HomeRadiologyVol. 308, No. 1 PreviousNext Reviews and CommentaryFree AccessEditorial–Centennial ContentInterventional Radiology: Reflections and ProjectionsM. Victoria Marx M. Victoria Marx Author AffiliationsFrom the Department of Radiology, Keck School of Medicine, University of Southern California, LAC+USC Medical Center, 1200 N State St, D&T Tower 3D321, Los Angeles, CA 90033.Address correspondence to the author (email: [email protected]).M. Victoria Marx Published Online:Jul 25 2023https://doi.org/10.1148/radiol.230174MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In See also the editorials by LaBerge and Weiss and Hafezi-Nejad in this issue.IntroductionAs I write this editorial for the centennial of Radiology, I reflect on the past. Fifty years ago, I was in high school. TVs had picture tubes. The Society of Cardiovascular Radiology was founded. Since then, the world, and our medical field, has undergone remarkable change. My son finished high school over 10 years ago. I can watch TV on my cellphone. And the Society of Cardiovascular Radiology has transformed from a 73-member academic club to an internationally recognized professional organization representing the primary specialty of interventional radiology (IR).The initial name chosen for the current Society of Interventional Radiology (SIR) in 1973 was the Society of Cardiovascular Radiology because of the importance of angiography in the field of diagnostic imaging. The word interventional was added in 1983 in recognition of the broadening range of minimally invasive procedures being developed by innovators in the field. This new name, Society of Cardiovascular and Interventional Radiology, was so long it required an abbreviation on the society logo. The name was shortened in 2002 to the Society of Interventional Radiology in recognition of IR gaining traction in the larger medical community. This progression in the society name reflects the evolution of the identity of IR as a specialty.The three pillars of IR are diagnostic imaging, image-guided minimally invasive procedures, and periprocedural patient care. The evolution of IR over the past 50 years occurred because of advancements in imaging technology, medical device technology, information and communication technology, and economics. Advances in imaging technology, particularly CT, MRI, and US, led interventionalists to focus on treatment rather than diagnosis. Advances in fluoroscopic imaging made more treatments possible. The increasing use of minimally invasive image-guided procedures drove device and technique development—both from IR physicians and corporate entities. Advancements in information acquisition and postprocessing allowed more complex interventions to be performed. These aspects of the field became so complex that physicians in IR became informally responsible for periprocedural patient care.The economic driver of our evolution into being a clinical specialty relates to other medical specialties such as vascular surgery moving into the minimally invasive image-guided procedural space. IR became a mature clinical specialty when our definition and training requirements included patient care. In 2012, the American Board of Medical Specialties approved a primary certificate for IR and diagnostic radiology (DR) (1). In 2014, the Accreditation Council for Graduate Medical Education approved residency program requirements in IR (2). In 2016, IR was included in the National Resident Matching Program Main Residency Match (3), and the first large class of IR/DR residents completed training in 2022.What Do I Think Will Happen in the Evolution of IR over the Next 20 Years?Advancements in imaging and procedural technology will continue to occur. I imagine a time when we will see inside the human body using less ionizing radiation and less iodinated contrast material. I envision minimally invasive devices and techniques that are more elegant and streamlined than our current options, such as biodegradable filters and stents. I am sure that IR will be involved in the management of conditions we haven’t even thought of yet. I foresee formal IR subspecialty training programs, societies, and journals. This trend has already started with the Society of Interventional Oncology and the Society for Pediatric Interventional Radiology. I see more translational research and prospective clinical trials led by interventional radiologists. I see collaborations between interventional radiologists, immunologists, and geneticists. I see more recognition of IR by the public. I see more recognition of IR in the C-suites of health systems. I see IR having a seat with more decision-making bodies in the governmental and economic arenas. I see the propagation of IR around the world as a primary medical specialty. I see IR becoming established in current geographically underserved areas. The potential is limitless.Although my opinion of the future of IR is optimistic, there are some very serious issues in IR that must be addressed within the next 20 years. These relate to the relationship of IR with DR in the academic and nonacademic worlds. I have divided the issues into three main buckets, recognizing that the contents of the buckets overlap.Access to CareIR procedures can be divided into two main categories: basic and advanced. Examples of basic procedures are tissue biopsy and fluid collection drainage. Examples of advanced procedures are arterial embolization and pulmonary embolectomy. In the academic world, a trend that has paralleled the implementation of the IR/DR residency has been the migration of basic image-guided procedures, such as abscess drainage, from diagnostic imaging to IR. This has downstream effects. One is that procedures previously thought to be part of the domain of DR are now thought of as unique to the domain of IR. That is a change in mindset that will impact increasing numbers of residency graduates. The other is the increasing population of DR residency graduates with little procedural experience in the work environment. In some practices, senior diagnostic radiologists may train their incoming colleagues in these general DR radiology procedural skills. However, some current residents may decide not to pursue professional opportunities after graduation that require them to perform basic image-guided procedures. This could easily result in limited access to care for patients in rural or underserved areas, where the health system does not have the patient population to support an interventional radiologist whose career goal is a practice that includes a high percentage of advanced IR procedures.Leaders in IR and DR will need to work together to make sure that the academic environment and residency programs are designed with optimal patient care in mind. A lack of attention to this issue could easily lead to the domination of midlevel providers in the realm of “basic” IR procedures. While this evolution is not necessarily bad, it will lead to tensions in the workforce like those that exist between anesthesiologists and nurse anesthetists.Identity, Advocacy, and EconomicsThe relationship between the specialties of DR and IR requires careful nurturing. Most interventional radiologists think of themselves as specializing in IR. But our American Board of Radiology board certification indicates we are certified in “Interventional Radiology/Diagnostic Radiology.” Interventional radiologists order and interpret innumerable imaging studies in evaluating patients, in planning procedures, and during postprocedure patient care.Unlike many newly defined specialties, the field of IR cannot apply to have a certifying board separate from the American Board of Radiology. Leaders in IR and DR need to work closely together to ensure that current and future residents understand and incorporate this dual certification into their professional identity. It is a huge piece of the specialty’s strength.Why is this on my mind? I have known DR faculty to marginalize IR/DR residents on their rotations, saying “You’re going into IR. You won’t need to know this.” These types of statements are detrimental to resident education and harmful to the overall relationship between the specialties. I have also known of IR/DR residents who put minimum effort into some DR rotations for the same rationale. Again, this type of behavior can have a negative impact on individual education, limit career opportunities, and harm interdisciplinary relationships. The reality of the patient care world is that all interventional radiologists need to have a wide range of imaging expertise.The relationship between the SIR and the American College of Radiology (ACR) also requires thoughtful attention moving forward. Interventional radiologists look to SIR for resources and support related to governmental and economic issues. SIR has been and continues to be a very effective voice for the specialty. But SIR is a relatively small organization. ACR is a huge organization and the dominant voice of radiology in the realms of governmental and economic advocacy. ACR includes a specialty commission on interventional and cardiovascular imaging. ACR has a strong interest in ensuring that all Americans continue to have access to all aspects of radiologic care.Practice ModelsThe historical practice model of academic departments has been for IR to be a division of a radiology department. The historical practice model of private practice has been for diagnostic radiologists in a physician-owned practice to perform basic image-guided procedures (eg, abscess drainage, biopsy, and lumbar puncture) along with diagnostic image interpretation, and for interventional radiologists to read diagnostic cases in between performing procedures. These models may not be a good fit for physicians currently in DR or IR/DR residency. Many new diagnostic radiologists want to work entirely from a remote location. New IR physicians expect to have time, space, and staffing for a clinic and inpatient consultations. Academic departments have found this easier to adapt to than nonacademic groups, and IR departments have started to exist. Yet not all private practices have enough patients referred to IR to support a new IR practitioner or the additional expense of a clinic. They may not have the infrastructure to properly manage their finances. The added complexity of radiology being structured as a hospital-based service with an exclusive contract further complicates the addition of clinical IR provided by practitioners outside the group with the contract. This tension is increased now with the development of large multistate diagnostic imaging groups and with the widespread use of remote subspecialty interpretation of imaging studies stimulated by the COVID-19 pandemic. Interventional radiologists are among the few radiologists who must perform their patient care in person onsite. They may be the anchor of their group, preserving an existing exclusive contract, or they may be an expense that prompts the hospital to look elsewhere for radiology. As a result of these tensions, some interventional radiologists are gravitating to practice models that are separate from DR. These practice models include multispecialty or service line groups (focusing on a type or patient or disease) or an independent practice at office-based laboratories.What is likely to be the healthiest way forward? The most sustainable way forward? Which model provides access to the best possible care for the widest group of people? I am not a businessperson or a diplomat. Given those limitations, I do think that the most efficient and effective way to practice IR in the future will be IR groups that have outpatient offices separate from hospitals and that join hospital medical staff in a geographic area to provide IR care. Hospitals could provide limited support for the clinic operation to give time for practice building. These IR groups could exist within larger radiology groups that include DR or could be separate from DR groups. Practice agreements for DR and for IR would need to be carefully crafted and clearly spell out their individual domains and relationship with each other. A key element of the domain definition would be the delineation of responsibility for basic image-guided procedures and on-call emergency IR and DR care. A hub-and-spoke model of IR care to service smaller hospitals in a network could be developed where patients requiring complex IR procedures could be transferred to a tertiary care center with full IR capability. In the end, I strongly believe that the identification of IR as a primary specialty will require a redesign of the dominant model for the practice of the specialty and for its relationship with the practice of DR.ConclusionI have rambled on a bit about what I think should happen and may happen over the next 20 years in the world of IR. I am sure others out there have other opinions. I know they will share those opinions with me—probably on social media. Thank you in advance for your thoughts.I am confident that I will be right about one reality 20 years from today. In 2043, the majority of interventional radiologists in the United States will have trained under the paradigm of IR as a primary clinical specialty. In addition, most practicing physicians in all other specialties will have trained alongside them. The entire world of organized medicine will take it for granted that IR is a primary clinical specialty and recognize its practitioners as experts in diagnostic imaging, image-guided procedures, and patient care. That is exciting. That is an outcome I hope I get to see.In this special centennial issue on IR, please see the commentaries by LaBerge (4) and Weiss and Hafezi-Nejad (5). I also refer the reader to the articles by Elsayed and Solomon (6), Brock et al (7), and Almansour et al (8).Disclosures of conflicts of interest: M.V.M. Honoraria for invited lectures from Washington University and University of Virginia; support for annual meeting attendance as gold medalist from Society of Interventional Radiology; trustee of the American Board of Radiology; member of radiology Residency Review Committee for Accreditation Council for Graduate Medical Education.References1. Specialty & Subspecialty Certificates. American Board of Medical Specialties. http://www.abms.org/board/American-board-of-radiology. Accessed March 28, 2023. Google Scholar2. ACGME Program Requirements for Graduate Medical Education in Interventional Radiology. Accreditation Council for Graduate Medical Education. https://www.acgme.org/globalassets/pfassets/programrequirements/415_interventionalradiologyv2_2022.pdf. Accessed March 28, 2023. Google Scholar3. Match Data & Report Archives. National Resident Matching Program. https://www.nrmp.org/wp-content/uploads/2021/07/Main-Match-Results-and-Data-2016.pdf. Accessed March 28, 2023. Google Scholar4. LaBerge J. Evolution of a Specialty: From Proceduralist to Practitioner. Radiology 2023;308(1):e230226. Google Scholar5. Weiss CR, Hafezi-Nejad N. Interventional Radiology: Past, Present, and Future. Radiology 2023;308(1):e230809. Google Scholar6. Elsayed M, Solomon SB. Interventional Oncolog: 2043 and Beyond. Radiology 2023;308(1);e230139. Link, Google Scholar7. Brock KK, Chen SR, Sheth RA, Siewerdsen JH. Imaging in Interventional Radiology: 2043 and Beyond. Radiology 2023;308(1):e230146. Link, Google Scholar8. Almansour H, Li N, Murphy MC, Healy GM. Interventional Radiology Training: International Variations. Radiology 2023;308(1):e230040. Link, Google ScholarArticle HistoryReceived: Feb 6 2023Revision requested: Feb 10 2023Revision received: Mar 29 2023Accepted: Apr 3 2023Published online: July 25 2023 FiguresReferencesRelatedDetailsCited ByEvolution of a Specialty: From Proceduralist to PractitionerJeanne M. LaBerge25 July 2023 | Radiology, Vol. 308, No. 1Interventional Radiology: Past, Present, and FutureClifford R. Weiss, Nima Hafezi-Nejad, 25 July 2023 | Radiology, Vol. 308, No. 1Recommended Articles RSNA Education Exhibits RSNA Case Collection Vol. 308, No. 1 Metrics Altmetric Score PDF download

