By Jerry Zeidenberg

What if you could treat pa-tients with serious medicalproblems faster and moresafely than ever before, but

the public and even your medical peersdidn’t know about it?

It’s a strange and unfortunatedilemma, but it’s exactly the situationfaced by Interventional Radiologists inCanada.

In recent years, Interventional Radiol-ogy has taken giant strides. It has devel-oped scores of procedures that result inquicker and safer treatments for patients.These procedures include:

• embolization (including fibroids andgastrointestinal bleeding)• gastroenteral stenting (including bil-iary stents)• vascular stenting (including abdomi-nal aortic aneurysm stenting)• vertebroplasty• sclerotherapy• image-guided venous line insertion• angioplasty• and many more.

By sending patients home sooner andkeeping them out of hospital beds, Inter-ventional Radiologists get people back towork and into the care of their familiesmuch sooner. Not only does this improvepatient satisfaction, but it also reduces

costs for hospitals and the healthcaresystem in general.

Public and professional awarenessYet, the public isn’t taking full advantage ofthese services – not by a longshot. What’smore, GPs aren’t referring their patients toIRs to the extent they could, and in manycases, governments aren’t funding IR pro-cedures that would free-up beds andshorten wait lists.

As a result, Canada is missing a bigopportunity to improve the quality ofcare and medical outcomes, and to re-duce wait times for surgical procedures.

“There are a lot of patients in Canada

IR can quickly treat patients and reduce Canada’s wait listsConsidered by many to be a revolution in patient care, Interventional Radiology has demonstrated its abilityto treat patients with serious illnesses faster and more safely than ever before.

NOVEMBER/DECEMBER 2007

REPORT ON INTERVENTIONAL RADIOLOGY

INSIDE

LAGGING THE G7

DR. LINDSAY MACHAN

RFA FOR LIVER CANCER

IR in WINDSOR, ONT.

ULTRASOUND ABLATION

SPINE THERAPIES

IR experts at the Centre Hospitalier de l’Université de Montréal (CHUM): Left to right, François Hamel, IR technologist; Ian Gaulin, IR technologist; Michel Gouin, IR technologist: Dr. Marie-France Giroux, In-terventional Radiologist; Dr. Vincent Oliva, Interventional Radiologist; Dr. Gilles Soulez, Interventional Radiologist; Catherine Bouchard, IR technologist; Dr. Alexandre Dugas, radiology resident.

Continued on following page

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REPORT ON INTERVENTIONAL RADIOLOGY

who could use Interventional Radiology,but they’re not aware of what we can dofor them, and neither are their GPs,” as-serted Dr. Marie-France Giroux, presidentof the Canadian Interventional RadiologyAssociation, and a vascular IR specialistat the Centre Hospitalier de l’Universitéde Montréal (CHUM).

A case in point is the ablation of uter-ine fibroids. Rather than going under theknife in an operating room, followed byseveral days of recovery in hospital andweeks at home, Interventional Radiolo-gists are threading catheters through thefemoral arteries to reach fibroids and em-bolize them – blocking their blood sup-ply and killing them off.

Instead of open surgery, it’s a mini-mally invasive technique, with reducedpain, blood loss and risk of infection.What’s more, the patient gets through theprocedure much more quickly. “With em-bolization, I can have the patient back athome the next day and back to workwithin a week,” said Dr. Giroux.

However, most women don’t knowthis option is available to them. Oddlyenough, neither do GPs. “Most GPs andgynecologists don’t know us, they’re notaware of what we do and we rarely hearfrom them,” commented Dr. Giroux.

Often enough, smart and Internet-savvy women have been discovering the

procedure for themselves on the Web.Many have been phoning their local hos-pitals to ask about its availability.

“We’ve got to do a better job of makingGPs and other physicians aware of whatwe do, not only for fibroids but for agreat number of other diseases,” she said.With that in mind, CIRA and the Cana-dian Association of Radiologists haveembarked on a campaign to inform theirpeers about Interventional Radiology.

New bloodAs a relatively new and fast-developingmedical specialty, Interventional Radiol-ogy does face an awareness hurdle. Butbuilding a profile with patients and peersisn’t the only roadblock.

Attracting a new crop of physiciansinto the field is also a challenge. As de-mand for IR escalates – and Dr. Girouxhas no doubt that demand will grow.Given the choice, patients will want toavoid open surgery for faster, less invasiveoperations. As a result, additional highlytrained professionals will be needed.

At the moment, many medical stu-dents aren’t even aware of IR as a careeroption – or it’s so low-profile, they don’tgive it serious consideration.

“The students all hear about specialtieslike cardiology, but they just don’t hearabout Interventional Radiology,” she said.

Part of the solution will be found ineducating medical students about IR asan exciting and fulfilling career option.

To that end, CIRA recently encouragedan information meeting for U of T med-ical students. The aim was to educatethem about Interventional Radiology.

What’s more, CIRA has organized avoluntary program for residents inToronto to spend a day with an Inter-ventional Radiologist, to see what thework is like.

IR in Canada lags other nationsAs Millennium Consulting Group re-cently discovered, in its study entitledNon-Invasive Image-Guided Diagnosisand Therapy for Canadians 2006, thereare some 1,800 radiologists in Canada, ofwhom 150 conduct IR procedures. Butonly 50 of them do Interventional Radiol-ogy on a regular basis.

On a comparative basis, we’re laggingfar behind other countries, which havemany more radiologists specializing ininterventional procedures.

Significantly more will be needed inCanada if this country is to provide thequality of care provided by other indus-trialized nations.

