- Email: [email protected]
Dr. Adam responds
Letters to the Editor
Re: Interventional Radiology: Veni, Vidi, Vanished? From: Maurice A. van den Bosch, MD, PhD Stanford University Department of Radiology The Lucas Center for MR Spectroscopy and Imaging 1201 Welch Road Stanford, CA 94305-5488 Editor: With great interest I read the 2006 Charles T. Dotter Lecture by Andreas Adam in the October issue of the Journal of Vascular and Interventional Radiology (1). It is always highly interesting when one of the world leaders in interventional radiology shares his knowledge and vision about the future of interventional radiology. However, the last word of the lecture title (“Interventional Radiology: Veni, Vidi, Vanished?”) puzzled me, especially because I started my fellowship in interventional radiology this year after finishing my residency in diagnostic radiology totally convinced that image-guided minimal invasive disease treatment is the subspecialty of the future. In Dr. Adam’s lecture, the two main factors described that might determine the future of interventional radiology are “its position in relation to other specialties and its relation to diagnostic imaging.” With regard to the position of interventional radiology to other specialties, an overview of the turf battle with vascular surgeons and cardiologists in the field of peripheral vascular interventions is provided, and it is concluded that the activity of interventional radiologists in this area is declining. The key factor for this is the clinical control of patients by other specialists. I believe, however, that this is an issue that can be changed in the future if interventional radiologists succeed in collaborating with referring physicians in specialized units or departments designed for image-guided minimal invasive treatment of different disease processes such as interventional oncology, peripheral vascular disease, and women’s health. In this way, interventional radiologists will be part of a treatment team and become more actively involved in patient care, including direct communication with the patient, selection of time and type of procedure, and dealing with postprocedural complications. Another advantage of this strategy would be increased public awareness for interventional radiology as an independent specialty, which could positively affect the image of interventional radiology by people outside the field (2). With regard to the relation of interventional radiology to diagnostic imaging, I was surprised to read that “foreshortened training in diagnostic radiology” was advised to recruit enough interventional radiologists. I think that imaging is an essential element of interventional radiology, and profound knowledge of advanced imaging techniques provides us with an advantage over nonradiologist specialists interested in image-guided interventions. It allows us to pioneer with novel image-guided minimal invasive tech-
DOI: 10.1016/j.jvir.2006.11.001
niques. An example why profound knowledge of advanced imaging techniques is so important is provided by the fact that fluoroscopy, which has been used for vascular interventions by interventional radiologists for decades, was finally adapted by other specialists, too, who learned to use and interpreted the images of this imaging modality. However, with the development of more sophisticated imaging techniques within the radiology departments, a recent trend toward computed tomography (CT) and magnetic resonance (MR) imaging guided interventions has occurred. Especially within the area of interventional oncology, both CT and MR imaging have proved their value above fluoroscopy, not only for imaging the target lesion and monitoring the procedure but also for evaluation of the treatment response (3). Although image-guided tumor ablation has become a huge growth area for interventional radiology, the competition of other specialists is clearly less than it is in the area of vascular interventions, mainly because they are unfamiliar with the imaging techniques used. It can be expected, however, that image-guided cancer therapy will change rapidly within time, with molecular imaging—a specialty aimed at the characterization, visualization, and quantification of specific cellular and molecular processes underlying a disease—making its way toward the clinical arena (4). Although interventional radiology has traditionally relied on morphologic imaging, these new functional imaging techniques at the molecular level allow increased target characterization and delineation and improved treatment monitoring. Moreover, when the exact disease mechanism in a single patient is known, an individually tailored treatment regimen can be designed, with maximal therapeutic effect and minimal side-effects (personalized medicine). It can therefore be expected that molecular imaging will affect the area of image-guided cancer therapy in the future, and interventional radiologists can be part of this development. With the techniques that can be used for image-guided therapy continuously evolving and the area of diseases suited for image-guided therapy rapidly expanding, interventional radiology has a bright future and offers an exciting and dynamic working area for the young radiologist. References 1. Adam A. The 2006 Charles T Dotter Lecture: Interventional radiology: veni, vidi, vanished? J Vasc Interv Radiol 2006; 17: 1399 –1403. 2. Ruiz JA, Glazer GM. The state of radiology in 2006: very high spatial resolution but no visibility. Radiology 2006; 241:11–16. 3. Goldberg SN, Grassi CJ, Cardella JF, et al. Image-guided tumor ablation: standardization of terminology and reporting criteria. J Vasc Interv Radiol 2005; 16:765–78. 4. Krestin GP, Bernsen MR. Molecular imaging in radiology: the latest fad or the new frontier? Eur Radiol 2006; 16:2383–2385.