Interventional radiology (IR) was recognized by the American Board of Medical Specialties (ABMS) as a unique primary specialty in 2012. The 3 pillars of the IR domain were established as diagnostic imaging, image-guided procedural expertise, and periprocedural patient care. After recognition of this specialty, the Accreditation Council for Graduate Medical Education (ACGME) approved residency program requirements for IR in 2014. The American Board of Radiology (ABR) provides dual certification in IR/diagnostic radiology (DR) to qualified practitioners who pass the IR/DR certification examination. These 2 founding events are now 11 and 9 years old, respectively. That makes this year, 2023, an appropriate time to evaluate the 10-year effect of this new medical specialty and its new training paradigm. In this special issue, we have invited a group of thought leaders in IR to provide their perspectives on where we have come from, where we are, and what the future might hold for our specialty. Topics include the history of IR specialization, development and implementation of IR residency programs, current status and projected future of IR residency programs, development of IR subspecialization, and importance of research in the IR domain. Another commentary provides a view on the global effect of primary specialty status for IR in the United States. This special issue also includes articles providing a resident perspective on this new paradigm, objective data on IR residency recruitment related to diversity and inclusion, and implications of primary specialty status on the future of IR practice. Finally, 2 past Presidents of the Society of Interventional Radiology (SIR) provide their thoughts on the implications of primary specialty status for IR on the professional organizational relationship between IR and DR. We thank the Editor-in-Chief Dan Sze for inviting us to organize this special issue of our flagship scholarly publication, Journal of Vascular and Interventional Radiology (JVIR). We thank all authors of these thoughtful commentaries for accepting our invitation to contribute to JVIR and, most importantly, for contributing their time, knowledge, and work into our exciting field. We hope that this issue of JVIR is thought-provoking to the IR community and that it sparks further conversation and strategies on the future of IR.

