The Evidence for Why? Professor Pete Gaines Working in partnership with

INTERVENTIONAL RADIOLOGY IN THE 21ST CENTURY - THE EVIDENCE Prof. PA Gaines Hallam University & Sheffield Vascular Institute

Plan – 3 questions Is what we do worthwhile? Is our emergency work worthwhile? Are we providing a good service? Data from randomised trials appears in italics

Conclusions Interventional Radiology plays a major part in the treatment of almost all body systems Routine IR work significantly improves both patients quality of life and life expectancy IR saves lives and should always be available to manage the acutely sick Interventional Radiology is indispensable in the 21st Century Provision needs attention

Who’s that?

Is what we do worthwhile?

Peripheral Arterial Disease 20% of population older than 60 yrs have significant arterial disease affecting the legs. Claudication

Peripheral Arterial Disease

Quality of life of patients with claudication

Peripheral Arterial Disease 20% of population older than 60 yrs have significant arterial disease affecting the legs. Claudication –Iliac disease – Angioplasty and stenting is safer than surgery and just as effective –Infra-inguinal disease – Angioplasty combined with exercise better than exercise alone –Significantly improves quality of life –Cost effective

Peripheral Arterial Disease Critical Limb Ischaemia Unless treated the patient will loose the leg –Iliac disease - TASC recommends endovascular intervention as first option –Infra-inguinal disease - Endovascular as good as surgery at preventing long term amputation and death –Significantly improves the patient’s quality of life

Abdominal Aortic Aneurysms: AAA

EndoVascular Aneurysm Repair EVAR

EVAR for AAA 30 day death and complications reduced by half Equivalent long term reduction in aneurysm related deaths Length of stay reduced by half Benefit increases with increasing age

Fibroids

UAE is safer than surgery and is preferred by women. UAE is cheaper and leads to a better quality of life than surgery. Hopeful study, 2007

Nephrostomy

Technical success literature- 88% Technical success UK- 94% The UK nephrostomy audit. Can a voluntary registry produce robust performance data? Chalmers N, Jones K, Drinkwater K, Uberoi R, Tawn J.Clin Radiol Aug;63(8):888-94

Chemoembolisation 2 RCTs Chemoembolisation can significantly improve the life expectancy of patients with hepatocellular carcinoma Lo, C-M et al. Hepatology 2002;35: Llovet, JM et al. Lancet 2002;359:

Message 1 Routine IR work significantly improves both patients quality of life and life expectancy

EMERGENCY INTERVENTIONAL RADIOLOGY

Trauma The integration of whole body CT into polytrauma improves survival Advanced Trauma Life Support 8 th Ed – embolisation is the treatment of choice for patients with traumatic arterial haemorrhage from the pelvis Huber-Wagner; Lancet 2009, 4621 pts

GI bleeding

TIPSS recommended as the treatment of choice for uncontrolled variceal haemorrhage Non-variceal upper GI bleeding not controlled by endoscopy should be treated by embolisation … In patients with massive lower GI bleeding, if colonoscopy fails to define the site of bleeding embolisation is recommended. SIGN guidelines 105; Management of acute upper and lower GI bleeding. A national clinical guideline

Abdominal Aortic Aneurysms: AAA

Ruptured AAA

2008 systematic review and meta-analysis – eEVAR 21% mortality eEVAR introduction leads to a significant reduction in the community death rate from ruptured AAA.

Postpartum Haemorrhage Embolisation recommended as both treatment and prophylaxis for high risk patients. Joint Statement from Royal College of Obstetricians and Gynaecologists, RCR and BSIR. The role of emergency and elective Interventional Radiology in Postpartum Haemorrhage. 2007

Drainage of necrotising pancreatitis Panter study Patients with infected or suspected necrotising pancreatitis did better with percutaneous drainage approach rather than open surgery. And its cheaper NEJM 2010;362:

Message 2 Your routine work significantly improves both patients quality of life and life expectancy Emergency work saves lives

Are we providing a good service?

NCEPOD Recognises an under-provision of IR Recognises that this puts lives at risk

NCEPOD 2000; ‘The increased demand for interventional procedures is as yet unmet by the number of consultant radiologists who are available’ 2005; Few Trusts have a comprehensive on-call IR service. Recommended ‘Trusts should ensure the availability outside normal working hours of radiology services’

Richard on-call survey Could identify only 7 hospitals with 24/7 on- call service. Of these 7 only 5 provided biliary drainage, 5 eEVAR, 4 TIPSS,

NCEPOD 2000; ‘Interventional Vascular Radiology and Interventional Neurovascular Radiology’ 2005; Abdominal Aortic Aneurysm: A service in need of surgery? 2007; Trauma: who cares? 2007; Emergency Admissions: A journey in the right direction? 2009; Acute kidney injury: adding insult to injury. 2009; Deaths in acute Hospitals: Caring to the end.

NCEPOD 2000; ‘The increased demand for interventional procedures is as yet unmet by the number of consultant radiologists who are available’ 2005; Few Trusts have a comprehensive on-call IR service. Recommended ‘Trusts should ensure the availability outside normal working hours of radiology services’ 2007 low use of IR to manage life threatening bleeding ‘….likely to represent the lack of Interventional Radiology Consultants who posses the necessary expertise’. 2009; Poor provision of out-of-hours ultrasound and nephrostomy cited as causes of poor outcomes in the “acute kidney injury”. 2009; Deaths in acute Hospitals: Caring to the end.

Acute sick patients 54% have radiology performed out-of- hours, Out-of-hours Radiology –plain films 90% –CT 70% –MR 28% –Non-cardiac angiography 27% 2009 NCEPOD; Deaths in acute hospitals: caring to the end

Acute sick patients - recommendations Hospitals that admit patients as an emergency must have access to plain radiology and CT scanning 24 hrs. per day with immediate reporting. (This recommendation was previously reported in ‘Emergency Admissions: A Journey in the Right Direction?’ in 2007) Diagnostic and Interventional Radiology services should be adequately resourced to support the 24 hr. needs of their clinicians and patients

Meanwhile… Healthcare Commission Review into Birmingham Children’s Hospital specifically identified a lack of access to IR. No comprehensive service for children in the UK. Lack of IR considered to be a critical factor in the inquest into 10 maternal deaths at Northwick Park Hospital

Conclusions Interventional Radiology plays a major part in the treatment of almost all body systems Routine IR work significantly improves both patients quality of life and life expectancy IR saves lives and should always be available to manage the acutely sick Interventional Radiology is indispensable in the 21st Century Provision needs attention

Who’s that?

THE END

Conclusions You are better than you think you are Patients are being failed by poor provision

Food for thought… UK Nephrostomy audit risk factors for complications; 1. Anaemia 2. Rigors 3. Elevated creatinine 4. Limited numbers

ICSS - adverse events by volume

Open AAA repair – TRUST VOLUME Volumegrouping low0-39 medium40-79 high>79

Open AAA repair – CONSULTANT VOLUME Volumegrouping low0-39 medium40-79 high>79

eEVAR Volumegrouping low0-8 medium9-16 high>16

Numbers are important