatly benefited from the support of our allied healthcare specialists, including nursing and radiography professionals, as well as our treasured clinical specialty colleagues who contributed valuable surgical and medical insights through lively multidisciplinary discussions.

The Scientific Programme Committee would like to extend its thanks for the unwavering support from Nike Alesbury, the President, Vice-President, Executive Officers, Julie Ellison, Abbey Templar-Phillips and the CIRSE team.

We look forward to seeing you again in Liverpool and this time no excuses, bring your trainers!

Dr Conrad von Stempel

Past Chair of the Scientific Programme Committee (SPC)

Dr Matthew Gibson

SPC Chair 2025

BSIR 2024 – A PERSPECTIVE FROM THE CHAIR OF THE BSIR TRAINEE COMMITTEE

As a newly qualified consultant and the Past Chair of the BSIR Trainee Committee, I have been to my fair share of BSIR Annual Scientific Meetings (ASMs). Each year the conference has a slightly different feel and 2024 was no exception. The enthusiasm from delegates and faculty alike was palpable and the Scientific Programme Committee did a wonderful job of putting together an exciting and varied programme.

For the first time, trainee content was spread throughout the conference, with different sessions targeted towards trainees each day, starting at 9am on Day One. Trainees and junior members made the most of the content available to them throughout the conference, which covered many areas including careers, research and finding a consultant job. The presence of more trainee and junior members throughout the week allowed more time for networking, spending time in the active learning zone and attending masterclasses for a more in depth look at specialist topics. A particular highlight of the trainee programme was the Dragon’s Den style research pitches, which were brilliantly delivered.

The BSIR Juniors lounge and BSIR Trainee IR Museum were focal points allowing trainees to meet peers and learn more about IR away from the hustle and bustle of the exhibition hall. These have been very popular features from the last few conferences and are hopefully here to stay! Similarly, the ‘Diagnosis to Discharge’ series aimed at more senior trainees was incredibly insightful and has gained excellent feedback.

The ASM would be nothing without industry partners, and it was great to see trainees engaging with industry and all the educational content available to them. This is something that trainees previously did not have a lot of time to do, with the trainee content previously limited to the last day of the conference. It is useful to forge relationships with industry outside of the workplace and the ASM is a great place to do this.

It was wonderful to see so many poster and oral presentations submitted by trainees and juniors. The abstract submissions for the ASM 2025 will be opening later this year and are a great way to become more involved with the conference.

My personal highlights of the conference included the Equality, Diversity and Inclusivity (EDI) content scattered throughout the week. From the fantastic EDI session on day one to Professor Tze Wah’s inspirational Wattie Fletcher Lecture, this conference felt more inclusive and diverse than in previous years. I particularly enjoyed seeing more balanced moderator panels and faculty and this is echoed in feedback from trainees and consultants alike.

Rounding off the conference with an informative discussion on the newly launched IR GIRFT review, Dr Alex Barnacle was, as always, a hugely inspirational speaker. More so than in previous years, I returned to work with fresh enthusiasm and ideas to share with my colleagues.

My first BSIR ASM experience was in Liverpool in 2014. I was one of the few female trainees attending the BSIR Trainee Day, as it was then, and I came away inspired but feeling like I had barely scraped the surface of the specialty. Ten years on, the BSIR ASM is a much larger, more vibrant conference with greater opportunities for learning, networking and sharing of ideas. I’m excited to see what this year’s ASM will bring!

Dr Katrina Harborne Consultant Interventional Radiologist, Worcester Royal Hospital

BSIR NURSES AND RADIOGRAPHERS COMMITTEE – REPORT ON BSIR 2024

as a complete success for the BSIR

ar We like a challenge - or being m ommittee are always up for trying m mpting a conference-based Escape Ro eting (ASM) programme The thought be er and networking opportunity. For th it can be a daunting prospect, so we fe Th

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cular anatomy knowledge. The room w nd it was a great event.