On June 24th 2022 the US Supreme Court, in a 5-4 decision, overturned Roe v. Wade, the landmark 1973 ruling that established the constitutional right to abortion. We are radiologists and medical physicists, many of whom hold or have held leadership roles in our professional community. We are deeply concerned about this erosion of reproductive choice and bodily autonomy across the many States that will now further restrict or even ban access to abortion. Radiologists are physicians who use medical imaging - such as ultrasound, CT, and MRI - to diagnose and treat disease. We use imaging to monitor pregnancy from start to finish and have perspective on the myriad of issues that can arise, making us qualified to speak on the importance of bodily autonomy and the right to choose whether or not to proceed with a pregnancy. Diagnostic radiologists are experienced in evaluating post-surgical complications and interventional radiologists are thoroughly trained in minimally invasive techniques to stop uncontrolled bleeding and place drains to treat abscesses. "Today, approximately 21 million women around the world obtain unsafe, illegal abortions each year, and complications from these unsafe procedures account for approximately 13% of all maternal deaths, nearly 50,000 annually." 1The American College of Obstetricians and Gynecologists (ACOG). "Facts are important: abortion is healthcare." https://www.acog.org/advocacy/facts-are-important/abortion-is-healthcare#:~:text=ACOG's%20November%202017%20Statement%20of,undue%20interference%20by%20outside%20parties. Accessed May 13, 2022. These are our patients, and their morbidity and mortality is entirely preventable with access to safe and legal abortion. We support our patients, of all genders, in making their own informed decisions about their healthcare and management. We urge lawmakers and policy makers to ensure access to reproductive health including safe, legal abortion to all who need these essential healthcare services. Signed Aditya Karandikar, MD A.J. Mariano, MD Adam A. Dmytriw, MD, MPH, MSc Agnieszka Solberg, MD Alan H. Matsumoto, MD Alda L. Tam, MD Alexandra H. Fairchild, MD Alexia Tatem, MD, MPH Alexie Riofrio, MD Alice Fung, MD Alice Zhou, MD Alison Roth, PhD Allison Gittens, MD Ami A. Shah, MD Amie Y. Lee, MD, FSBI Amina Farooq, MD Amit Chakraborty, MD Amy C. Taylor, MD Amy Killeen, MD Amy L. Kotsenas, MD, FACR Amy Lynn Conners, MD Amy Oliveira, MD Anand Narayan, MD, PhD Andi Senter, MD Andrea A. Birch, MD, FACR Andrew Bruner, MD Aneesa Majid, MD, MBA, FSIR Angela Tong, MD Anika L. McGrath, MD Anjali Malik, MD Ann Leylek Brown, MD Anna Nidecker, MD Anne C. Hoyt, MD Anne Roberts, MD Arjun Patel, MD Arthur Fleischer, MD, FACR, FAIUM, FSRU Asha Sarma, MD Ashley Hastings-Robinson, MD Babak Rejaie, MD Bahar Mansoori, MD Bamidele F. Kammen, MD Benjamin Meyer, MD Beth Vettiyil, MD Beth Zigmund, MD Bindu Avutu, MD, MPH Brian Latimer, MD, PhD Brian Park, MD Brooke Morrell, MD Bruce Curran, MS, ME Cameron Henry, MD Camilo Jaimes, MD Cara Connolly, MD Caroline Robson, MBChB Carolyn C. Meltzer, MD, FACR Carolynn DeBenedectis, MD Cassy L. Cook, MD Catherine Everett, MD, MBA, FACR Catherine H. Phillips, MD Chelsea Dunning, PhD Chelsea Neesham, MD Cheri L. Canon, MD, FACR, FSAR Christian Fauria-Robinson, MD Christie M. Lincoln, MD Christine Dove, MD Christine Glastonbury, MBBS Christine Rehwald, MD Christopher Hess, MD, PhD Christopher Murphy, MD Christy Pomeranz, MD Claudia F.E. Kirsch, MD, PhD Cody Quirk, MD Constantine M. Burgan, MD Courtney Scher, DO Courtney Tomblinson, MD Cristina Fuss, MD Cynthia Santillan, MD Dania Daye, MD, PhD Daniel B. Brown, MD, FSIR Daniel J. Young, MD Daniel Kopans MD Daniel Vargas, MD Dann Martin, MD, MS Darren L. Transue, MD David Thompson, MD David W. Jordan, PhD, FACR, FAAPM Deborah Shatzkes, MD Derek Sun, MD Desiree M. Clement, MD Domenico Mastrodicasa, MD Doris Lin, MD, PhD Edward Lo, MD Elainea Smith, MD Elena Korngold, MD Eleza Golden, MD Elianna L. Goldstein, MD, MS Elizabeth A. Russ, MD Elizabeth England, MD Elizabeth H. Dibble, MD Elizabeth K. Arleo, MD, FACR, FSBI Elizabeth M. Hecht, MD, FSAR Elizabeth Morris, MD Elizabeth P. Maltin, MD, FACR Elizabeth Snyder, MD Emmanuel Carrodeguas, MD Erin A. Cooke, MD Erin Shropshire, MD Erin Simon Schwartz, MD, FACR Etta Pisano, MD Evan Lehrman, MD Faezeh Sodagari, MD Faisal Shah, MD, MBA Florence X. Doo, MD Francesca Rigiroli, MD George K. Vilanilam, MD Geraldine McGinty, MD Gina Landinez, MD Girish Bathla, MD Grace G. Zhu, MD Grace Gwe-Ya Kim, PhD Graham Keir, MD Habib Rahbar, MD Hailey Choi, MD Harmanpreet Bandesha, DO Harrison Lee, MD, MBA Haydee Ojeda-Fournier, MD, FSBI Heather Early, MD Heather Greenwood, MD Ichiro Ikuta, MD, MMSc Irena Dragojevic, PhD J. Hugo Decker MD, PhD James Matthew Kerchberger, MD, MPH Jamie Holtz, MD Jamie Hui, MD Jamie Lee Twist Schroeder, MD, DPhil Jana Ivanidze, MD, PhD Janine T. Katzen, MD Jason Chiang, MD, PhD Jeffers Nguyen, MD Jeffrey D Robinson, MD, MBA, FACR Jeffrey Shyu, MD, MPH, MA Jennifer C. Broder, MD Jennifer Chen, MD Jennifer J. Wan, MD Jennifer Kemp, MD, FACR Jennifer R. Buckley, MD, MBA Jennifer S. Weaver, MD Jesse M. Conyers, MD Jessica B. Robbins, MD Jessica Hayward, MD Jessica R. Leschied, MD Jessica Wen, MD, PhD Jiyon Lee, MD Jocelyn Park, MD Joelle Wazen, MD John Mongan, MD, PhD Jonathan Breslau, MD Jordan Cuskaden, MD Jordan Perchik, MD José Pablo Martínez Barbero, MD, PhD, EDiNR Jubin Jacob, MD Julia Schoen, MD, MS Justin Banaga, MD Kalpana Kanal, PhD, FACR Karla A. Sepulveda, MD Karyn Ledbetter, MD Katarzyna J. Macura, MD, PhD Katherine E. Maturen, MD MS Katherine Frederick-Dyer, MD Kathleen A. Ward, MD, FACR, FAAWR Kathryn McGillen, MD Katia Dodelzon, MD, FSBI Katie M. Davis, DO Kayla Cort, DO Kelly Kisling, PhD Kemi Babagbemi, MD, FACR Kevin C. McGill, MD, MPH Kevin J. Chang, MD, FACR, FSAR Kevin Terashima, MD Khashayar Farsad, MD, PhD Kimberly Feigin, MD Kimberly Kallianos MD Kimberly McFarland, MD Kimberly S. Winsor, MD Kimberly Seifert, MD, MS Kirang Patel, MD Kristin K. Porter, MD, PhD, FSAR Kristin M. Foley, MD Krupa Patel-Lippmann, MD Lacey J. McIntosh, DO Laura Barkley, MD Laura E. Heyneman, MD Laura Padilla, PhD Lauren Groner, DO Lauren M. Harry, MD, MS Lauren M. Ladd, MD Laurie Abrams, MD Leah H. Portnow, MD Leah Schafer, MD Leah Sieck, MD Leonard Morneau, MD Leslie Allen, MD Lindsay Busby, MD, MPH Lisa Kang, MD Lisa Walker, MD Lisa Wang, MD, MBA, MPH Lori Strachowski, MD, FSRU, FAOCR Lucy B. Spalluto, MD, MPH Luyao Shen, MD M Mahesh, MS, PhD, FAAPM, FACR, FACMP, FSCCT, FIOMP M. Victoria Marx, MD Majid Chalian, MD Margaret Fleming, MD, MSc Mariam Moshiri, MD Marianne R. Petruccelli, MD Mark D. Sugi, MD Mark P. Supanich, PhD Marla B.K. Sammer, MD, MHA Mary Tenenbaum, MD Maryellen Sun, MD, FACR, FSAR Masis Isikbay, MD Matthew J. Barkovich, MD Matthew J. Miller, MD Matthew S. Johnson, MD Maya Vella, MD Melika Rezaee, MD Melissa A. Davis, MD, MBA Melissa M. Chen, MD Meredith S. Byers, MD Meridith J. Englander, MD, FSIR, FACR Michael Durst, MD Michael Oumano, PhD Michael S. McCollum, DO Michelle Ouyang, MD Mignonne B. Morrell, MD Mitva Patel, MD Monica J. Wood, MD Morgan P. McBee, MD Nancy J. Fischbein, MD Narasim S. Murthy, MD Nataliya Kovalchuk, PhD Neil Lall, MD Neville Eclov, PhD Nicole Kurzbard Roach, MD Nikhil Madhuripan, MD Nikki S. Ariaratnam, MD Nina S. Vincoff, MD Nishanth Khanna, MD Nishita Kothary, MD, FSIR Noushin Yahyavi-Firouz-Abadi, MD Olga R. Brook, MD Orit A. Glenn, MD Pamela K. Woodard, MD Parag J. Patel, MD, MS Parisa Mazaheri, MD Patricia Rhyner MD, FACR Peter R. Eby, MD, FACR Pradnya Mhatre, MD Preethi Raghu, MD Priyanka Jha, MBBS Rachel F. Gerson, MD Rebecca Milman, PhD Rina Patel, MD Robert L. Gutierrez, MD Robert Marks, MD Robyn Gebhard, MD Rochelle F. Andreotti, MD, FACR, FAIUM, FSRU Rohini Nadgir, MD Rukya Masum, MD Ruth B. Goldstein, MD Ryan Manger, PhD Ryan Woods, MD, MPH Sabala Mandava, MD Samantha G. Harrington, MD, MSc Samir Parikh, MD, FACR Sammy Chu, MD, FRCPC Sandeep S. Arora, MBBS Sandra M. Meyers, PhD Sanjay Prabhu, MBBS Sara Shams, MD, PhD Sarah Nobles, MD Sarah Pittman, MD, FRCPC Sarah Rothan, MD Sejal N. Patel, MD Shabnam Mortazavi, MD, MPH Shalini V. Mukhi, MD Sheila Enamandram, MD, MBA Shelby Payne, MD Shravan Sridhar MD, MS Stephen Stein, MD, FACR Steven P. Poplack, MD Steven W. Hetts, MD, FACR Susan Richardson, PhD Suzanne Shepherd, MD Tarek A. Hijaz, MD Teresa Chapman, MD Theresa Caridi, MD, FSIR Thomas W. Loehfelm, MD, PhD Tiffany L. Chan, MD Tim Jenkins, MD Tina Shiang, MD Titania Juang, PhD Toshimasa J. Clark, MD Uzma Waheed, MD Valeria Potigailo, MD Vasantha Aaron, MD Vinil Shah, MD Virginia Planz, MD Vivek Kalia, MD, MPH Walid Ashmeik, MD Wendy DeMartini, MD William D. Donovan, MD, MPH, FACR William P. Dillon, MD Yasha Gupta, MD Yi Li, MD Yilun Koethe, MD Zachary Hartley-Blossom, MD, MBA Zhen Jane Wang, MD These views reflect the opinions of the authors only and do not equal endorsement from their associated affiliations.

Over the last two decades, there has been a concerted push by interventional radiologists (IR) to revamp the IR training paradigm (1). The single year Vascular and Interventional Radiology (VIR) fellowship was suboptimal in providing adequate training in the increasingly complex procedural and nonprocedural patient care aspects of IR (2). In 2012, the American Board of Medical Specialties (ABMS) recognized Interventional Radiology (IR) as a primary specialty and programs began receiving accreditation in 2014 by the ACGME (3).

The COVID-19 pandemic has forced the transition of the traditional residency interview to a virtual format. This new interview format creates additional challenges and opportunities for both programs and applicants. The specific challenges of the virtual interview format are described, as well as means to mitigate those challenges. In addition, opportunities to improve residency selection from the program end are described.

脑卒中是一个全球重大的公共健康问题,取栓治疗为本世纪脑卒中领域最重要的研究进展,而取栓手术必须在严格的时间窗内才能取得良好的结果.这就需要投入非常多的神经介入医师来保证7天全天候的服务,而目前专业的神经介入医师严重不足.介入放射医生本身具有丰富的各种介入器械操作经验,如果再经过简单的神经专业相关培训,完全有能力和神经科医生一起来从事取栓治疗,从而弥补神经介入医生紧缺的现状.为此,美国、欧洲及澳大利亚介入放射协会发布一项关于介入放射医生从事急性脑卒中治疗的联合声明,该声明对人口密度大的我国可能更有指导意义.

Dr. Khaja and his University of Michigan colleagues in the departments of Surgery and Radiology provide a review of the process they followed to develop a surgical internship linked to the UM PGY2 – PGY6 integrated IR residency program ( 1 Khaja M.S. Sherk W.M. Gauger P.G. et al. Establishing a surgical preliminary year in the IR residency: keys to success. Acad Radiol. 2018; 26: 295-297 Google Scholar ). The paper is short and makes the project seem straightforward. Do not be fooled by that. This was a process that took a thoughtful approach to educational priorities, collaboration within and between departments, articulately written documents explaining and justifying the change, persuasive conversations with department chairs as well as institutional and national Graduate Medical Education (GME) organizations, and lots of meetings.

