Management of a future in continuous evolution “interventional vascular radiology”

Maynar, M.

doi:10.1016/j.rxeng.2020.11.004

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Boy aged 2 years and 4 months with fever and asymmetry in his auscultation; severe bronchospasm. The anteroposterior X-ray shows signs of bilateral and symmetrical pulmonary hyperinflation, peribronchial thickening and bilateral interstitial pattern. There is a small paracardiac opacity in the base of the left lung that may be a small atelectasis/mucus plug. No SARS-CoV-2 PCR was performed. He required admission to ICU with leucocytosis of 18.7×1000/μL and CRP 6.09mg/dL. He had a favourable course and was discharged after 3 days." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "E. Aguirre Pascual, D. Coca Robinot, C. Gallego Herrero, M. Navallas Irujo, M. Rasero Ponferrada, M. Pont Vilalta" "autores" => array:6 [ 0 => array:2 [ "nombre" => "E." "apellidos" => "Aguirre Pascual" ] 1 => array:2 [ "nombre" => "D." "apellidos" => "Coca Robinot" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Gallego Herrero" ] 3 => array:2 [ "nombre" => "M." "apellidos" => "Navallas Irujo" ] 4 => array:2 [ "nombre" => "M." "apellidos" => "Rasero Ponferrada" ] 5 => array:2 [ "nombre" => "M." "apellidos" => "Pont Vilalta" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0033833820301818" "doi" => "10.1016/j.rx.2020.11.008" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0033833820301818?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173510721000318?idApp=UINPBA00004N" "url" => "/21735107/0000006300000002/v1_202103070728/S2173510721000318/v1_202103070728/en/main.assets" ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "Editorial" "titulo" => "Management of a future in continuous evolution “interventional vascular radiology”" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "103" "paginaFinal" => "105" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M. Maynar" "autores" => array:1 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Maynar" "email" => array:1 [ 0 => "mmaynar@hotmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Profesor de la Universidad de Las Palmas de Gran Canaria (ULPGC)" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Director Científico de la Cátedra de Tecnologías Médicas de la ULPGC" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Gestión de un futuro en continua evolución.“Radiología vascular intervencionista”" ] ] "textoCompleto" => "It is strange to write an article in times as special as these. We are under lockdown. Our routines are log-jammed. An infection caused by a virus, deemed a pandemic, is causing a spike in deaths.I started this article on one day or another in April 2020. More than a hundred days ago, somebody pointed out that there was something different about the social space that we occupy.Interventional vascular radiology emerged in the second half of the 20th century and represented a great step forward towards the development of minimally invasive surgery (MIS).Returning to the present, is it not striking that, with qualified healthcare systems created to promote social well-being — that is, to cure patients with various ailments, or at least relieve their suffering — a virus would shake the foundations of these systems?This global social reality might prompt us to wonder why interventional vascular radiology is not used routinely.In 1953, Seldinger had a grand idea: entering vessels without exposing them to direct vision. Since then, various technological advances have led to the development of what is called MIS. This could be the foundation for better understanding how this type of surgery has evolved.It should not be forgotten that particularly intelligent healthcare professionals have not been solely responsible for developing MIS. Engineers, physicists, veterinary surgeons and many others — professionals across all disciplines — make daily strides towards advancements in MIS.A grasp of this, along with new developments, regulated training, communication and all manner of technology, will shed light on where things have gone wrong in demanding actions and specialisation.It should be borne in mind that, in the era of analogue radiology, radiologists were the most competent, best-educated people in hospitals. They saw what others could not, and made decisions based on spectacular non-invasive diagnoses.I have always believed that our specialisation first erred in failing to work out, plan and develop very different training from that imparted when the specialisation originated — training dedicated exclusively to diagnosis — whereas the new branch evolved as follows:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1Diagnostic/interventional: "somewhat" invasive.</li><li class="elsevierStyleListItem" id="lsti0010">2Therapeutic: the vast majority, addressing cerebral haemorrhages, aortic rupture and even such a common condition as intermittent claudication so as to prevent amputation, and helping to address such widespread social problems as dyspareunia.</li></ul>That is to say, we are talking about major surgical changes when we obviously cannot relate with only training in a specialisation with a knowledge base in diagnosis.It is important to bear in mind that the major global population boom in recent years (from 3.5 billion to more than 7.5 billion), coupled with tremendous developments in technology, has led to many specialists using radiological diagnostic techniques to formulate opinions on their patients, leaving radiologists dealing almost exclusively with uncertain and complex cases.If other specialists are permitted to use diagnostic methods such as ultrasound, an even more limited role for radiologists in imaging-guided treatments can be envisioned.Obviously, not all types of MIS can be included in a single specialisation. So, how can bridges be built between evolving practices and training? This question could be addressed on two levels:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015">1Interventionism.</li><li class="elsevierStyleListItem" id="lsti0020">2Endoluminal techniques, i.e. treatments incorporating such physiologically complex systems as the vascular system, the genitourinary system and the gastrointestinal system (including the liver).</li></ul>The minimally invasive diagnostic part includes biopsies, drains, direct punctures and so on. Good radiological training in anatomy and use of technology such as magnetic resonance imaging, computed tomography and ultrasound should be the focus of the educational approach.These are physicians who want to be somewhat more aggressive — to be interventional.Ongoing advances call for defined training over time with periods for updating.With regard to treatments, both temporary and definitive, any physician who wishes to go about their work according to the Seldinger technique, within MIS, will require specific training in surgical concepts.Both radiologists and all other specialists who wish to have the two qualifications or acquire new segments of knowledge would undoubtedly have to train as they trained in their base specialisation. This means that a cardiologist who wants to use MIS based on the Seldinger technique should invest a certain amount of time (yet to be determined) in training to earn the qualification of interventional cardiologist. The process would be much the same for all other specialists: gastroenterologists, radiologists, urologists, etc.Clinical