While publicity and education willcertainly be needed to bring more radiol-ogists into the fold, there’s another factorrequired, as well. That’s recognition ofInterventional Radiology as a sub-spe-ciality by an official organization. Doingso will give it the cachet required to at-tract new practitioners. “Some studentswon’t take it seriously until there’s adiploma to go with it,” said Dr. Giroux.This accreditation would also pave theway for a more uniform training programacross the country.

Strangely enough, the main accredita-tion body in this country, the Royal Col-lege of Physicians and Surgeons ofCanada, earlier this year rejected an ap-plication by CIRA for recognition as asub-specialty – even though IR is alreadyrecognized as such in the United Statesand the United Kingdom.

The move has puzzled those in the IRcommunity, to say the least. “Our col-leagues in the U.S. and the U.K. think it’sinsane that we’re not recognized,” saidDr. Giroux.

The Royal College cited several reasonsfor denying the application, but two fac-tors were chief among them. First, it heldthat Interventional Radiology isn’t clinicalenough – in the sense that InterventionalRadiologists simply perform pro-cedures and don’t follow upon the progress of patients.

Second, it asserted that the path to be-coming an Interventional Radiologistwould be restricted to Diagnostic Radiologists.

However, Dr. Giroux contested bothof these assertions. In her own practice,she actively follows up with her pa-tients, and asserts that her colleaguesdo, too. She stresses that InterventionalRadiology has evolved over the years.“Ten years ago, an IR would simply puta line in, to support a specialist. Now,

it’s not like that. It’s more clinical – wesee our patients, we follow up withthem afterwards”.

“We’re working together with nephrol-ogists, cardiologists, vascular surgeons,and many others,” she said, creatingteams of specialists who are all checkingon the health of the patients.

In that sense, IR is becoming muchlike other branches of specialized medi-cine. “All specialties are becoming moreclinical,” she observed. “We’re all tak-ing care of our patients, we’re not leav-ing the complications for others to dealwith. This is at least the direction more

advanced practices are heading in. Weare trying to change the old non-clini-cal pattern with an IR sub-specialtyprogram, but the Royal College has re-jected this new way of training our fu-ture colleagues.”

On the topic of pathways into Inter-ventional Radiology, Dr. Mark Baerlocher,a radiology resident at the University ofToronto and already a prolific author ofarticles in medical journals, stressed thefield will be open to all physicians whoare interested – but they will need to takethe required training and pass the exams.

Dr. Giroux asserts that CIRA fully ad-dressed the concerns of the Royal Col-

lege, along with answering other ques-tions. As such, she feels the applicationrejection may have been sparked by afear of ‘turf wars’ – a belief that otherspecialties and sub-specialties fear theywon’t be able to perform procedures tra-ditionally owned by IR.

Here again, the fears appear to be un-founded. Leading groups have submittedsupport for the Interventional Radiolo-gists’ application – including cardiolo-gists, neurosurgeons, vascular surgeons,nephrologists, urologists, gynecologists,obstetricians, critical care physicians,and others.

That’s because, as Dr. Giroux explains,Interventional Radiologists are workingtogether with these specialists as part ofteams, often helping them solve prob-lems in a new way. What’s more, as sheputs it, even when IRs do perform proce-dures on patients who would otherwisego to a neurosurgeon or nephrologist, inCanada there are more than enough pa-tients waiting for treatment to keep alldoctors busy!

Moreover, the proposed IR sub-spe-cialty program had even planned somespecific sub-programs for other special-ists to become accredited in specificprocedures – for example, for vascularsurgeons to become accredited in angioplasty.

Dr. Giroux said CIRA will apply againto the Royal College for recognition

as a sub-speciality – unfortu-nately, the rules require a wait-ing period of three years. But ifthe application is again rejected,she said there are other coursesof action.“We may apply for recognitionfrom the U.S. or the U.K., or wemight establish our own cre-dentials, with training and test-ing of students,” she noted.“We don’t absolutely need theRoyal College.”

IR can reduce Canada’s wait lists

“We’ve got to do a better

job of making GPs and

other physicians aware

of what we do,” says Dr.

Marie-France Giroux.

Dr. Marie-France Giroux, Presi-dent of the Canadian Interven-tional Radiology Association, anda vascular IR specialist at theCentre Hospitalier de l’Universitéde Montréal (CHUM).

Continued from previous page

25,000

20,000

15,000

10,000

5,000

0Canada France Germany Italy Japan UK US Average

Source: Millennium Research Group

IR treatments, per million population, by G7 country, 2005

REPORT ON INTERVENTIONAL RADIOLOGY

Check with members of the pub-lic, and they’ll tell you thatCanada has about the besthealthcare system in the world.

Just tweak the waiting list problem a bit,they say, and all will be well.

In truth, Canada is missing the boaton the latest revolution in medical care –Interventional Radiology. While we dohave Interventional Radiologists in thiscountry, we’ve got fewer on a per capitabasis than any other industrialized na-tion. What’s more, we’re attracting newrecruits to the field more slowly than anyof these other countries.

As a result, we’re also performingfewer IR procedures than other membersof the G7. That’s a shame, because of thebenefits that are lost to patients.

Interventional Radiology can dramati-cally reduce hospital stays for patients,minimize infection, cut the rate of mor-bidity and mortality, and thereby im-prove overall outcomes and cut costs for

the healthcare system in general.Despite such advantages, the growth

of this newly emerging specialty isn’t be-ing supported by governments or med-ical associations to the extent that itshould.