BACKGROUND:The National Board of Medical Examiners (NBME) and the United States Medical Licensing Examination (USMLE) has convened a conference of "key stakeholders" on March 11-12, 2019 to consider reporting the results of the USMLE Step 1 as pass/fail.DISCUSSION:While the original purpose of the USMLE Step 1 was to provide an objective basis for medical licensing, the score is increasingly used in residency applicant screening and selection because it is an objective, nationally recognized metric allowing comparison across medical schools in and outside the United States. Excessive reliance on the Step 1 score in the matching process has led to "Step 1 Culture" that drives medical schools to "teach to the test," increases medical student anxiety, and disadvantages minorities that have been shown to score lower on the USMLE Step 1 examination. The outsize role of the USMLE Step 1 score in resident selection is due to lack of standardization in medical school transcripts, grade inflation, and the lack of class standing in many summative assessments. Furthermore, the numeric score allows initial Electronic Residency Application Service filtering, commonly used by programs to limit the number of residency applications to review.CONCLUSION:The Association of Program Directors in Radiology (APDR) is concerned that pass/fail reporting of the USMLE Step 1 score would take away an objective measure of medical student's knowledge and the incentive to acquire as much of it as possible. Although the APDR is not in favor of the Step 1 exam being used as a screening tool, in the absence of an equal or better metric for applicant comparison the APDR opposes the change in Step 1 reporting from the numeric score to pass/fail.

Interventional radiology (IR) training programs have undergone many changes in the recent past. These changes largely revolve around making programs more "clinical" in nature by requiring each program to have a formal consult service, outpatient clinics, and admitting privileges. Instituting these changes has been challenging, but the programs are up and running. As a testament to the success of these changes, IR has now become one of the very most competitive residencies to enter. This article provides insights into the process of change within the IR training paradigm, and describes the personal experience of one of the architects of the new training programs.