Throughout the 3 days we delivered 3 panel presentation and discussion sessions which were based on advancing practice, service development and patient safety All of which were attended well, with fruitful discussions and debates with the speakers. We are very grateful to all 9 of our presenters, who were all from different professional backgrounds, including advanced clinical practitioners, enhanced practitioners, practice educators and patient safety experts It is not easy to stand and present on a national platform and they were all extremely engaging. Each one should be very proud of themselves

The slow dating and well-being session on Friday morning, was again a well-attended session, much to our surprise and delight after the amazing Gala Dinner on Thursday evening During this session, delegates took part in colouring and drawing activities with calm music, whilst having thought-provoking discussions on the importance of recognising burnout, sharing ideas for staff team building and the importance of debriefing. Delegates also left with goodie bags which included teabags, pens, lip balm, healthy snacks, water and incense sticks to go with the wellbeing theme

The Gala Dinner was a great evening! The BSIR Nurses and Radiographers Committee had a fabulous time - I don’t think we left the dancefloor, the atmosphere was buzzing and it was such a joyous event. We all left extremely happy with our heels in our conference canvas bags and trainers on our feet, certainly the sign of a good night out.

Overall, we all thoroughly enjoyed Brighton and the ASM was a great success. We even shared a house as a Committee, which made the conference even more special We walked a million steps, made our debut on TikTok (the less said about that chicken dance the better), had some truly amazing conversations and enlisted some new members.

We are looking forward to the challenge of making Liverpool even better! So, bring on Liverpool #BSIR2025

Kayleigh Hizzett

Assistant Professor of Diagnostic Radiography, University of Bradford Chair of BSIR Nurses and Radiographers Special Interest Committee (SIC)

BSIR Advanced Skills Course

Leeds, 23-24 April

Liverpool, 11-13 November

BSIRNR CPD Event BSIR ASM 2025

Birmingham, 8 March

BSIR Paediatric IR UK Annual Meeting

Birmingham, 19 May

BSIR Basic Skills Course (IR Juniors)

Leicester, 4 April

BSIR Vascular VITALS

St Albans, 24-25 March

BSIR IOUK Annual Meeting

London, 19-20 June

BSIR 2024 – WINNERS OF BEST POSTER PRIZES

As ever, we received a large number of high-quality abstracts for oral presentation during the Scientific Sessions and for poster prizes.

Not everyone gets to see the all of the posters, so to make it easy for you to review, here are the abstracts of the Poster Prizes from BSIR 2024.

EDUCATIONAL POSTERS

Tunneled haemodialysis catheter design and performance -a comprehensive review of the literature

Agarwal G1, Aljumaa J2, Dupont P3, Shaygi B4

1 Imperial College Healthcare NHS Trust | Department of Radiology, London, United Kingdom, 2 King Faisal Specialisy Hospital and Research Center, Saudi Arabia, 3 The Royal Free London NHS Foundation Trust | Department of Nephrology, London, United Kingdom, 4 London North West University Healthcare NHS Trust, | Department of Interventional Radiology, London, United Kingdom

Purpose

Central venous catheters are increasingly used for haemodialysis vascular access in a significant proportion of patients. There have been many design innovations over the years, particularly relating to catheter tip-shape, to minimise complications and increase durability. This study aims to provide an overview of different tipdesigns and compare their performance, complications and patency rates.

Methods

A comprehensive literature review was performed identifying studies published before September 2023 (last 20 years) in MEDLINE, Embase and Google Scholar databases with relevant medical subject headings and search terms such as hemodialysis, vascular access and catheter design. Studies relating to non-tunneled catheters and studies not in English were excluded. er symmetric-tip and split-tip catheters performed better with regards to thrombosis and recirculation rates respectively.