“There’s a paradigm shift going on,with everyone moving in this direction –except in Canada,” commented Dr. MarkBaerlocher, a radiology resident at theUniversity of Toronto’s Faculty of Medi-cine, who is specializing in Interven-tional Radiology and has published sev-eral papers about the hurdles faced by IRin Canada. “There’s a lack of funding, re-sources and support.”

Sometimes called “bloodless surgery”,Interventional Radiology substitutescatheters for scalpels and repairs seriousproblems in the body via tiny incisions.Highly trained Interventional Radiolo-gists can cut out or cauterize tumours,fix aneurysms, and repair fibroids with-out open surgery.

According to a 2006 study of Interven-tional Radiology in Canada by Toronto-based Millennium Research Group, thecost of IR devices, suites, staffing, andlab time is significant, but investments ininterventional radiology would be re-turned several times over in healthcarecost savings.

In addition to the financial return oninvestment, many patients’ lives wouldbe saved and improved, hospital bedswill be used more efficiently, thereby in-creasing patient turnover and decreasingwait times.

The report, titled Non-invasive Image-guided Diagnosis and Therapy for Cana-dians, 2006, recommends that the Cana-dian government should develop a strat-egy to support IR in Canada and bringthe level of treatment, at a minimum, up

to par with other G7 nations. Accordingto the MRG report, if IR treatments areadopted in this way, a total of $180 mil-lion in direct savings to the Canadianhealthcare system and $92 million in in-direct societal savings could be realized.

Increased adoption of IR in Canadacould eliminate 98,000 days that patients

are currently spending in the hospital.That’s a total of 268.5 patient years spentin hospitals that could be eliminated im-mediately.

Because the average length of stay inCanadian hospitals is approximately 7.2days, this translates to 13,400 more pa-tients who could be treated annually –something that would have a big impacton wait lists.

In order to realize these benefits,however, it’s estimated that $221 mil-lion of additional funding must be allo-cated directly to IR in Canada annually.In 2005, Canada spent $162.5 millionon IR treatments.

While the increased funding isneeded, there are several other chal-lenges that must also be addressed:• Patient referral patterns are limited. Inmany cases, GPs and specialists don’tknow about the availability of Interven-tional Radiological procedures.• Physician fee schedules are not sup-portive of IR. There are many proce-dures that are not funded, or the fundingdoesn’t encourage radiologists to dedi-cate the time and effort to become profi-cient in them.• Human resources constraints. Thereare simply not enough trained Interven-tional Radiologists in Canada.

The cost of IR devices, suitesand staffing is significant, butinvestments in IR would bereturned several times over inhealthcare savings.

Canada lags behind in the application of IR

7TH ANNUAL SCIENTIFIC MEETING OF CIRA

MAY 28TH (FELLOWS DAY)MAY 29TH TO MAY 31ST

AT THE SOFITEL MONTRÉAL

www.car.ca/cira

Preliminary Program coming soon!For info : cira@car.ca

A recent study estimates

that increased use of IR

could reduce hospital

stays in Canada by

98,000 days per year.

REPORT ON INTERVENTIONAL RADIOLOGY

Our writer, Paul Brent, recentlyinterviewed Dr. LindsayMachan about the state of In-terventional Radiology in

Canada. In addition to being an Associ-ate Professor at the University of BritishColumbia’s Faculty of Medicine, and anInterventional Radiologist at the Vancou-ver Hospital and Health Sciences Centre,Dr. Machan is a co-founder of AngiotechPharmaceuticals Inc., of Vancouver. Thecompany produced one of the first drug-eluting stents, and in the process, revo-lutionized the treatment of coronaryartery disease.

Q: Dr. Machan, you are described as aninnovator and entrepreneur. Can you tellus a little about your background?

Machan: I was a co-founder of AngiotechPharmaceuticals, a Vancouver-based pub-lic company. We first developed a drug-eluting stent, the Paclitaxel-coated stent,and we licensed it to Boston Scientificand Cook (Medical). It has been used inover three million people now. Angiotechnow has 1,800 employees, so you needreal professionals running it. My skill setdoesn’t work best in a big business struc-ture. I still have an office there and I stillconsult to them.

Q: Is the Canadian Interventional Radiol-ogy Association correct – is Canadafalling behind other developed nations inthe use of Interventional Radiology?

Machan: Yes. There is no question thatwe are behind. We are really the only de-veloped country that has public medi-cine only. Unfortunately, Canadianhealthcare is run like a Soviet farmingcollective of the 1950s. InterventionalRadiology, by its rapidly changing natureand the fact that we do so many differentprocedures, doesn’t lend itself well tothat kind of a model.

Our healthcare system is extremelybureaucrat-heavy, and these people liketo have things documented. By its verynature, Interventional Radiology is some-thing where you are doing a lot of differ-ent procedures, and a procedure thatwould sound the same to an administra-tor might be a 10-minute procedure inone patient using $50 worth of dispos-ables, and it might be a four-hour proce-dure in another patient requiring consid-erably more resources.

Interventional Radiology is the ab-solute sine qua non of what our adminis-trators and politicians say they want,which is care closer to home, keeping pa-tients out of hospital, shortening hospitalstays. Interventional Radiology does allthat incredibly well. But the missingpiece is that the bureaucrat who admin-

isters your disposables budget, what itcosts to use all those catheters, etc.,doesn’t realize the gain by having the pa-tient go home more quickly. That comesout of someone else’s budget, or in fact,the benefit may only be in how the pa-tient feels. So there is absolutely no mo-tivation for that person who doesn’t typi-cally get rewarded for innovation, butgets seriously punished for not stayingwithin the budget they administrate.That is a real stopper in the system.