In 2018, we mark the 30th anniversary of the inaugural publication from the Society of Interventional Radiology (SIR) Standards Division: “Guidelines for Establishing a Quality Improvement Program in Vascular and Interventional Radiology” (1Sacks D. McClenny T.E. Cardella J.F. et al.Society of Interventional Radiology Clinical Practice Guidelines.J Vasc Interv Radiol. 2003; 14: S199-S202Abstract Full Text Full Text PDF PubMed Scopus (1247) Google Scholar). SIR took a prescient stance with the creation of the Standards Division, correctly anticipating the need to help physicians integrate evidence-based medical knowledge into daily practice and to ensure high-quality outcomes and patient safety in vascular and interventional radiology. To date, thanks to the unflagging efforts of our member volunteers over the decades, the Standards Division has published 24 Position Statements, 17 Practice Parameters, 32 Quality Improvement Standards, 26 Reporting Standards, and 9 Credentialing & Training Statements. The Division has also diligently maintained the repository of documents by reviewing them every 5 years and revising as necessary with current data. Lastly, the SIR Standards Division has served as the voice for interventional radiology on international consensus guidelines and multisociety consensus documents. As with many specialty societies, the early documents were created using a simple consensus methodology; however, SIR Standards documents evolved in 1995 to incorporate methodologic elements, including the use of the Modified Delphi Consensus Method (2Fink A. Kosefcoff J. Chassin M. et al.Consensus methods: characteristics and guidelines for use.Am J Public Health. 1984; 74: 979-983Crossref PubMed Scopus (1394) Google Scholar, 3Leape L.L. Hilborne L.H. Park R.E. et al.The appropriateness of use of coronary artery bypass graft surgery in New York State.JAMA. 1993; 269: 753-760Crossref PubMed Scopus (226) Google Scholar), which are required to comply with criteria set forth by the Agency for Healthcare Research and Quality National Guidelines Clearinghouse (4AHRQ Guidelines Clearing House. Available at: www.guideline.gov. Accessed April 24, 2018.Google Scholar). Despite adherence to a rigorous scientific and consensus process, clinical practice guidelines (CPGs) developed by specialty societies were, and continue to be, the subject of general criticisms and concerns on the national stage (5Grilli R. Magrini N. Penne A. et al.Practice guidelines developed by specialty societies: the need for a critical appraisal.Lancet. 2000; 355: 103-106Abstract Full Text Full Text PDF PubMed Scopus (558) Google Scholar, 6Classen D.C. Mermel L.A. Specialty society clinical practice guidelines: time for evolution of revolution?.JAMA. 2015; 314: 871-872Crossref PubMed Scopus (32) Google Scholar, 7Chong A.B. Taylor M. Schubert G. et al.Interventional radiology clinical practice guideline recommendations for neurovascular disorders are not based on high-quality systematic reviews.AJNR Am J Neuroradiol. 2017; 38: 759-765Crossref PubMed Scopus (5) Google Scholar), with many advocating for CPGs to be developed by public entities, such as the National Institutes of Health or the Agency for Healthcare Research and Quality (6Classen D.C. Mermel L.A. Specialty society clinical practice guidelines: time for evolution of revolution?.JAMA. 2015; 314: 871-872Crossref PubMed Scopus (32) Google Scholar). This public health issue was addressed when the US Congress assigned the Institute of Medicine (IOM) to develop a set of criteria for CPG development. The IOM recommendations were summarized in 2011 in “Clinical Practice Guidelines We Can Trust” (8Committee on Standards for Developing Trustworthy Clinical Practice Guidelines, Institute of Medicine. Clinical Practice Guidelines We Can Trust. National Academies Press, Washington, DC2011Google Scholar) and “Finding What Works in Health Care: Standards for Systematic Reviews,” (9Eden J. Levit L. Berg A. et al.Institute of Medicine (US) Committee on Standards for Systematic Reviews of Comparative Effectiveness Research, Institute of MedicineFinding What Works in Health Care: Standards for Systematic Reviews. National Academies Press, Washington, DC2011Google Scholar) which redefined CPGs as follows: “Clinical practice guidelines are statements that include recommendations intended to optimize patient care that are informed by a systematic review of the evidence and an assessment of the benefits and harms of alternative care options.” Furthermore, the IOM recommendations stressed the importance of subjecting the scientific body of evidence on which CPGs were based to critical evaluation, the need for transparency in the methodology being used by the writing group, and a candid disclosure of conflict of interests with industry for the members involved in the CPG development (6Classen D.C. Mermel L.A. Specialty society clinical practice guidelines: time for evolution of revolution?.JAMA. 2015; 314: 871-872Crossref PubMed Scopus (32) Google Scholar). While it needs to be acknowledged that the IOM recommendations and proposed methodologies are themselves primarily consensus-based, rather than evidence-based, and their impact on clinical outcomes is as yet unknown (10Jacobs A.K. Anderson J.L. Halperin J.L. The evolution and future of the ACC/AHA clinical practice guidelines: a 30-year journey: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Circulation. 2014; 130: 1208-1217Crossref PubMed Scopus (76) Google Scholar), there has been widespread adoption of this new standard approach to CPG development. This has created a challenging environment for specialty societies, which may lack the infrastructure and financial resources to be compliant (6Classen D.C. Mermel L.A. Specialty society clinical practice guidelines: time for evolution of revolution?.JAMA. 2015; 314: 871-872Crossref PubMed Scopus (32) Google Scholar). As we begin our tenure as an independent specialty, we have instituted several process changes within the Standards Division to meet the evolution in methodology of CPG development and to continue the Division’s strong tradition of helping members optimize the quality of care for patients. The following process changes have been implemented:1.Each fall, SIR will issue an Annual Open Call for Topics providing members with the opportunity to propose topics for guideline development via an online submission process. The suggested topics are reviewed and prioritized by the Chairs of the Standards Division and SIR leadership.2.All documents have adopted an updated methodology for evidence grading and assessment of strength of recommendation (Appendix A; 11OCEBM Levels of Evidence Working Group. The Oxford 2011 Levels of Evidence. Oxford Centre for Evidence-Based Medicine. Available at: https://www.cebm.net/index.aspx?o=5653. Accessed May 16, 2018.Google Scholar, 12Guyatt G.H. Oxman A.D. Vist G.F. et al.GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendation.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar) to fulfill IOM standards for guidelines development. Accepted definitions of the hierarchical classification of evidence, commonly used by systems such as Oxford and GRADE, are included, and an assessment of the strength of recommendation is defined to assist in clinical decision making (11OCEBM Levels of Evidence Working Group. The Oxford 2011 Levels of Evidence. Oxford Centre for Evidence-Based Medicine. Available at: https://www.cebm.net/index.aspx?o=5653. Accessed May 16, 2018.Google Scholar, 12Guyatt G.H. Oxman A.D. Vist G.F. et al.GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendation.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar). Similar classification systems are used by other specialty practice societies, such as the American College of Cardiology/American Heart Association (10Jacobs A.K. Anderson J.L. Halperin J.L. The evolution and future of the ACC/AHA clinical practice guidelines: a 30-year journey: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Circulation. 2014; 130: 1208-1217Crossref PubMed Scopus (76) Google Scholar). The level of evidence assessment will be used to create the evidence tables that inform the Standards documents. For documents that incorporate clinical recommendations, the strength of recommendation will be used to denote how well the recommendation is supported by systematic evidence. It should be noted that a recommendation with level C or D evidence does not necessarily imply that the recommendation is weak (10Jacobs A.K. Anderson J.L. Halperin J.L. The evolution and future of the ACC/AHA clinical practice guidelines: a 30-year journey: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Circulation. 2014; 130: 1208-1217Crossref PubMed Scopus (76) Google Scholar), as many important clinical questions may not lend themselves to clinical trials, and very clear clinical consensus may exist supporting the usefulness or effectiveness of a therapy (10Jacobs A.K. Anderson J.L. Halperin J.L. The evolution and future of the ACC/AHA clinical practice guidelines: a 30-year journey: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Circulation. 2014; 130: 1208-1217Crossref PubMed Scopus (76) Google Scholar). In fact, in an audit of the 3,271 recommendations from 19 CPGs developed by the American College of Cardiology/American Heart Association published in 2013, of the class I (strong) recommendations, only 11% were based on the highest level of evidence, and 46% were informed by evidence from limited data or expert opinion (10Jacobs A.K. Anderson J.L. Halperin J.L. The evolution and future of the ACC/AHA clinical practice guidelines: a 30-year journey: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Circulation. 2014; 130: 1208-1217Crossref PubMed Scopus (76) Google Scholar).3.All documents have adopted the New SIR Adverse Event Classification System (Appendix B) (13Khalilzadeh O. Baerlocher M.O. Shyn P.B. et al.Proposal of a new adverse event classification by the Society of Interventional Radiology Standards of Practice Committee.J Vasc Interv Radiol. 