Results

There were 2 meta-analyses comparing either step-tip, split-tip, and symmetrical-tip designs with one another; eleven randomised controlled trials and fifteen cohort studies were identified comparing outcomes of tunneled haemodialysis catheter designs. Regarding rates of infection, there was no statistically significant difference amongst the three tip-designs studied in the meta-analyses. There was a lower thrombosis rate for symmetric-tip compared to both step and split-tip, but this conclusion was drawn from only two and three studies respectively. Split-tip catheters had lower blood recirculation rates than step-tip. There was no difference patency rates at one, six and twelve months between tip-designs.

Conclusions

This review summarizes current evidence comparing different tunneled haemodialysis catheter designs to help guide catheter choice. Overall, there is not a clear superior catheter design in terms of durability, however symmetric-tip and split-tip catheters performed better with regards to thrombosis and recirculation rates respectively.

EDUCATIONAL POSTERS

intervention 2010 to 2022. Following primary intervention, 50.6% (n=40) had recurring symptoms, 17 of which underwent further intervention (42.5%) at a mean of 426.7 days. Of those who underwent a second intervention, 12 had stents relining the previous stent, 5 had a balloon angioplasty to the old stent. There was little difference in terms of mortality following the use of a balloon or stent. We observed that those who underwent a second intervention with a stent were more likely to undergo a third intervention compared with a balloon angioplasty alone (OR 5, 95% CI 0.44-56.62, p=0.19). A total of 7 within our cohort went on to have a 3rd intervention, 2 of whom had a 4th intervention (with one case of antiphospholipid syndrome).

Management of chronic mesenteric ischaemia can be challenging, and often patients may need to undergo secondary intervention. Despite the frequency of ISR in this context, there is a paucity of evidence surrounding the management of recurrent mesenteric ischaemia. The role of drug coated technology will need to be evaluated.

trainees primarily in Resource Limited Countries (RLCs). This review contrasted these opportunities with ones provided to trainees within North America and Europe.

Results

This review found that the opportunities for international collaborative fieldwork for UK IR trainees are sparse. The availability of opportunities in the US is significantly greater as is the awareness and appreciation of the benefits of such international collaborations for trainees. Benefits include greater experience with a variety of pathologies, a larger volume of workload, improved cultural competency and greater cost-conscious and more sustainable practices. It is pertinent that any future global partnership opportunities for UK clinicians are crafted with care to benefit both UK and international healthcare professionals, institutions and patients within RLCs.

Conclusion

Significant work is needed to expand opportunities for global health fieldwork for IR trainees in the UK. It is incumbent upon the major radiology societies within the UK to expand these opportunities to develop a robust, world-leading workforce to enhance our global health positionality and reflexivity

defined as post-intervention residual stenosis <30%. The primary patency rate was defined as the time from the initial intervention to any subsequent intervention to maintain hepatic artery patency, first occurrence of hepatic artery thrombosis(HAT), or reaching a censored event.

Results

A total of 22 patients were included. All patients had deranged liver function at the time of detection of HAS, and 36.4% developed ischemic cholangiopathy. A stenosis of > 70% was present in 59.1%, and the remaining demonstrated 50-70% stenosis. Vessel tortuosity was present in 77.3% and a kink was present in 31.8%.

Technical success was 90.9% (20/22). Clinic success was achieved in 95% (19/20). The primary artery patency rates at 1 and 2 year were 90.9% (20/22) and 68.8% (11/16), respectively. Longer patency rates cannot be reliably differentiated due to small cohort and patients’ death. The 1,3,5 year overall survival rates were 100%, 88.9%, and 71.4%, respectively. No major complication. Re-intervention in 15% (3/20) [stent=2, Angioplasty=1], re-transplantation in 10% (2/20).

Conclusion

Angioplasty is an effective endovascular intervention for clinically significant HAS to prevent HAT and graft loss. Stenting could be considered in recurrences.