Dr. Adam responds: I am very grateful for the comments by Dr. van den Bosch on the Dotter lecture and I share his view that image-guided minimally invasive therapy is a subspecialty of the future; indeed, I expressed the same opinion during the lecture
DOI: 10.1016/j.jvir.2006.10.021
165
166
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Letters to the Editor
itself. To some extent, some of the apparent differences between Dr. van den Bosch’s and my views are related to the fact that the article is the transcript of a lecture delivered using a combination of words and images. If I were to tackle the same issues solely in print, the subtleties might not have been lost. Far from believing that interventional radiology will vanish, I am convinced that it will grow and flourish. However, it is now impossible to keep it solely within the family of radiology. During the past two decades, our discipline had the opportunity to create an independent clinical specialty within the house of radiology. However, initially, this concept was rejected because of concerns about fragmentation of the specialty. By the time it was realized that this would be the only way for radiologists to maintain our role in certain fields, such as peripheral vascular intervention, it was far too late. I share Dr. van den Bosch’s vision of collaboration with clinical disciplines as one of the ways forward but the price may have to be a “relabeling” of the individuals practicing the relevant procedures. My comments in relation to diagnostic imaging have been misinterpreted. I believe that an interventional radiologist is first and foremost a radiologist and that imaging is at the heart of our specialty. However, if we are to devote more time in formal training on the procedures and equipment that we use and on the clinical aspects of our discipline, our knowledge of diagnostic imaging has to be focused on those aspects that are relevant to our daily practice. There is little point in learning high-resolution computed tomography of the lung or the details of bone dysplasias instead of being formally instructed on procedural techniques. What I am advocating is not substandard but focused training in imaging. Indeed, in the lecture I emphasized the need for sufficient training in diagnostic imaging for board certification in diagnostic radiology and I make the point that if this does not happen, we will not have enough recruits for interventional radiology. I am delighted by Dr. van den Bosch’s enthusiasm for our specialty, which I share. I have no doubt that he will have a very interesting working life, although I suspect that he will see many changes, as indeed have I. Prof. Andy Adam Guy’s King’s and St. Thomas’ School of Medicine Department of Radiology St. Thomas’ Hospital Lambeth Palace Road London SE1 7EH United Kingdom
Talent Stent-Graft and Iliac Thrombosis From: Ilias Dalainas, MD, PhD Giovanni Nano, MD School of Vascular Surgery University of Milan Via Triulziana 36 20097 San Donato Milan, Italy
DOI: 10.1016/j.jvir.2006.09.002
January 2007
JVIR
Editor: We read with great interest the article by Seriki et al (1) describing their experience with the Talent endoprosthesis (Medtronic, Minneapolis, Minn) in the treatment of abdominal aortic aneurysms, and we congratulate them for their excellent clinical results and meticulous follow-up. We were not surprised to see that they had a late iliac limb thrombosis treated with a femorofemoral crossover bypass. We have also noted the same complication with the same endograft in three patients. The first patient was treated with a surgical thrombectomy and transluminal intraprosthesis angioplasty without stent implantation, the second patient was treated with angioplasty and placement of an Excluder iliac stentgraft (W.L. Gore & Associates, Elkton, Md) into the Talent iliac endoprosthesis, and the third patient was treated with a femorofemoral crossover bypass. In our department, 307 endografts have been implanted for abdominal aortic aneurysm exclusion from October 1998 until June 2006. There were four Zenith (Cook, Bloomington, Ind), three Endofit (Le Maitre Vascular Inc, Burlington, Mass), 10 Anaconda (Vascutek, Terumo, Inchinnan, Scotland), 23 Vanguard (Boston Scientific, Natick, Mass), 48 Lifepath (Edwards Lifesciences LLC, Irvine, Calif), 58 PowerLink (Endologix Inc., Irvine, Calif), 137 Excluder, and 24 Talent endografts. Iliac limb thrombosis has also been observed with other endografts. Thrombosis occurred in one patient treated with a Vanguard stent-graft and another treated with a PowerLink stent-graft. However, this complication occurred in three of the 24 patients treated with the Talent stent-graft. Other authors have noted the same complication with the