specialists would have "interventional" added to their titles on completing their training, and surgical specialists would have to demonstrate training in MIS techniques to be able to employ them. To this will be added simulation technologies for training and updating.Traditional surgery should not be conflated with MIS, and the latter should certainly not be minimised.Surgeons chose open surgery as a way to treat diseases and address other indications, such as cosmetic surgery, but the techniques are clearly different.As to the question of what things will be like in a few years, obviously nobody can know for sure, but looking to the past aids in imagining the future.Education should be open to all, but it should always be regulated. Hence, in addition to the above points, it must be understood that all specialists will have the option to add to or round out their clinical routines and knowledge in their different specialisations for the time deemed necessary to acquire a qualification that, in general, will not have formed part of the training programme in their base specialisation. Obviously, this applies to radiologists as well, but should radiologists create that qualification?Knowledge is everybody's business, and leaders should discuss the matter within a university framework. The phrase "university framework" refers not to university buildings, but to a global educational framework.All techniques will continue to change for as long as we live, increasingly offering new, less invasive methods for any clinical or therapeutic action.Working as a group, sharing knowledge, imparting education consistent with desired learning and staying up to date according to designed standards — these should serve as an outline. What we must never do is make use of techniques in which we are not trained. A specialist is somebody who has trained and stayed up to date in a specialisation.It is important to learn from the pandemic. We do not need a virus to teach us to live in a healthy way.A symphony orchestra conductor once said that a leader is a generalist surrounded by great specialists. This could serve as a guiding principle for knowledge management in our professional setting.From a future vantage point, we could consider such fundamental things as:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0025">•Having a daily practice in which we see not only patients referred by other specialists, but also patients seeking an initial consultation. In this case, if the patient lacks direct information from a specialist, we would contact the group specialist.</li><li class="elsevierStyleListItem" id="lsti0030">•If a direct aortic approach (i.e. through percutaneous sutures) is possible, then we would never address the case without the group vascular surgeon being informed.</li><li class="elsevierStyleListItem" id="lsti0035">•Remember that a stent is a foreign body and that vascular disease lies in the vascular wall.</li><li class="elsevierStyleListItem" id="lsti0040">•The logic of the old saying that the most permeable bypass is the one that is never performed should be applied to an incurable disease, vascular disease, when talking about placing a stent.</li></ul>The ideal stent should have the following characteristics:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0045">•It should feature microcoils, like a car's suspension system, to prevent breakage.</li><li class="elsevierStyleListItem" id="lsti0050">•It should prevent hyperplasia by controlling, from outside, contact between electrolytes and the metal mesh of the stent itself.</li><li class="elsevierStyleListItem" id="lsti0055">•Undoubtedly, drug-eluting stents have indications, but what happens when the drug runs out? Could it be reloaded through microcatheters, such that the medication could be changed?</li><li class="elsevierStyleListItem" id="lsti0060">•Finally, where there is no hyperplasia the stent could be removed, if deemed necessary, using a magnetised system.</li></ul>Continuing in the vein of what it means to be a leader, we might remember that the radial artery has always been a part of human anatomy; this or that specific technique might change, but the radial artery forms part of all humans' anatomy, barring certain anatomical variants.At present, this artery can be routinely accessed; technology enables not only radial but also pedal access and access through any other small-calibre vessel.Remember, these are not new findings; these are technological advances enabling access to human anatomy through many more sites than a few years ago.Similarly, to paint a picture of the volume of things that could yet be done:<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0065">•Is a biliary stent indicated in terminal tumour diseases? It is indicated to resolve bothersome signs and symptoms such as acholia, choluria and pruritus. However, if the patient lives and the stent becomes occluded, then another treatment cycle is needed, and this carries certain morbidity for the patient. Wouldn't a custom internal/external drain be better so that, should it become occluded, it can be changed easily with a catheter in an outpatient procedure?</li><li class="elsevierStyleListItem" id="lsti0070">•Let us think for a moment about tumour diseases that require the patient to visit their physician each time a complication arises, only to be referred to another physician who almost always uses percutaneous techniques to temporary effect. Why not create a medical group, with a direct telephone line, so that the patient may resolve such complications, which will unfortunately accompany them throughout their lives — ascites, drains, embolisations, etc. — as quickly as possible?</li></ul>As physicians, let's create a "fast track" in healthcare segments.Let's not forget the Hippocratic oath, which tells us that we are never to tell patients "no": we are to listen to them and refer them to somebody more knowledgeable than ourselves.Here are more points for reflection: artificial intelligence, combined with our experience, represents the possibility of choosing, with as much certainty as possible, the correct response to whatever problem is troubling us in order to help our patients.I have attempted to express a vision that we physicians and specialists must realise: we must create spaces wherein anyone who wishes to work in the same manner may do so based not on entitlement, but on knowledge.Let's establish meetings and guidelines for training and updating. Let's create and train teams with a view to fulfilling our sole objective: patient care.The pandemic represents a break in our lives, a mere accident. Knowledge structures are creative and enduring.This essay was completed sometime in November 2020, as a virus continued to roil the world." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: M. Maynar, Gestión de un futuro en continua evolución. “Radiología vascular intervencionista”, Radiología. 2021;63:103–105." ] ] ] "idiomaDefecto" => "en" "url" => "/21735107/0000006300000002/v1_202103070728/S2173510721000197/v1_202103070728/en/main.assets" "Apartado" => array:4 [ "identificador" => "20744" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Editorial" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735107/0000006300000002/v1_202103070728/S2173510721000197/v1_202103070728/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173510721000197?idApp=UINPBA00004N"]

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