The way we fund our radiology de-

partments also doesn’t lend itself verywell to the practice of Interventional Ra-diology. The usual approach is to give alump sum to the radiology departmentand say, ‘Deliver all these services forthis amount of money and do not goover this.’

Of course there is an ever-increasingdemand for interventional procedures,for all the obvious reasons: proceduresapplicable to a broader range of illness,our aging population, and better edu-cated patients who want minimally inva-sive therapies. And yet, you have thesefixed numbers to deliver these services.Not only is the money not there, it is in-credibly hard for any radiologist to makethese things happen. You have to be will-ing to deal with conflict to make thishappen, and the radiologist already has afull day.

Q: Is the standing of IR part of theproblem?

Machan: There are very few pureInterventional Radiologists inCanada. Most people whopractice Interventional Radiol-ogy also do general radiology.This is an issue because theywant to provide these servicesbut it is not necessarily howthey earn the bulk of their in-come. If they were pure Inter-ventional Radiologists and

they had to survive only by doing inter-ventional procedures to earn their keep,they might be more aggressive about pur-suing these procedures.

Another part of it is that Interven-tional Radiology is very open-ended.Those procedures really can take either15 minutes or four hours, and then thereis all the patient care that comes with it;talking to people on the phone, seeingpatients up on the ward. That doesn’tmix well with a diagnostic radiologypractice, where the length of time to readan exam is less variable and the hours ofwork are relatively constant (and oftenmore humane). As well, after capitalequipment, interventional disposablesare the largest drain on the budget. Andon an hourly basis, physician remunera-tion been relatively poor compared withdiagnostic radiology. So you have a situa-tion where a physician has to expendconsiderable energy to fight for a budgetfor procedures that pay less than the di-agnostic component and result in longerand less predictable hours.

Q: You used to be on the faculty of ayearly IR conference in Prague shortly af-ter the fall of the Berlin wall. I under-stand you don’t do that anymore, be-

cause the former East Bloc countries arenow doing more advanced proceduresthan we are in Canada.

Machan: Yes, they passed us with breath-taking quickness, certainly within fiveyears. I found myself talking about proce-dures that were being offered in only afew centres in Canada, but which weremore broadly offered in Romania.

Q: Can we catch up?

Machan: Of course. It would requiresome pretty significant changes in theway we fund Interventional Radiology.CIRA (Canadian Interventional RadiologyAssociation) and CAR (Canadian Associ-ation of Radiologists) have to continuetheir efforts to educate both the publicand particularly the health ministers andthe people who work for them, about thepower of Interventional Radiology.

Q: If there was one thing you could havechanged right away, what would it be?

Machan: Interventional Radiology has tobe a higher priority for most radiologydepartments across the board, and forthe various bureaucracies that governour healthcare system across the country.They need to really understand thepower of Interventional Radiology, that itis good medicine.

Q: Is there innovation going on in thefield in Canada?

Machan: There is, but it is getting pro-gressively more difficult to do it. Particu-larly, the group in Montreal, GillesSoulez and Vincent Oliva, are doingsome very innovative basic science work.They are developing some interestingnew ways to combine biomaterials withbiologically active substances.

The kinds of innovations that they areworking on in Montreal, if they do cometo fruition could make a profound differ-ence in patient care. You take the pacli-taxel-eluting stent. It was the most suc-cessful first year of a medical deviceever, actually the most successful firstyear of any medical product, even out-selling the first year of Viagra. So new

medical devices can really change theway patients are handled.

Q: What sort of developments do yousee in IR in the next five to 10 years?

Machan: We are starting to see thelocal administration of drugs anddifferent types of energy such as us-ing combinations of ultrasound fortargeted release of drugs to enhance

their effectiveness or using local drugdelivery and various types of energy fortumor ablation. For this type of treat-ment, you need to have improved imag-ing guidance. Fluoroscopy, just plain X-ray, that is not enough anymore. Fusionimaging, which is the superimpositionof cross-sectional imaging plus fluoro orendoscopic techniques, or the combina-tion of ultrasound plus CT or MR, thosewill allow improved real-time for mini-mally invasive treatments. That’s someof what we are going to be seeing.

IR needs to be made a higherpriority in the healthcare systemInnovator and Interventional Radiologist Dr. Lindsay Machan urges Canadian government officials andhospital administrators to adopt new practices that support and encourage more IR procedures.

Former East Bloc

countries are now doing

more advanced IR

procedures than we are

in Canada.

Dr. Lindsay Machan, Associate Professor atthe University of British Columbia’s Facultyof Medicine, and an Interventional Radiolo-gist at the Vancouver Hospital and HealthSciences Centre.

REPORT ON INTERVENTIONAL RADIOLOGY

By Jerry Zeidenberg

Sometimes, Interventional Radiol-ogy isn’t just an alternative toconventional surgery. On occa-sion, it’s the only viable option.

When cancer patients are too old or weakto sustain a traditional operation, or thenature of the tumours prohibits an opensurgical procedure, a minimally invasiveIR procedure may still be possible.

Liver cancer is a case in point. Therelatively new technique of radio fre-quency ablation (RFA) has scored docu-mented successes in the treatment of pri-mary liver tumours, or hepatocellularcarcinoma (HCC).

“Only about 15 percent of patientsfirst presenting with HCC or liver metas-tases from colorectal carcinoma are can-didates for surgical resection,” com-mented Dr. John Kachura, an Interven-tional Radiologist at the UniversityHealth Network, in Toronto, where heand a group of colleagues have been per-forming RFA of liver tumours since 1999.