same endoprosthesis (2– 4). Conversely, Espinosa et al (5) treated 193 patients with the Talent stent– graft and found no cases of iliac thrombosis. Carpenter and colleagues noted iliac thrombosis in 1.8% of the patients treated with the PowerLink endograft (6) and no iliac thrombosis in patients treated with the Zenith system (7). In a revision of multiple trials in which the Excluder endograft was compared with surgical repair (8), it was shown that this stent-graft has very little predilection to iliac thrombosis. The Talent endograft system has proved its efficacy and durability in the endovascular treatment of aortic aneurysms in many studies (1–5); however, further investigation to test this apparent tendency of iliac thrombosis is warranted. References 1. Seriki DM, Ashleigh RJ, Butterfield JS, et al. Midterm follow-up of a single-center experience of endovascular repair of abdominal aortic aneurysms with the Talent stent-graft. J Vasc Interv Radiol 2006; 17:973–977. 2. Dalainas I, Moros I, Gerasimidis T, et al. Mid-term comparison of bifurcated modular endograft versus aorto-uni-iliac endograft in patients with abdominal aortic aneurysm. Ann Vasc Surg 2007; in press. 3. Torsello G, Osada N, Florek HJ, et al. Long-term outcome after Talent endograft implantation for aneurysms of the abdominal aorta: a multicenter retrospective study. J Vasc Sug 2006; 43:277– 284. 4. Saratzis N, Antonitsis P, Melas N, et al. Midterm results of endovascular abdominal aortic aneurysm repair with the Talent stent-graft in a single center. Int Angiol 2006; 25:197–203. 5. Espinosa G, Ribeiro M, Riguetti C, et al. Six-year experience with Talent stent-graft repair of abdominal aortic aneurysms. J Endovasc Ther 2006; 12:35– 46. 6. Carpenter JP. The PowerLink bifurcated system for endovascular aortic repair: four-year results of the US multicenter trial. J Cardiovasc Surg 2006; 47:239 –243.
Re: Interventional Radiology: Veni, Vidi, Vanished? From: Maurice A. van den Bosch, MD, PhD Stanford University Department of Radiology The Lucas Center for MR Spectroscopy and Imaging 1201 Welch Road Stanford, CA 94305-5488 Editor: With great interest I read the 2006 Charles T. Dotter Lecture by Andreas Adam in the October issue of the Journal of Vascular and Interventional Radiology (1). It is always highly interesting when one of the world leaders in interventional radiology shares his knowledge and vision about the future of interventional radiology. However, the last word of the lecture title (“Interventional Radiology: Veni, Vidi, Vanished?”) puzzled me, especially because I started my fellowship in interventional radiology this year after finishing my residency in diagnostic radiology totally convinced that image-guided minimal invasive disease treatment is the subspecialty of the future. In Dr. Adam’s lecture, the two main factors described that might determine the future of interventional radiology are “its position in relation to other specialties and its relation to diagnostic imaging.” With regard to the position of interventional radiology to other specialties, an overview of the turf battle with vascular surgeons and cardiologists in the field of peripheral vascular interventions is provided, and it is concluded that the activity of interventional radiologists in this area is declining. The key factor for this is the clinical control of patients by other specialists. I believe, however, that this is an issue that can be changed in the future if interventional radiologists succeed in collaborating with referring physicians in specialized units or departments designed for image-guided minimal invasive treatment of different disease processes such as interventional oncology, peripheral vascular disease, and women’s health. In this way, interventional radiologists will be part of a treatment team and become more actively involved in patient care, including direct communication with the patient, selection of time and type of procedure, and dealing with postprocedural complications. Another advantage of this strategy would be increased public awareness for interventional radiology as an independent specialty, which could positively affect the image of interventional radiology by people outside the field (2). With regard to the relation of interventional radiology to diagnostic imaging, I was surprised to read that “foreshortened training in diagnostic radiology” was advised to recruit enough interventional radiologists. I think that imaging is an essential element of interventional radiology, and profound knowledge of advanced imaging techniques provides us with an advantage over nonradiologist specialists interested in image-guided interventions. It allows us to pioneer with novel image-guided minimal invasive tech-