2017; 28: 1432-1437Abstract Full Text Full Text PDF PubMed Scopus (349) Google Scholar). This new system was developed by members of the Standards of Practice Committee and introduced in 2017. It is designed to approximate the surgical Clavien-Dindo scale and the National Cancer Institute Common Terminology Criteria for Adverse Events scale. All adverse events occurring within 30 days of a procedure should be included. The system consists of 2 parts. Part A requires a descriptive narrative of the adverse event (including sedation and anesthesia) and severity characterization. Classification of the adverse event under Part A is suitable for scientific reporting as well as for adverse event reviews within a practice, practice group, facility, or specialty. Part B involves analysis of causality, which takes into consideration patient and procedural risk modifiers as well as adverse event preventability and management. It is designed to enable a confidential and constructive review of an adverse event within an interventional radiology practice or practice group (peer review). Applicability of Part B for scientific publication is limited, and there is none for public use (13Khalilzadeh O. Baerlocher M.O. Shyn P.B. et al.Proposal of a new adverse event classification by the Society of Interventional Radiology Standards of Practice Committee.J Vasc Interv Radiol. 2017; 28: 1432-1437Abstract Full Text Full Text PDF PubMed Scopus (349) Google Scholar).4.Finally, thanks to a commitment from SIR leadership, support for the Standards Division will fundamentally shift toward the development of documents that will be helpful to the membership, impactful, and able to withstand methodologic scrutiny by payers, policymakers, and the medical community at large. Since 2007, aided in part by an Agency for Healthcare Research and Quality grant, the American Academy of Orthopaedic Surgeons has been making a concerted effort to improve the development of their CPGs and now offers consultative services to help other specialties create CPGs that meet IOM criteria. We are excited to announce that SIR is working with the American Academy of Orthopaedic Surgeons Evidence-Based Medicine Unit to develop a CPG on inferior vena cava filters. The purpose of this CPG will be to provide clinicians with evidence-based recommendations to assess the use of inferior vena cava filters in the treatment of patients with thromboembolic disease. The process began in April 2018 and is expected to be completed within 12–18 months. Appendix ALevel of Evidence and Recommendation Classification System 11OCEBM Levels of Evidence Working Group. The Oxford 2011 Levels of Evidence. Oxford Centre for Evidence-Based Medicine. Available at: https://www.cebm.net/index.aspx?o=5653. Accessed May 16, 2018.Google Scholar, 12Guyatt G.H. Oxman A.D. Vist G.F. et al.GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendation.BMJ. 2008; 336: 924-926Crossref PubMed Google ScholarLEVEL OF EVIDENCEAHIGH QUALITY EVIDENCETypes of EvidenceCharacteristics of EvidenceMultiple RCTsSystematic reviews or meta-analyses of high-quality RCTsRCT data supported by high-quality registry studiesHomogeneity of RCT study populationIntention-to-treat principle maintainedAppropriate blindingPrecision of data (narrow CIs)Appropriate follow-up (consider duration and patients lost to follow-up)Appropriate statistical designBMODERATE QUALITY EVIDENCE—Randomized Study DesignTypes of EvidenceCharacteristics of Evidence≥ 1 RCTsSystematic reviews or meta-analyses of moderate-quality RCTsRCTs with limitations (eg, < 80% follow-up, heterogeneity of patient population, bias, etc)Imprecision of data (small sample size, wide CIs)CMODERATE QUALITY EVIDENCE—Nonrandomized Study DesignTypes of EvidenceCharacteristics of EvidenceNonrandomized trialsObservational or registry studiesSystematic reviews or meta-analyses of moderate quality studiesNonrandomized controlled cohort studyObservational study with dramatic effectOutcomes researchEcological studyDLIMITED QUALITY EVIDENCETypes of EvidenceCharacteristics of EvidenceObservational or registry studies with limited design and executionSystematic reviews or meta-analyses of studies limited by design and executionCase seriesCase-control studiesHistorically controlled studiesEEXPERT OPINIONTypes of EvidenceCharacteristics of EvidenceExpert consensus based on clinical practiceExpert opinion without explicit critical appraisal or based on physiology, bench research, or “first principles”STRENGTH OF RECOMMENDATIONStrong RecommendationSupported by high quality evidence for or against recommendationModerate RecommendationSupported by moderate quality evidence for or against recommendation; new research may be able to provide additional contextWeak RecommendationSupported by weak quality evidence for or against recommendation; new research likely to provide additional contextNo RecommendationInsufficient evidence in the literature to support or refute recommendationCI = confidence interval; RCT = randomized controlled trial. Open table in a new tab CI = confidence interval; RCT = randomized controlled trial. Part A: Adverse Event (AE) Description Descriptive narrative of adverse event (including sedation and anesthesia) and severity characterization. This part is suitable for scientific use (presentations, publications, etc) as well as for adverse event reviews within a practice, practice group, facility or specialty (13Khalilzadeh O. Baerlocher M.O. Shyn P.B. et al.Proposal of a new adverse event classification by the Society of Interventional Radiology Standards of Practice Committee.J Vasc Interv Radiol. 2017; 28: 1432-1437Abstract Full Text Full Text PDF PubMed Scopus (349) Google Scholar).1.Mild adverse event: No therapy or nominal (non-substantial) therapy (post-procedural imaging performed and fails to show manifestation of adverse event); near miss (eg, wrong site of patient prepped, recognized and corrected prior to procedure, wrong patient information entered for procedure, etc)2.Moderate adverse event: Moderate escalation of care, requiring substantial treatment, eg, intervention (description of intervention and result of intervention) under conscious sedation, blood product administration, extremely prolonged outpatient observation or overnight admission post outpatient procedure not typical for the procedure (excludes admission or hospital days unrelated to adverse event)3.Severe adverse event: Marked escalation of care, ie, hospital admission or prolongation of existing hospital admission for > 24 h hospital admission that is atypical for the procedure, inpatient transfer from regular floor/telemetry to ICU or complex intervention performed requiring general anesthesia in previously non-intubated patient (generally excludes pediatrics or in circumstances where general anesthesia would primarily be used in lieu of conscious sedation, eg, in mentally challenged or severely uncooperative patients)4.Life-threatening or disabling event, eg, cardiopulmonary arrest, shock, organ failure, unanticipated dialysis, paralysis, loss of limb or organ5.Patient death or unexpected pregnancy abortion *The SIR Adverse Event Severity Scale is intended to approximate the surgical Clavien-Dindo scale and the NCI CTCAE scale. The SIR scale is tailored toward the procedures and adverse events encountered in IR practices. The grading of interventional oncology adverse events can selectively incorporate relevant adverse event grading definitions published in the current CTCAE for oncological interventions, which may be particularly relevant in the context of research publications. All adverse events occurring within 30 days of a procedure should be included in the adverse event description and analysis, regardless of causality, in the interest of objectivity. The adverse event scale itself does not assess operator performance. Modifier: M = multiple adverse events, each of which is counted and evaluated separately if possible. Part B: Adverse Event Analysis The following part pertains to adverse event analysis. It is designed to enable a confidential and constructive review of any adverse event within an IR practice or practice group. Applicability for scientific publications is limited and there is none for other public use. The following content is meant to provide a strictly confidential, legally non-discoverable, non-punitive, objective, consistent and clinically constructive analytic guide that may result in quality improvement measures to advance the quality of patient care in interventional radiology (13Khalilzadeh O. Baerlocher M.O. Shyn P.B. et al.Proposal of a new adverse event classification by the Society of Interventional Radiology Standards of Practice Committee.J Vasc Interv Radiol. 2017; 28: 1432-1437Abstract Full Text Full Text PDF PubMed Scopus (349) Google Scholar). Causality Category 1. Adverse event not caused by the procedure Category 2. Unknown whether adverse event was caused by the procedure Category 3. Adverse event caused by the procedure Patient and Procedural Risk Modifier Category 1. High risk patient AND technically challenging procedure Category 2. High risk patient (eg, ASA 4, uncorrectable coagulopathy, poor functional status (ECOG 3 and 4), polypharmacy/polyintravenous therapy and transfusion, septicemia, hemodynamic instability, recent catastrophic event/ICU admission/major surgery or interventions) etc, OR low risk patient and technically challenging procedure (eg, TIPS with occluded portal vein, percutaneous biliary drain placement in non-dilated biliary system, etc) Category 3. No modifier Adverse Event Preventability Category 1: Rarely preventable: ie, well described and “typical” for the procedure and occurring despite adequate precautionary and preventive measures Category 2: Potentially preventable Category 3: Consistently preventable: eg, inappropriateness of procedural indication (may use checklist, see below) Adverse Event Management Category 1: Most operators would have handled the adverse event similarly Category 2: Some operators would have handled the adverse event differently Category 3: Most operators would have handled the adverse event differently Examples of Consistently Preventable Event•Wrong patient•Absolute contraindication for procedure•Wrong side for procedure•Wrong procedure•Wrong medication/contrast agent/blood product (dose/administration route)•Exposure to known allergens•Intra-arterial placement of catheter meant to be intravenous or non-venous placement of IVC filter•Ferromagnetic devices contraindicating performance of MR imaging•Failure to follow up or communicate laboratory, pathology, or radiology results•Use of known malfunctioning equipment or patient monitor system•Lack or inappropriate use of monitoring equipment during sedation ASA = American Society of Anesthesiologists; CTCAE = Common Terminology Criteria for Adverse Events; ECOG = Eastern Cooperative Oncology Group; ICU = intensive care unit; IVC = inferior vena cava; NCI = National Cancer Institute; TIPS = transjugular intrahepatic portosystemic shunt.