“RFA now gives many more patients apossible curative treatment,” says Dr.Kachura. “I would estimate that 50 per-cent of patients presenting with HCCcould be considered for RFA. Certainlymost patients with one-to-three HCC tu-mours, each 4cm in size or smaller,could be considered for RFA.”

What’s more, Dr. Kachura and his col-leagues have collected statistics and per-formed studies showing the value of RFAfor liver cancer. “Another exciting aspectfor our group of Interventional Radiolo-gists at the UHN and Mount Sinai Hospi-tal is that our results of treating patientswith RFA are on par with some of thestrongest studies in medical literature.Our five-year patient survival of 50 per-cent is the same as that seen with surgi-cal resection, yet RFA offers a less inva-sive and safer method.”

The results are so impressive that anOntario government review of the tech-nique, in 2004, concluded that RFA ofunresectable liver cancer should be sup-ported at several hospitals in theprovince.

At the same time, the report noted

that practitioners who treat and coordi-nate liver cancer patients, or the patientsthemselves, may not yet be aware of RFAor other ablative treatments for unre-sectable HCC! That’s still likely to be the

case today, moreover, as awareness of theefficacy of a variety of Interventional Ra-diology treatments is still quite low.

Radio-frequency ablation is performedby inserting a needle electrode, at the tip

of a catheter, into a tumour and applyingelectrical current. The heat leads to ther-mal coagulation that kills the tumourand also closes up small blood vessels,thereby minimizing the risk of bleeding.

Study shows that IR patientsurvival rates equal thoseundergoing surgical resections,but RFA offers a less invasiveand safer technique.

RFA proves its worth against liver cancer

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Dr. John Kachura is an Interventional Radiologistat the University Health Network in Toronto.

REPORT ON INTERVENTIONAL RADIOLOGY

By Paul Brent

While many Canadians, med-ical professionals in-cluded, feel the pull ofwestern migration, Dr. Jack

Speirs chose to go the opposite way. ABritish Columbia native who receivedhis medical training at UBC, he movedeast to do his radiology training at De-troit’s Henry Ford Hospital and followedthat with his interventional fellowshipthere as well.

All the time he was working in De-troit, Dr. Speirs was living on the otherside of the border, in Canada’s version ofMotor City. “I ended up liking Windsorso much I stayed,” he said.

For the past decade, the InterventionalRadiologist has worked at Windsor’s Hô-tel-Dieu Grace Hospital (HDGH), the re-gion’s premier tertiary acute care hospi-tal. During that span he has witnessedthe rapid evolution of IR from a primar-ily diagnostic discipline to therapeuticone at the 312-bed facility.

“When I joined Hôtel-Dieu, the inter-ventional realm was primarily diagnos-tic, with a small amount of angioplasty,”said Dr. Speirs. “Over the past six orseven years, we have experienced verysignificant growth in terms of what wedo and the number of cases that we doas well.”

Part of that increase has been fueledby simple demographics. The overallpopulation is aging and people are com-ing to the facility with more conditionsthat are suitable for IR procedures. Aswell, the greater Windsor area has one ofthe highest rates of atherosclerosis in thecountry. That in turn has promptedHDGH to develop expertise in angio-plasty and stent-graph techniques.

Dr. Speirs and three other Interven-tional Radiologists handle about 2,200cases every year, utilizing 35 differentprocedures to support the centre’s widerange of specialties. Hôtel-Dieu’s IR teamis kept busy supporting the hospital’sdialysis and oncology departments, aswell as conducting vascular and neuro-surgical procedures.

“Hôtel-Dieu is pretty unique in that weoffer pretty much the entire breadth ofservices,” said Dr. Speirs. “You have to bea master of a lot of different techniques.”

As the nexus of medical care for theWindsor area, Hôtel-Dieu’s staff of 1,859has a heavy load of work. The hospitalcares for nearly 139,000 patients everyyear, performing 23,275 day surgeries an-nually, 1,700 cardiac catheterizations and30,537 dialysis procedures.

“We are pretty much the only centrein the [local health integrated network]that does a substantial volume of inter-vention,” said Speirs. “What thatmeans is we have to take care of the

dialysis patients, we do a lot of workfor oncology, like vascular work for on-cology, embolizations for oncology, wedo lots of radio-frequency ablation foroncology.

“We also have the vascular surgeryand neurosurgery units at the hospital,so we do a large amount of work to sup-port those, as well. And we do a fairamount of palliative stenting, likeesophageal stenting, for our oncologyand palliative care group.”

As Hôtel-Dieu has grown into the re-gional hub for medical care in Windsor,the centre’s Interventional Radiologypractice has grown along with it. Theevolution of IR from a diagnostic spe-cialty to a viable treatment option hasincreased the number of patients thatthe hospital can serve each year and hasgenerally improved the quality of lifefor patients.

Many medical procedures that used totie up surgical theatres and ICU beds forrecovery have now been replaced withnon-invasive techniques that have pa-tients out the same day or with dramati-cally shorter recovery stays.

“Having shifted procedures from theOR to the interventional suite has been ahuge benefit, not only for the quality oflife for the patient but providing addi-

tional capacity for the hospital itself,”said Claudia denBoer Grima, Hôtel-Dieu’s integrated vice-president of clini-cal support services.

Thanks to the Internet, patients (or inthe case of the elderly, their children)can come armed with an impressive lay-man’s knowledge of medical conditionsand newer treatment options. “We have amore savvy consumer, so they come witha set of expectations,” she said. “As the

demand increases, from the consumerand with our increased ability to dothese procedures successfully in a mini-mally invasive way, we actually have lessfunding to do it with.”