DOI: 10.1016/j.jvir.2006.11.001
niques. An example why profound knowledge of advanced imaging techniques is so important is provided by the fact that fluoroscopy, which has been used for vascular interventions by interventional radiologists for decades, was finally adapted by other specialists, too, who learned to use and interpreted the images of this imaging modality. However, with the development of more sophisticated imaging techniques within the radiology departments, a recent trend toward computed tomography (CT) and magnetic resonance (MR) imaging guided interventions has occurred. Especially within the area of interventional oncology, both CT and MR imaging have proved their value above fluoroscopy, not only for imaging the target lesion and monitoring the procedure but also for evaluation of the treatment response (3). Although image-guided tumor ablation has become a huge growth area for interventional radiology, the competition of other specialists is clearly less than it is in the area of vascular interventions, mainly because they are unfamiliar with the imaging techniques used. It can be expected, however, that image-guided cancer therapy will change rapidly within time, with molecular imaging—a specialty aimed at the characterization, visualization, and quantification of specific cellular and molecular processes underlying a disease—making its way toward the clinical arena (4). Although interventional radiology has traditionally relied on morphologic imaging, these new functional imaging techniques at the molecular level allow increased target characterization and delineation and improved treatment monitoring. Moreover, when the exact disease mechanism in a single patient is known, an individually tailored treatment regimen can be designed, with maximal therapeutic effect and minimal side-effects (personalized medicine). It can therefore be expected that molecular imaging will affect the area of image-guided cancer therapy in the future, and interventional radiologists can be part of this development. With the techniques that can be used for image-guided therapy continuously evolving and the area of diseases suited for image-guided therapy rapidly expanding, interventional radiology has a bright future and offers an exciting and dynamic working area for the young radiologist. References 1. Adam A. The 2006 Charles T Dotter Lecture: Interventional radiology: veni, vidi, vanished? J Vasc Interv Radiol 2006; 17: 1399 –1403. 2. Ruiz JA, Glazer GM. The state of radiology in 2006: very high spatial resolution but no visibility. Radiology 2006; 241:11–16. 3. Goldberg SN, Grassi CJ, Cardella JF, et al. Image-guided tumor ablation: standardization of terminology and reporting criteria. J Vasc Interv Radiol 2005; 16:765–78. 4. Krestin GP, Bernsen MR. Molecular imaging in radiology: the latest fad or the new frontier? Eur Radiol 2006; 16:2383–2385.
Dr. Adam responds: I am very grateful for the comments by Dr. van den Bosch on the Dotter lecture and I share his view that image-guided minimally invasive therapy is a subspecialty of the future; indeed, I expressed the same opinion during the lecture
DOI: 10.1016/j.jvir.2006.10.021
165
166
•
Letters to the Editor
itself. To some extent, some of the apparent differences between Dr. van den Bosch’s and my views are related to the fact that the article is the transcript of a lecture delivered using a combination of words and images. If I were to tackle the same issues solely in print, the subtleties might not have been lost. Far from believing that interventional radiology will vanish, I am convinced that it will grow and flourish. However, it is now impossible to keep it solely within the family of radiology. During the past two decades, our discipline had the opportunity to create an independent clinical specialty within the house of radiology. However, initially, this concept was rejected because of concerns about fragmentation of the specialty. By the time it was realized that this would be the only way for radiologists to maintain our role in certain fields, such as peripheral vascular intervention, it was far too late. I share Dr. van den Bosch’s vision of collaboration with clinical disciplines as one of the ways forward but the price may have to be a “relabeling” of the individuals practicing the relevant procedures. My comments in relation to diagnostic imaging have been misinterpreted. I believe that an interventional radiologist is first and foremost a radiologist and that imaging is at the heart of our specialty. However, if we are to devote more time in formal training on the procedures and equipment that we use and on the clinical aspects of our discipline, our knowledge of diagnostic imaging has to be focused