Stroke is a major public health issue. Worldwide, the incidence of new strokes is 16.9 million per year (1Krishnamurthi R.V. Feigin V.L. Forouzanfar M.H. et al.Global Burden of Diseases, Injuries, Risk Factors Study 2010 (GBD 2010); GBD Stroke Experts GroupGlobal and regional burden of first-ever ischaemic and haemorrhagic stroke during 1990-2010: findings from the Global Burden of Disease Study 2010.Lancet Glob Health. 2013; 1: e259-e281Abstract Full Text Full Text PDF PubMed Scopus (852) Google Scholar). In the United States, the incidence of new strokes is 795,000 per year, of which 87% are ischemic (2Benjamin E.J. Virani S.S. Callaway C.W. et al.American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics SubcommitteeHeart disease and stroke statistics—2018 update: a report from the American Heart Association.Circulation. 2018; 137: e67-e492Crossref PubMed Scopus (4418) Google Scholar). Endovascular thrombectomy (EVT) is proven to provide better clinical outcomes in patients with ischemic strokes caused by large-vessel occlusion compared with best medical therapy alone (3Albers G.W. Marks M.P. Kemp S. et al.DEFUSE 3 InvestigatorsThrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging.N Engl J Med. 2018; 378: 708-718Crossref PubMed Scopus (2485) Google Scholar, 4Berkhemer O.A. Fransen P.S. Beumer D. et al.MR CLEAN InvestigatorsA randomized trial of intraarterial treatment for acute ischemic stroke.N Engl J Med. 2015; 372: 11-20Crossref PubMed Scopus (4544) Google Scholar, 5Bracard S. Ducrocq X. Mas J.L. et al.THRACE investigatorsMechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial.Lancet Neurol. 2016; 15: 1138-1147Abstract Full Text Full Text PDF PubMed Scopus (784) Google Scholar, 6Campbell B.C. Mitchell P.J. Kleinig T.J. et al.EXTEND-IA InvestigatorsEndovascular therapy for ischemic stroke with perfusion-imaging selection.N Engl J Med. 2015; 372: 1009-1018Crossref PubMed Scopus (3890) Google Scholar, 7Goyal M. Demchuk A.M. Menon B.K. et al.ESCAPE Trial InvestigatorsRandomized assessment of rapid endovascular treatment of ischemic stroke.N Engl J Med. 2015; 372: 1019-1030Crossref PubMed Scopus (4148) Google Scholar, 8Jovin T.G. Chamorro A. Cobo E. et al.REVASCAT Trial InvestigatorsThrombectomy within 8 hours after symptom onset in ischemic stroke.N Engl J Med. 2015; 372: 2296-2306Crossref PubMed Scopus (3342) Google Scholar, 9Mocco J. Zaidat O.O. von Kummer R. et al.THERAPY Trial InvestigatorsAspiration thrombectomy after intravenous alteplase versus intravenous alteplase alone.Stroke. 2016; 47: 2331-2338Crossref PubMed Scopus (206) Google Scholar, 10Muir K.W. Ford G.A. Messow C.M. et al.PISTE InvestigatorsEndovascular therapy for acute ischaemic stroke: the Pragmatic Ischaemic Stroke Thrombectomy Evaluation (PISTE) randomised, controlled trial.J Neurol Neurosurg Psychiatry. 2017; 88: 38-44Crossref PubMed Scopus (215) Google Scholar, 11Nogueira R.G. Jadhav A.P. Haussen D.C. et al.DAWN Trial InvestigatorsThrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct.N Engl J Med. 2018; 378: 11-21Crossref PubMed Scopus (2853) Google Scholar, 12Saver J.L. Goyal M. Bonafe A. et al.SWIFT PRIME InvestigatorsStent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke.N Engl J Med. 2015; 372: 2285-2295Crossref PubMed Scopus (3502) Google Scholar). Furthermore, endovascular thrombectomy has proven to be cost-effective (13Shireman T.I. Wang K. Saver J.L. et al.SWIFT PRIME InvestigatorsCost-effectiveness of Solitaire stent retriever thrombectomy for acute ischemic stroke: results from the SWIFT-PRIME Trial (Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke).Stroke. 2017; 48: 379-387Crossref PubMed Scopus (84) Google Scholar). The American Heart Association (AHA) and multiple international stroke organizations recommend EVT as standard of care for selected patients (14Casaubon L.K. Boulanger J.M. Blacquiere D. et al.Heart and Stroke Foundation of Canada Canadian Stroke Best Practices Advisory CommitteeCanadian Stroke Best Practice Recommendations: hyperacute stroke care guidelines, update 2015.Int J Stroke. 2015; 10: 924-940Crossref PubMed Scopus (160) Google Scholar, 15National Institute for Health and Care ExcellenceMechanical clot retrieval for treating acute ischemic stroke.http://www.nice.org.uk/guidance/ipg548Date: 2016Google Scholar, 16Powers W.J. Rabinstein A.A. Ackerson T. et al.American Heart Association Stroke Council2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.Stroke. 2018; 49: e46-e110Crossref PubMed Scopus (3297) Google Scholar, 17Wahlgren N. Moreira T. Michel P. et al.ESO-KSU, ESO, ESMINT, ESNR and EANMechanical thrombectomy in acute ischemic stroke: consensus statement by ESO-Karolinska stroke update 2014/2015, supported by ESO, ESMINT, ESNR and EAN.Int J Stroke. 2016; 11: 134-147Crossref PubMed Scopus (276) Google Scholar, 18White P.M. Bhalla A. Dinsmore J. et al.Standards for providing safe acute ischaemic stroke thrombectomy services (September 2015).Clin Radiol. 2017; 72: 175.e1-175.e9Abstract Full Text Full Text PDF Scopus (25) Google Scholar). Based on 2015 AHA guidelines, it is estimated that approximately 10–20 patients per 100,000 per year are eligible for EVT in the United States (19Chia N.H. Leyden J.M. Newbury J. Jannes J. Kleinig T.J. Determining the number of ischemic strokes potentially eligible for endovascular thrombectomy: a population-based study.Stroke. 2016; 47: 1377-1380Crossref PubMed Scopus (95) Google Scholar, 20Rai A.T. Seldon A.E. Boo S. et al.A population-based incidence of acute large vessel occlusions and thrombectomy eligible patients indicates significant potential for growth of endovascular stroke therapy in the USA.J Neurointerv Surg. 2017; 9: 722-726Crossref PubMed Scopus (169) Google Scholar). However, only a fraction of these patients are currently being treated (21Smith E.E. Saver J.L. Cox M. et al.Increase in endovascular therapy in Get With The Guidelines—Stroke after the publication of pivotal trials.Circulation. 2017; 136: 2303-2310PubMed Google Scholar). In addition, the most recent AHA guidelines now include patients with symptom duration as long as 24 hours and consider the treatment of vessel occlusions in locations other than the internal carotid artery and M1 segments, such as the anterior cerebral artery and M2 branches (16Powers W.J. Rabinstein A.A. Ackerson T. et al.American Heart Association Stroke Council2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.Stroke. 2018; 49: e46-e110Crossref PubMed Scopus (3297) Google Scholar). With these expanded indications, it is now estimated that as many as 31 patients per 100,000 per year may be eligible for EVT in the United States (22Rai A.T. Domico J.R. Buseman C. et al.A population-based incidence of M2 strokes indicates potential expansion of large vessel occlusions amenable to endovascular therapy.J Neurointerv Surg. 2018; 10: 510-515Crossref PubMed Scopus (43) Google Scholar). Are there enough physicians to treat these patients? The population of the United States in 2017 was 326 million. Based on the estimate of 31 patients per 100,000 per year, there should be approximately 100,000 patients per year eligible for EVT in the United States. Stroke centers vary in case volume, but if the average stroke center performs 200 EVT procedures per year and requires 4 physicians to provide 24-hour, 7-day service, 500 stroke centers with at least 2,000 physicians are needed. The United States currently has only 231 certified comprehensive and thrombectomy-capable stroke centers (23The Joint Commission. Certification Data Download.https://www.qualitycheck.org/data-download/certification-data-download/Date: 2018Google Scholar, 24DNV GL Healthcare. Search Hospitals.https://www.dnvglhealthcare.com/hospitals?search_type=and&q=&c=&c=20806&c=&c=&prSubmit=SearchDate: 2017Google Scholar). The population of Europe is 741 million, corresponding to 230,000 EVT-eligible patients and the need for 4,600 physicians at 1,150 stroke centers. If more than 4 physicians per stroke center are needed to provide services and avoid 1:4 on-call shifts, the need for physicians becomes even more acute. Geographic inaccessibility to stroke centers also reduces treatment with EVT (25Perez de la Ossa N. Abilleira S. Dorado L. et al.Catalan Stroke Code and Reperfusion ConsortiumAccess to endovascular treatment in remote areas: analysis of the Reperfusion Treatment Registry of Catalonia.Stroke. 2016; 47: 1381-1384Crossref PubMed Scopus (42) Google Scholar). Patients can be treated locally with intravenous thrombolytic agents and then transferred to an endovascular-capable stroke center, but this leads to delays in EVT of 95–140 minutes (26Goyal M. Jadhav A.P. Bonafe A. et al.SWIFT PRIME InvestigatorsAnalysis of workflow and time to treatment and the effects on outcome in endovascular treatment of acute ischemic stroke: results from the SWIFT PRIME randomized controlled trial.Radiology. 2016; 279: 888-897Crossref PubMed Scopus (184) Google Scholar, 27Ng F.C. Low E. Andrew E. et al.Deconstruction of interhospital transfer workflow in large vessel occlusion: real-world data in the thrombectomy era.Stroke. 2017; 48: 1976-1979Crossref PubMed Scopus (71) Google Scholar, 28Rinaldo L. Brinjikji W. McCutcheon B.A. et al.Hospital transfer associated with increased mortality after endovascular revascularization for acute ischemic stroke.J Neurointerv Surg. 2017; 9: 1166-1172Crossref PubMed Scopus (50) Google Scholar). Alternatively, patients can be transported directly to an endovascular stroke center, but this may delay intravenous thrombolytic therapy (29American Heart AssociationAbout the severity-based stroke triage algorithm for EMS.https://www.heart.org/idc/groups/ahaecc-public/@wcm/@gwtg/documents/downloadable/ucm_492024.pdfDate: 2017Google Scholar). Neither approach addresses the issues of adequate physician numbers to perform EVT or the geographic distribution of interventional physicians. The shortage of physicians and comprehensive stroke centers providing EVT has been confirmed by the stroke neurology community (30Davis S.M. Campbell B.C.V. Donnan G.A. Endovascular thrombectomy and stroke physicians: equity, access, and standards.Stroke. 2017; 48: 2042-2044Crossref PubMed Scopus (15) Google Scholar, 31Grotta J.C. Lyden P. Brott T. Rethinking training and distribution of vascular neurology interventionists in the era of thrombectomy.Stroke. 2017; 48: 2313-2317Crossref Scopus (21) Google Scholar), who recommend that patients be treated locally rather than having long transfer delays. Interventional radiologists have core residency neuroimaging training, including computed tomography and magnetic resonance imaging. In addition, interventional radiologists have fellowship training and experience with angiography, guiding catheters, sheaths, closure devices, and thrombolytic medications; are extremely facile with microcatheters and microwires; and perform advanced revascularization procedures throughout the body. Additional training is necessary to learn the clinical and technical factors unique to stroke patients. Models for the additional training have been published (32Berlis A. Weber W. Interventional stroke treatment in Germany is a joint effort between neuro and general interventional radiologists.Cardiovasc Intervent Radiol. 2016; 39: 1539-1540Crossref PubMed Scopus (2) Google Scholar, 33Connors III, J.J. Sacks D. Black C.M. et al.Society of Interventional RadiologyTraining guidelines for intra-arterial catheter-directed treatment of acute ischemic stroke: a statement from a special writing group of the Society of Interventional Radiology.J Vasc Interv Radiol. 2009; 20: 1507-1522Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar, 34Lenthall R. McConachie N. White P. Clifton A. Rowland-Hill C. UK Neurointerventional Group and British Society of NeuroradiologistsBSNR training guidance for mechanical thrombectomy.Clin Radiol. 2017; 72: 175.e11-175.e18Abstract Full Text Full Text PDF Scopus (19) Google Scholar, 35The Royal College of RadiologistsSupplementary guidance to facilitate the training of interventional radiology (IR) consultants to undertake stroke thrombectomy.https://www.rcr.ac.uk/sites/default/files/mt_interim_guidance_document_30-10-2017_final.pdfDate: November 2017Google Scholar) and may be revised in the future. This training is intended to provide interventional radiologists with the cognitive and technical skills necessary to treat patients and obtain outcomes that meet international benchmarks (36Sacks D. Baxter B. Campbell B.C.V. et al.Multisociety consensus quality improvement revised consensus statement for endovascular therapy of acute ischemic stroke: from the American Association of Neurological Surgeons (AANS), American Society of Neuroradiology (ASNR), Cardiovascular and Interventional Radiology Society of Europe (CIRSE), Canadian Interventional Radiology Association (CIRA), Congress of Neurological Surgeons (CNS), European Society of Minimally Invasive Neurological Therapy (ESMINT), European Society of Neuroradiology (ESNR), European Stroke Organization (ESO), Society for Cardiovascular Angiography and Interventions (SCAI), Society of Interventional Radiology (SIR), Society of NeuroInterventional Surgery (SNIS), and World Stroke Organization (WSO).J Vasc Interv Radiol. 2018; 29: 441-453Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar). Published data support this training model in the United States and Europe. In a 2015 survey in the United States, 60% of primary stroke centers reported that they provided EVT, and, of these, 41% rely on interventional radiologists (37Alberts M.J. Range J. Spencer W. Cantwell V. Hampel M.J. Availability of endovascular therapies for cerebrovascular disease at primary stroke centers.Interv Neuroradiol. 2017; 23: 64-68Crossref PubMed Scopus (18) Google Scholar). In The Netherlands, more than 75% of EVT procedures are performed by interventional radiologists because of the shortage of neurointerventionists (van Zwam W, personal written communication, July 23, 2018). This includes the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) centers, whose outcomes first confirmed the significant benefit of EVT compared with best medical therapy. These findings are consistent with the fact that the Society of Neurointerventional Surgery, with 600 members worldwide (38Society of Neurointerventional SurgeryAbout us.http://www.snisonline.org/aboutusDate: 2018Google Scholar), does not have the capacity to cover EVT treatment worldwide or in the United States. Results from individual hospital case series of EVT performed by interventional radiologists have demonstrated outcomes comparable to those of international trials (39Behzadi G.N. Fjetland L. Advani R. Kurz M.W. Kurz K.D. Endovascular stroke treatment in a small-volume stroke center.Brain Behav. 2017; 7: e00642Crossref PubMed Scopus (7) Google Scholar, 40Belisle J.G. McCollom V.E. Tytle T.L. et al.Intraarterial therapy for acute ischemic strokes.J Vasc Interv Radiol. 2009; 20: 327-333Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 41Burkart D.J. Day J.S. Henderson K. Borsa J.J. Efficacy of peripheral interventional radiologists performing endovascular stroke therapy guided by CT perfusion triage of patients.J Vasc Interv Radiol. 2013; 24: 1267-1272Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 42Gandini R. Del Giudice C. Chegai F. et al.Encouraging and positive trend towards treatment of acute ischemic stroke performed by vascular interventional radiologist.Cardiovasc Intervent Radiol. 2014; 37: 1384-1386Crossref PubMed Scopus (5) Google Scholar, 43Šaňák D. Köcher M. Veverka T. et al.Acute combined revascularization in acute ischemic stroke with intracranial arterial occlusion: self-expanding solitaire stent during intravenous thrombolysis.J Vasc Interv Radiol. 2013; 24: 1273-1279Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar, 44Volny O. Krajina A. Belaskova S. et al.Mechanical thrombectomy performs similarly in real world practice: a 2016 nationwide study from the Czech Republic.J Neurointerv Surg. 2018; 10: 741-745Crossref PubMed Scopus (29) Google Scholar). At present, there are no publications including the Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials (HERMES) data that show different outcomes associated with interventional radiologists compared with neurointerventionists (4Berkhemer O.A. Fransen P.S. Beumer D. et al.MR CLEAN InvestigatorsA randomized trial of intraarterial treatment for acute ischemic stroke.N Engl J Med. 2015; 372: 11-20Crossref PubMed Scopus (4544) Google Scholar, 45Goyal M. Menon B.K. van Zwam W.H. et al.Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials.Lancet. 2016; 387: 1723-1731Abstract Full Text Full Text PDF PubMed Scopus (3883) Google Scholar). There is a clinical need for more interventional physicians to provide EVT. Interventional radiologists have a current and growing role in this care, and interventional radiology societies are committed to provide the necessary stroke education to interventional radiologists. The position of the authoring interventional radiology societies is as follows:a.Acute ischemic strokes caused by occlusion of large arteries to the brain is a significant clinical and public health problem.b.Reversal of symptoms from these strokes requires rapid and safe removal of the occluding thrombus. The improvements in clinical outcomes after endovascular therapy for a large-vessel occlusion have been proven.c.The availability of EVT remains limited by distance from endovascular-capable stroke centers and lack of 24-hour, 7-day availability at some hospitals.d.EVT should be provided as part of the services of a rigorous, structured, multispecialty care team including vascular neurologists, with tracking of outcomes.e.The appropriateness of new facilities offering EVT depends on the needs of the community and infrastructure of the hospital, including 24-hour, 7-day availability of neurology, anesthesiology, and diagnostic and interventional radiology services.f.Appropriately trained interventional radiologists can evaluate stroke patients and provide emergent EVT with good outcomes.g.The neurointerventional skills used by interventional radiologists to perform EVT are not intended to perform specific neurointerventional procedures such as cerebral aneurysm occlusion and cerebral embolization.h.Appropriately trained interventional radiologists can provide care, especially where neurointerventional physicians are not available, and help provide 24-hour, 7-day care working in partnership with neurointerventional physicians where they are available.i.Training of interventional radiologists to perform EVT should consist of clinical neurology and care of the stroke patient, stroke imaging, and performance of EVT.