Forty responses were received, 47.5% from nursing staff/HCAs, 20% doctors, 17.5% admin staff and 15% radiographers. The majority of responses recognised the importance of junior doctors in preparing patients for interventions (92.1%), and indicated their skillset was complimentary to current IR staff (85%). 90% reported the junior doctor supported other team members in day-to-day work. 92.5% agreed that patient safety was improved with their presence. 87.5% reported an improvement in efficiency and workflow. Overall, 92.5% considered junior doctors essential to the IR team, and advocated for a dedicated IR junior doctor within any IR departments (95%).

Conclusion

Junior doctors currently do and will in future play an increasingly vital role in IR departments, positively influencing patient care, workload, efficiency of workflow and teamworking. These findings are supportive of the establishment of dedicated junior doctor position within all IR departments. This would also serve to identify and nurture the future generations of interventional radiologists.

Results

The average age of the patients was 70.8 ± 12.5. The proportion of male patients was 68% (n = 68). There were no significant differences in the score averages (PACSS = 2.41 ± 1.32, PARC = 2.53 ± 1.33, Fanelli = 2.40 ± 1.29; p = 0.717). There was a significant difference in the distribution of calcium scores among the 3 scoring systems (p = 0.003). The ICC for the overall score was of a moderate-good reliability (0.83, 95% CI [confidence interval] 0.78 – 0.88) but was of poor-moderate reliability in assessing severe levels of calcification (0.52, 95% CI 0.40 – 0.62).

Conclusion

There is poor agreeability between the three main calcium scoring systems. Contemporary calcium scoring methods may be inadequate to assess severe levels of vessel calcification.

BSIR ESSAY AND CASE STUDY AWARDS 2024

Each year, BSIR offers Essay and Case Study Awards to support Medical Students, Foundation Doctors, Trainees and Nurses & Radiographers to attend the BSIR Annual Scientific Meeting.

The quality of these applications is often high and we are pleased to share the top scoring applications in this edition of the newsletter.

TOP SCORING BSIR CASE STUDY AWARD

Why

does Interventional Radiology inspire you and what excites you most about the future of Interventional Radiology?

Noemi Cinti, Medical Student, Hull York Medical School

Interventional Radiology (IR) is a young specialty, constantly introducing new techniques to the medical world. However, novel approaches pose their own unprecedented difficulties. Particularly, it was fascinating for me to come across a “world-first” case in my local hospital: the endovascular treatment of a paraophthalmic internal carotid artery (ICA) aneurysm in a patient with a type II right sided aortic arch (RAA). This case study will describe the strategies employed, and highlight how it inspired me.

This case involved a female 45-year-old patient with hypertension who presented with a 1-hour history of dysarthria and facial drooping. A non-contrast CT excluded acute intracranial infarction, but a 9mm left para-ophthalmic ICA aneurysm was discovered. She later underwent endovascular treatment.

Under general anaesthetic, the right common femoral artery was accessed under ultrasound guidance and a short 8-French groin sheath (Cordis, USA) was placed. A RAA with an aberrant left subclavian artery (type II) was found on navigation. Given the complexity of this anatomy, a variety of angiographic catheters was trialled. Eventually a combination of a JB2 curved catheter (Cordis) and Terumo wire (Terumo, Japan) allowed stable access into the left common carotid and ICA. A 6-French Benchmark catheter (Penumbra, Australia) was exchanged into the left ICA, although in a lower than usual position. Owing to this and the reduced stability of a co-axial system, following 3D rotational angiography, coil embolisation of the aneurysm was performed, using an Echelon 10 microcatheter (Medtronic, USA) and 6 Target coils (Stryker, USA) (Figure 1).

The patient recovered well with no complications. She was discharged after 24 hours, and 6-month follow-up MR angiography demonstrated complete aneurysm occlusion.

This procedure proved that para-ophthalmic aneurysms in patients with type II RAAs can be treated endovascularly, and that pre-treatment imaging should be reviewed to identify aortic arch variations. Finally, familiarity with a wide range of equipment can help with complex anatomy.