Treating a blockage in a patient’scarotid artery, for example, used to re-quire conventional surgery and a three-to-five-day stay in the intensive care

unit. Today, that same condition can bedealt with by angioplasty and stenting,and patients are typically released thenext morning.

Unfortunately, the way that govern-ments fund centres and procedures hasfailed to keep up with the rapid advance-ments in the Interventional Radiologyfield. While IR techniques are allowingmore work to be done, and are savinghospital resources by getting patients

home faster, they currently don’t appearas budgetary saviors.

“When we do the angioplasty stenting,that is not really counted in the statis-tics,” observed Dr. Speirs. “If we couldcount it as carotid surgery, we actuallyget a benefit because patients go home inone day instead of three days. But thereis no way to account for that, so it lookslike we are either doing fewer surgeriesor there is no change in the length of

stay. In fact, we are doing more cases andpeople are staying a shorter time.”

The benefits are obvious: local, ratherthan general anesthetic is used, so therisks associated with putting patientsunder are decreased; no big incisionsare made, so risks of infection are re-duced and recovery time is far shorter;and patients are spending less time inhospital, thereby freeing up resourcesfor other patients.

“From the hospital’s point of view,there are some significant costs associ-ated with the devices or gizmos. Howthat actually shakes out is often a bit ofan issue at the hospital level,” said Dr.Speirs. “From a patient’s perspective, it ispretty clear what is preferred, but whenit actually comes down to the dollars andcents, that is a bit more difficult for thesystem to sort out.”

Part of the problem is the diverserange of IR procedures that a centre cantypically provide. In HDGH’s case, the30-odd procedures it carries out cost be-tween $100 and $10,000, Speirs noted.“It’s tough to put a real price tag on it.For example, kyphoplasty costs $4,000,but you keep your patient out of hospi-tal, they are at home, they are indepen-dent. Treating an aneurysm is a very ex-pensive procedure, but the outcomes arestellar. Those are patients, often in theirFifties, who if they do end with a strokeor morbidity from conventional surgicalprocedures, it’s a big deal, and it costs alot of money.”

HDGH is now wrestling with how tofund the new Interventional Radiologytechnique to treat abdominal aorticaneurysms, dubbed EVAR (EndoVascularAneurysm Repair). “It is certainly asound approach and a procedure that we

really should be providing here, butthey certainly are a pricey proce-dure, probably about $12,000[apiece], so we have to determinehow we implement that and not addto our funding crunch,” said den-Boer Grima.HDGH considers itself a fast-fol-lower when it comes to new Inter-ventional Radiology techniques,rather than a pioneer, and prefers toride “the backside of the wave ofnew technologies,” rather than itscrest, as Dr. Speirs describes it. “Wetry not to adopt all of those (emerg-ing) technologies, we choose theones that seem like they are going tobe durable,” he said. While the IR staff at Hôtel-Dieu fol-lows research and innovation at thebigger Canadian universities, theyhave found that many of the ad-vancements originate from Europe.Dr. Speirs and his colleagues followthe European literature closely, notjust because of the innovation

there, but because professionals thereare forthcoming about what works andwhat doesn’t.

“One of problems, if you are in a fieldthat is very technology intensive, is thatthere are going to be some miscues, sothe latest and greatest isn’t always thebest,” he said. “We can’t embrace all ofthose technologies, but we need to takethe lead from centres that are on the cut-ting edge.”

Rads at regional hospital offerexpertise in many IR techniquesA team of four Interventional Radiologists, along with technologists and support staff, are handling about2,200 IR cases a year using 35 different procedures, at Windsor’s Hôtel-Dieu Grace Hospital.

The evolution of IR from

a diagnostic specialty to

a treatment option has

improved the quality of

life for many patients.

Dr. Jack Speirs (left), Interventional Radiologist, and Claudia denBoer Grima, Integrated Vice-President.

REPORT ON INTERVENTIONAL RADIOLOGY

By Jerry Zeidenberg

Imagine, cancer surgery that’s con-ducted without making any inci-sions. Imagine, furthermore, that adoctor isn’t needed to physically

conduct the operation. Instead, the pro-cedure is performed with accuracy by acomputer system.

It’s happening right now, and radiolo-gists and researchers at the UniversityHealth Network, in Toronto, are worldleaders in testing and developing thetechnology.

“In radiology, there’s been nothing likethis,” said Dr. David Gianfelice, directorof image-guided therapy at the UHN.“This may offer an alternative to somesurgical procedures as it is reproducible,has few side effects and significantly de-creases human error.”

Dr. Gianfelice leads what’s known asthe GTx program in Toronto, which ismarrying medical imaging techniques to

surgery and other procedures to produceinnovative new therapeutic solutions.GTx is seeding teams of physicians andresearchers with funds and resources,putting together experts with differentskills to encourage the creative fermentthat often results in new techniques forsolving problems.

Dr. Gianfelice’s own team is using atechnique called MR-guided focused ul-trasound (MRgFUS), which employs MRto map the size and location of a tumour,coupled with high energy ultrasoundwaves to destroy the tumor.

Completely computer controlled,without a surgeon or radiologist interven-ing directly on the patient, the systemfocuses high-frequency ultrasound waveson the tumour, heating the cells to 60°Cor more and thereby killing them, whileleaving surrounding tissue untouched.

Next, the MR, which envelops the pa-tient like a huge vanilla donut, checks tosee if the unwanted cells have beenkilled – a real-time quality control check.MR systems are highly sensitive to heat,and can readily tell if a particular spot inthe body has hit a certain temperature.