An increasing number of departments with radiology residency programs have implemented 24-7 in-house attending coverage. Reported positive effects include decreased report turnaround time (RTAT) and greater referral satisfaction, whereas negative effects include potential decrease in resident education and independence.

This article reviews the issue of occupational radiation exposure as a deterrent to recruitment of women into the field of interventional radiology and provides the reader with three strategies to optimize radiation protection during fluoroscopically guided procedures. These include personal protective shielding, use of ancillary shielding, and techniques that limit fluoroscopy x-ray tube output. When optimal radiation safety practices are implemented as the norm in the IR suite, very little extra needs to be done to ensure that fetal dose of a pregnant interventionalist is negligible.

Several prominent interventionalists have been publically recognized as having personal health issues that are, or could be, related to their work in the fluoroscopy environment.1CX acknowledges “huge debt” owed to endovascular pioneers affected by radiation. Interventional News, June 2016. p. 8–9. Biba PublishingGoogle Scholar These issues include malignancies and cataracts. The public discussion related to these individual experiences has included an element of regret, and a resurgence of interest in the need for a safe fluoroscopic work environment. The goal of this edition of Techniques in Vascular and Interventional Radiology (TVIR) is to provide the Interventional Radiology (IR) community with data and practical information that can help IRs to work safely over a long period of time. The articles in this edition provide a wealth of information related to occupational risks and many effective strategies to minimize those risks. All work in the IR environment involves exposure to ionizing radiation. Protection from the deleterious effects of chronic exposure to low doses requires knowledge of ways to limit the radiation emitted from the x-ray tube and use of shielding to minimize scatter radiation from the patient. These strategies must balance personal protection with physical comfort and the need to provide good patient care. Creation of a sustainable system of optimizing the safety of the IR work environment requires constant attention and teamwork. The goal of this collection of articles is to provide the reader with a broad range of information that will allow IRs to adopt up to date safety practices that are effective over time. The authors who have contributed their time and expertise to this journal include interventional radiologists and physicists from around the world. Drs Bartal, Sailer and Vano review the issues related to shielding provided by light weight lead aprons and provide some practical recommendations to guide personal decisions when choosing a lead apron. Drs Rees and Duncan review a wide range of options currently available (and just emerging) for protective shielding that is not worn by the worker. Drs Benjamin and Meisinger discuss ergonomic issues related to wearing lead protection and provide strategies that can decrease occupational musculoskeletal injury. Dr Machan discusses the recent recognition that risk of radiation-induced cataracts is greater than was previously thought and provides practical advice on minimizing that risk. Dr Balter provides an overview of objective data related to the risk of radiation-induced cancer for interventionalists—very reassuring data. Dr Marx presents a practical approach for interventional radiologists to manage fetal exposure to ionizing radiation. Finally, Dr Miller provides an overview of ways to optimize occupational radiation dose in the IR environment. He emphasizes the importance of using dose limitation methods consistently—practices that must be automatically incorporated into IR practice. Interventional radiology is a specialty that provides effective, minimally invasive patient care for patients with a broad range of disease states. Interventional radiologists are key members of the health care system. We deserve long and fulfilling careers that span decades. We deserve to retire in good health and to look back on our careers without regret. I hope that the information provided this journal helps you achieve that goal. I thank the authors for their generous expert contributions to this effort.

On July 22, 2015, the US Centers for Medicare and Medicaid Services (CMS) convened a Medicare Evidence Development and Coverage Advisory Committee (MEDCAC) panel to focus on lower extremity peripheral artery disease (PAD). Seven not-for-profit organizations—the American College of Radiology, American College of Cardiology, American Heart Association, Society for Cardiovascular Angiography and Intervention, Society of Interventional Radiology (SIR), Society for Vascular Medicine, and Vascular InterVentional Advances—came to together in an unprecedented effort to form a collaborative coalition on behalf of the more than 150,000 health care providers these organizations represent and, more importantly, the millions of patients with PAD their members manage, treat, and serve (1Shishehbor MH, Aronow HD, Bartholomew JR, et al.Vascular specialist response to Medicare Evidence Development Coverage Advisory Committee (MEDCAC) panel on peripheral artery disease of the lower extremities. Vasc Med April 10, 2016. http://vmj.sagepub.com/; published online. http://dx.doi.org/10.1177/1358863X16636955Google Scholar). The goal of this cooperative PAD Coalition was threefold: (i) to provide observations and recommendations to the MEDCAC panel based on best available scientific evidence of therapies for PAD, with an aim to improve health outcomes in the CMS population; (ii) to address areas where gaps in evidence may exist; and (iii) to make recommendations for CMS to consider regarding future determinations about Medicare coverage for medical therapy, exercise training, and surgical or endovascular revascularization in all patients with PAD, whether they have no symptoms, intermittent claudication, or critical limb ischemia (CLI). The PAD Coalition advice to the MEDCAC panel has the potential to ensure proper access to medically necessary care for millions of Americans over 65 years of age with all stages of PAD. The summary of the multispecialty PAD Coalition observations and recommendations to the MEDCAC panel was recently published. It included the following 10 key points (1Shishehbor MH, Aronow HD, Bartholomew JR, et al.Vascular specialist response to Medicare Evidence Development Coverage Advisory Committee (MEDCAC) panel on peripheral artery disease of the lower extremities. Vasc Med April 10, 2016. http://vmj.sagepub.com/; published online. http://dx.doi.org/10.1177/1358863X16636955Google Scholar):1.Patients with PAD may be unrecognized because of a lack of, or atypical, symptoms (2Hiatt W.R. Medical treatment of peripheral arterial disease and claudication.N Engl J Med. 2001; 344: 1608-1621Crossref PubMed Scopus (982) Google Scholar, 3Hirsch A.T. Murphy T.P. Lovell M.B. et al.Peripheral Arterial Disease Coalition. Gaps in public knowledge of peripheral arterial disease: the first national PAD public awareness survey.Circulation. 2007; 116: 2086-2094Crossref PubMed Scopus (185) Google Scholar).2.If unrecognized, PAD is associated with significant morbidity and mortality because of the presence of undiagnosed underlying coronary artery and cerebrovascular disease (4Hirsch A.T. Haskal Z.J. Hertzer N.R. et al.American Association for Vascular Surgery; Society for Vascular Surgery; Society for Cardiovascular Angiography and Interventions, et al. ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (writing committee to develop guidelines for the management of patients with peripheral arterial disease) endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation.J Am Coll Cardiol. 2006; 47: 1239-1312Abstract Full Text Full Text PDF PubMed Scopus (1071) Google Scholar).3.Timely diagnosis of PAD may lead to aggressive risk factor intervention as recommended by the American College of Cardiology/American Heart Association guidelines, and result in a lower incidence of adverse cardiovascular and limb events. In contrast, the absence of appropriate medical therapy in this setting significantly increases the risk for mortality (5Pande R.L. Perlstein T.S. Beckman J.A. Creager M.A. Secondary prevention and mortality in peripheral artery disease: national health and nutrition examination study, 1999 to 2004.Circulation. 2011; 124: 17-23Crossref PubMed Scopus (302) Google Scholar).4.The ankle brachial index should be reclassified as a diagnostic test to permit identification and treatment of asymptomatic patients with PAD.5.There is no benefit for routine supervised exercise training or any form of revascularization in patients with asymptomatic PAD.6.Comprehensive medical intervention, as described by current published guidelines, has immediate, near-term, and long-term benefits in patients with intermittent claudication.7.CMS should provide full coverage of supervised exercise training programs for patients with intermittent claudication.8.There is sufficient evidence for medical therapy, supervised exercise training, or revascularization in appropriately selected patients with intermittent claudication; however, revascularization should be limited to patients with significant lifestyle-limiting claudication who have failed medical and exercise training, as recommended by the current American College of Cardiology/American Heart Association guidelines (4Hirsch A.T. Haskal Z.J. Hertzer N.R. et al.American Association for Vascular Surgery; Society for Vascular Surgery; Society for Cardiovascular Angiography and Interventions, et al. ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (writing committee to develop guidelines for the management of patients with peripheral arterial disease) endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation.J Am Coll Cardiol. 2006; 47: 1239-1312Abstract Full Text Full Text PDF PubMed Scopus (1071) Google Scholar).9.Medical therapy and revascularization have immediate, near-term, and long-term impact on all outcomes for patients with CLI, but the revascularization strategy should be tailored for each patient.10.The concept of a CLI team, which may include endovascular specialists, interventional specialists, surgical specialists, podiatrists, orthotists, and other wound care specialists, may be beneficial to optimize care for this complex patient population. The messages from the PAD Coalition are not new; however, the multispecialty manner in which the messages were communicated is. The MEDCAC panel heard a broad group of practitioners who are dedicated to providing care for patients with PAD, speaking with a single voice on behalf of this underrecognized patient population. The multispecialty PAD Coalition was able to place patients with PAD at the focal point, reconciling subspecialty differences to truly advocate for the best care for patients with PAD. As health care moves more toward outcomes- and value-based payments and preventive and longitudinal care, patients, governmental agencies, and payers want alignment from all providers who care for patients with a specific disease process and for these providers to ultimately speak with a single, clear, collaborative, unambiguous, and patient-centric voice. The SIR and its members have a long history of involvement in collaborative care and treatment of patients with PAD and are proud to support and be an active member of the PAD Coalition. As the epidemic of CLI continues to grow, it is imperative that all specialties caring for patients with PAD see and understand the importance and impact of working together on behalf of the patients who have entrusted their lives and limbs to their care. We believe that the PAD Coalition represents an excellent model for specialists and our societies and organizations to follow in our expanding role as patient advocates.

The memberships of the Society of Interventional Radiology (SIR) Safety and Health Committee and the Cardiovascular and Radiological Society of Europe (CIRSE) Standards of Practice Committee represent experts in a broad spectrum of interventional procedures from both the private and academic sectors of medicine. Generally, these Committee members dedicate the vast majority of their professional time to performing interventional procedures; as such, they represent a valid broad expert constituency of the subject matter under consideration.

Implementation of an interventional radiology (IR) residency program requires significant planning, as well as clear communication and consensus among departmental and institutional stakeholders. The goal of this short article is to highlight key decisions and steps that are needed to launch an IR residency, and to illustrate a possible timeline for implementation of the integrated and independent IR residency models.

The memberships of the Society of Interventional Radiology (SIR) Safety and Health Committee and the Cardiovascular and Interventional Society of Europe (CIRSE) Standards of Practice Committee represent experts in a broad spectrum of interventional procedures from both the private and academic sectors of medicine. Generally, these Committee members dedicate the vast majority of their professional time to performing interventional procedures; as such, they represent a valid broad expert constituency of the subject matter under consideration.