on those aspects that are relevant to our daily practice. There is little point in learning high-resolution computed tomography of the lung or the details of bone dysplasias instead of being formally instructed on procedural techniques. What I am advocating is not substandard but focused training in imaging. Indeed, in the lecture I emphasized the need for sufficient training in diagnostic imaging for board certification in diagnostic radiology and I make the point that if this does not happen, we will not have enough recruits for interventional radiology. I am delighted by Dr. van den Bosch’s enthusiasm for our specialty, which I share. I have no doubt that he will have a very interesting working life, although I suspect that he will see many changes, as indeed have I. Prof. Andy Adam Guy’s King’s and St. Thomas’ School of Medicine Department of Radiology St. Thomas’ Hospital Lambeth Palace Road London SE1 7EH United Kingdom
Talent Stent-Graft and Iliac Thrombosis From: Ilias Dalainas, MD, PhD Giovanni Nano, MD School of Vascular Surgery University of Milan Via Triulziana 36 20097 San Donato Milan, Italy
DOI: 10.1016/j.jvir.2006.09.002
January 2007
JVIR
Editor: We read with great interest the article by Seriki et al (1) describing their experience with the Talent endoprosthesis (Medtronic, Minneapolis, Minn) in the treatment of abdominal aortic aneurysms, and we congratulate them for their excellent clinical results and meticulous follow-up. We were not surprised to see that they had a late iliac limb thrombosis treated with a femorofemoral crossover bypass. We have also noted the same complication with the same endograft in three patients. The first patient was treated with a surgical thrombectomy and transluminal intraprosthesis angioplasty without stent implantation, the second patient was treated with angioplasty and placement of an Excluder iliac stentgraft (W.L. Gore & Associates, Elkton, Md) into the Talent iliac endoprosthesis, and the third patient was treated with a femorofemoral crossover bypass. In our department, 307 endografts have been implanted for abdominal aortic aneurysm exclusion from October 1998 until June 2006. There were four Zenith (Cook, Bloomington, Ind), three Endofit (Le Maitre Vascular Inc, Burlington, Mass), 10 Anaconda (Vascutek, Terumo, Inchinnan, Scotland), 23 Vanguard (Boston Scientific, Natick, Mass), 48 Lifepath (Edwards Lifesciences LLC, Irvine, Calif), 58 PowerLink (Endologix Inc., Irvine, Calif), 137 Excluder, and 24 Talent endografts. Iliac limb thrombosis has also been observed with other endografts. Thrombosis occurred in one patient treated with a Vanguard stent-graft and another treated with a PowerLink stent-graft. However, this complication occurred in three of the 24 patients treated with the Talent stent-graft. Other authors have noted the same complication with the same endoprosthesis (2– 4). Conversely, Espinosa et al (5) treated 193 patients with the Talent stent– graft and found no cases of iliac thrombosis. Carpenter and colleagues noted iliac thrombosis in 1.8% of the patients treated with the PowerLink endograft (6) and no iliac thrombosis in patients treated with the Zenith system (7). In a revision of multiple trials in which the Excluder endograft was compared with surgical repair (8), it was shown that this stent-graft has very little predilection to iliac thrombosis. The Talent endograft system has proved its efficacy and durability in the endovascular treatment of aortic aneurysms in many studies (1–5); however, further investigation to test this apparent tendency of iliac thrombosis is warranted. References 1. Seriki DM, Ashleigh RJ, Butterfield JS, et al. Midterm follow-up of a single-center experience of endovascular repair of abdominal aortic aneurysms with the Talent stent-graft. J Vasc Interv Radiol 2006; 17:973–977. 2. Dalainas I, Moros I, Gerasimidis T, et al. Mid-term comparison of bifurcated modular endograft versus aorto-uni-iliac endograft in patients with abdominal aortic aneurysm. Ann Vasc Surg 2007; in press. 3. Torsello G, Osada N, Florek HJ, et al. Long-term outcome after Talent endograft implantation for aneurysms of the abdominal aorta: a multicenter retrospective study. J Vasc Sug 2006; 43:277– 284. 4. Saratzis N, Antonitsis P, Melas N, et al. Midterm results of endovascular abdominal aortic aneurysm repair with the Talent stent-graft in a single center. Int Angiol 2006; 25:197–203. 5. Espinosa G, Ribeiro M, Riguetti C, et al. Six-year experience with Talent stent-graft repair of abdominal aortic aneurysms. J Endovasc Ther 2006; 12:35– 46. 6. Carpenter JP. The PowerLink bifurcated system for endovascular aortic repair: four-year results of the US multicenter trial. J Cardiovasc Surg 2006; 47:239 –243.