If the targeted cells haven’t been‘cooked’, they’re zapped again, so thatwhen the procedure is finished, the tu-mour has been decimated.

Once on the table, the patient slidesright into the MR tunnel. The ultrasoundand MR are working in lockstep, andonce the procedure is set up, there is nohuman intervention required. (A radiolo-gist is needed to supervise, and technolo-gists also help prepare the patient andthe equipment.) Dr. Gianfelice explainsthat the computer-guided ultrasound ab-lation system can be more accurate thana the human eye and hand. That’s be-cause a surgeon relies on his sense of

sight, and the limits imposed by the sizeof his hands and instruments, whileworking in a small area of the body. Bycontrast, the focused ultrasound beam isaccurate to less than a millimeter. Andassisted by the MR imaging, it can accu-rately determine whether any cancerous

tissue has been left behind.What’s more, unlike the surgeon’s

hands, the ultrasound beam nevershakes.

It’s not the solution for every surgicalprocedure, but for some cancer masses,it has already demonstrated promisingresults.

In the last six months, since the pro-ject began, Dr. Gianfelice and his teamhave concentrated on patients withmetastatic bone cancers, in a bid to re-duce pain, and on women with uterinefibroids — benign tumours in the uterusthat can bleed and cause pain.

The results so far? “Very good, andvery promising,” said Dr. Gianfelice.

The treatment has reduced pain in allof the bone cancer patients treated so far,and participants who had the proceduredone three months ago have stopped tak-ing pain medication.

Women with uterine fibroids havealso obtained good results. At the timeof writing, five women had been treatedfor uterine fibroids using MRgFUS atthe UHN.

Dr. Gianfelice explained that each ofthe women had a four-hour procedure,and then were able to go home. “Theycould carry on with their lives the nextday, and even go to work,” he said.

A leading-edge therapy,pioneered by InterventionalRadiologists in Toronto,automates much of the ablative procedure.

Physicians destroy tumours using ultrasound

Save the Date

2008 SIROptions and Opportunities in IR33RD ANNUAL SCIENTIFIC MEETINGWASHINGTON, D.C. • MARCH 15-20

Join us in Washington, D.C., for the most comprehensive meeting devoted to interventional radiology that will address patient care, new treatments and breaking research through a diverse program of symposia, plenary sessions, categorical courses, abstract presentations, hands-on work-shops, lunch seminars and more.

International Forum and Reception

Sunday, March 16

Join an international collection of thought leaders at 2008 SIR. All international attendees of theSIR Annual Scientific Meeting are once again invited to attend the International Forum andReception to discuss global issues facing the IR community.

Register and make hotel reservations at www.SIRweb.org

February 8, 2008: Early Bird registration and hotel deadline

Make learning a priority for your staff at 2008 SIR in Washington. Register your partners, physicianassistants, nursing staff, radiology practitioner assistants and technologists, business managers andscientific researchers for 2008 SIR - a great educational and networking opportunity for the entiretreatment team.

For questions, please contact SIR at (703) 691-1805 or AnnualMeeting@SIRweb.org

2008 ANNUAL SCIENTIFIC

MEETING COMMITTEE

Matthew S. Johnson, MD, FSIRChair, 2008 Scientific Program

Kieran J. Murphy, MD, FSIRChair, 2008 Workshops

Debra E. Beach, APRNClinical Associate Committee Liaison

Ziv J Haskal, MD, FSIRChair, 2007 Program

Jeanne M. LaBerge, MD, FSIRChair, 2008 Program

Dr. David Gianfelice heads the GTx program.

By Paul Brent

Patients suffering from collapsedor fractured bones of the spinelikely don’t know it, or care, butthere is a lively debate in the

medical community about the best treat-ment for the crippling condition.

Since its development in the mid-1980s in France, vertebroplasty has sincebecome the standard minimally invasivespinal surgery procedure. Its popularityis easy to understand. It’s simple, fast, ef-fective and cheap.

Vertebroplasty, which literally meansfixing the vertical body, is a relativelysimple procedure designed to alleviatethe pain of spinal fractures by injectingorthopedic cement into spinal breaks. Inmost cases, the procedure can be con-ducted under local anesthetic and intra-venous sedation, and patients can be mo-bile within hours.

The “next generation” procedure,kyphoplasty, promises similar pain reliefand superior results in terms of restored

height for conditions that can be treatedby vertebroplasty. A high-tech riff on theearlier procedure, kyphoplasty uses aspecial balloon, or balloon tamp, in aneffort to better position the cement. Theresult, say its proponents, is similar painrelief, less risk of complications due topossible leakage of the cement, as well asbetter height restoration.

“Kyphoplasty is standing on the shoul-ders of vertebroplasty,” said Dr. RameshSahjpaul, a neurosurgeon with the Uni-versity of British Columbia who doesabout 50 of the procedures annually. “Itis an evolution, it is a technological ad-vance and it has allowed us to do more.Who knows what we can do two yearsfrom now with new types of balloons, orsomething else.”

Sahjpaul contends that kyphoplasty ismost effective in the worst cases and hasall but abandoned vertebroplasty. Thenewer procedure is more useful “for pa-tients who have significant collapse ofthe vertebral body or significant angula-tion, and it’s also useful in the field oftumor treatment,” he said.

The major drawback to kyphoplasty,both proponents and critics agree, is itscost. The procedure typically costs be-tween eight to 10 times what a vertebro-

plasty procedure will cost. In Canada,the cost for a kyphoplasty kit runs be-tween $3,500 and $4,000, practitionerssaid, versus $500 to $600 for a vertebro-plasty operation.