To conclude, this sophisticated procedure fuelled my passion for IR as a similar approach would have been unimaginable in the past: the doctors used their minimally invasive skills to coil the aneurysm, for a full and swift recovery. Moreover, this procedure had never been described before in the literature, and the operators had to use their expertise to develop a new strategy. I can see this happening repeatedly, cumulatively changing the future of medicine. This specifically is what inspires me about the future of IR, and I would be honoured to contribute to it.

REFERENCE LIST

TOP SCORING ESSAY SCHOLARSHIPS

This year scoring resulted in six equally scoring essays at the top of the applications. These were submitted by:

Jakki Brandon

Vinson Wai-Shun Chan

Fahad Mohammad

Neda Oskooee

Mubarak Osman

Victoria Smith

2024 was the first year that this award was opened to applications from Nurses and Radiographers and as such, we would like to share Jakki Brandon’s top scoring essay here.

What is the next paradigm shift in Interventional Radiology practice? Please focus on either new or changing procedures or IR service and delivery.

Jakki Brandon, St James’ Hospital, Leeds

In interventional oncology, the emergence and development of histotripsy presents a paradigm shift from minimally invasive to non-invasive treatment. This essay will provide an overview of the technology, combined with patient experience and impact.

The term histotripsy is a genesis of the Greek words ‘histo’, meaning soft tissue and ‘trispy’, meaning breakdown of (1).

Histotripsy is a non-invasive, non-thermal, non-ionizing, mechanical ablation technique which delivers high-intensity ultrasound pulses into targeted tissue (2). These pulses create rapidly expanding and collapsing cavitation bubbles within the treatment zone, causing the tissue to disintegrate into subcellular debris (3). Minimal cellular disturbance at treatment zone margins and preservation of surrounding tissue facilitates rapid absorption of cellular debris within 1-2 months (4). The well-defined ablation zone then involutes with minimal scarring (1, 5).

In the UK histotripsy has been used in clinical trials of primary and metastatic liver tumours (6) and primary solid renal tumours (7). Both these clinical trials achieved global firsts in terms of patients treated, with the former contributing to FDA approval of histotripsy for treatment of liver tumours (4).

Ongoing data from clinical studies will inform long-term outcomes, however preclinical results indicate local tumour suppression, local and systemic anti-tumour immune response, and improved survival outcomes (2). In addition to treating liver and renal tumours there are encouraging early indications for pancreatic cancer (8), neuro-interventions (9), bloodclot and hematoma liquefaction, and correction of neonatal congenital heart defects (2).

Observations from the author's clinical practice piqued an interest in the patient experience of those undergoing histotripsy. A literature search of NHS Knowledge Hub and Google Scholar found no studies reporting outcomes on patient experience, acceptability, or Quality of Life (QoL) for patients undergoing histotripsy. The scarcity of this evidence was also confirmed in a systematic review of ablative therapies, with recommendations for future histotripsy trials to incorporate QoL and patient acceptability (10).

The author reports that post-treatment patient testimony and anecdotal evidence demonstrate high levels of satisfaction and acceptability. However, whilst patients value the non-invasive nature of the treatment, there are unanticipated emotions reported of delayed ‘sinking in’ and the ‘surreal feeling’ of having gone through a lifechanging experience and treatment with no outwardly visible manifestation. The author has noted that, despite information and preparation throughout the pretreatment and consent process, some patients express that they feel more pain and fatigue than they anticipated. Moreover, some patients struggle to gauge recovery and manage resumption of normal life activities. This ranges from early overexertion, potentially leading to pain and fatigue, through to being reticent and gauging their recovery tentatively, akin to more invasive treatments.

Conclusion:

Evidence to date indicates clinical efficacy of histotripsy combined with favourable patient satisfaction testimonies. There are patient experience factors which the author advocates to be explored further. These include managing patients' expectation of pain and fatigue, optimal post-treatment advice on resumption of usual activities, and managing the emotional aspect of having a substantial physical treatment delivered non-invasively.

REFERENCE LIST