With an aging population and the de-mographic bulge of the Baby Boomernow starting to hit retirement age, thedemand for these non-invasive proce-dures to alleviate spinal fractures willonly grow. The main driver is the bonedisease osteoporosis, which strikes olderpeople in the form of fractures of the hip,wrist and spine.

Approximately 1.4 million Canadianssuffer from osteoporosis, according toOsteoporosis Canada. One in fourwomen over the age of 50 and one ineight men over 50 suffer from the condi-tion. The cost of treating osteoporosisand associated fractures is estimated tobe $1.9 billion each year in Canada, withthe majority of the costs coming fromlong term, hospital and chronic care.

Physically not very far away fromSahjpaul, but philosophically far apart inhis opinion of the relative merits of thetwo main spinal fracture procedures, isDr. Peter Munk, head of musculoskeletalimaging at the Vancouver General Hospi-tal and a professor at UBC. “A lot of thisis marketing hype in my opinion,” hestates.

Dr. Munk gives credit to kyphoplastydeveloper Kyphon Inc., of the U.S., forthe rising popularity of the new proce-dure. “In my opinion, kyphoplasty andvertebroplasty have very little differencein terms of the clinical outcomes. I domainly vertebroplasty, I do very little inthe kyphoplasty or skyphoplasty, onlyvery select cases.”

A similar, lesser known procedure tokyphoplasty that was developed in Is-rael, skyphoplasty utilizes a specialpolymer device that can be positionedwithin a vertebra and expanded, creat-ing a void which can be filled with bonecement. Israel’s Disc Orthopedic Tech-nology (Disc-O-Tech), which developedthe Sky Bone Expander skyphoplastydevice has agreed to sell the product toKyphon. The deal now awaits regulatoryapproval.

Skyphoplasty’s widespread use hasbeen hampered, Dr. Munk said, bylegal battles between Kyphonand the Israeli company,which saw Disc-O-Techlose the right to marketits product in the United

States. “We may be the only centre cur-rently in North America doing any at all.”

The vertebroplasty-kyphoplasty dividewhich has developed in the medical pro-fession owes its existence in part to thehistory of the two procedures. Vertebro-plasty was enthusiastically adopted bythe Interventional Radiology disciplinewhile kyphoplasty was developed by anorthopedic surgeon.

“The kyphoplasty was taken up moreby the surgeons and the ver-tebroplasty was taken upmore by the radiologists, andthere is kind of this schismin the field where you sort ofdo one or the other,” said Dr.Jack Speirs, an Interven-tional Radiologist withWindsor’s Hôtel-Dieu GraceHospital.

Because the proceduresare covered by most provin-cial health plans, cost is notreally a factor in which pro-cedure is used. “At least inOntario, you’ll find that mostof the kyphoplasty is doneby surgeons and most of the vertebro-plasty is done by radiologists,” said Dr.Speirs. “It’s hard to sort out the turf bat-tle between the two versus the reality ofwhich is the better procedure.”

While Dr. Speirs began treating spinalfractures with vertebroplasty, he hassince relied more on kyphoplasty to treathis hospital’s younger patients. “We tendto use vertebroplasty in patients who areolder and frailer because it is faster and

we are really trying to reduce their pain,”he said. “Kyphoplasty is also very good atreducing pain, but you (also) get a reduc-tion in the fracture. So what has hap-pened is that in the younger, more activepatients, we do the kyphoplasty and inthe older, more debilitated patients wedo the vertebroplasty.”

Dr. Speirs admits to having beenskeptical about the marketing claimssurrounding kyphoplasty, but said thatover time he became a supporter. “I defi-nitely don’t think kyphoplasty is foreverybody, it is just not worth themoney. But for a 60-year-old lady who isactive, who has two fractures, if you canreduce those fractures, they don’t get allthe deformity. But if you are 90 and arein a diaper in a nursing home, I’m notsure about that.”

The Windsor radiologist remains skep-tical about claims that kyphoplasty is

safer or may reduce pain more effec-tively, and acknowledges that “kypho-plasty is a lot more work.” He said a ver-tebroplasty procedure typically takesabout 20 minutes, while kyphoplastywill take about 40 minutes. “But I thinkthat there is some benefit to it.”

Dr. Speirs tells the story of a 96-year-old patient who already had two kypho-plasty procedures carried out in the U.S.,and then suffered another fracture. “Sheshowed up at our door in a fetal positionin a diaper. With some reluctance, wedid the [kyphoplasty] procedure and herdaughter recently sent me a picture fromher 97th birthday. She was back in hercondo and having a birthday party withall of her relatives. There’s a lady whootherwise would have been in a nursinghome somewhere, who is now living in-dependently.”

While the practitioners have for nowformed their own opinions on the meritsof kyphoplasty, vertebroplasty and to alesser extent skyphoplasty, time and clin-ical evidence – which is to date lacking –will determine the relative worth of thethree procedures.

“Right now there is almost a battle be-ing fought to see whether vertebroplasty

or kyphoplasty is going to surfaceto be the dominant preferred pro-

cedure,” said Vancouver Gen-eral’s Dr. Munk. “All three pro-

cedures will probably havecertain occasions for which

they are better, but that hasto be worked out and

sorted out in a scientificfashion, which hasn’t

happened yet.”

Interventional Radiologists repairspines using new techniquesWith an aging population, Canada will experience increasing numbers of patients with osteoporosis andspinal fractures. Luckily, new and effective therapies are at hand.

Dr. Peter Munk, Head ofMusculoskeletal Imag-ing at the VancouverGeneral Hospital anda Professor at UBC.

REPORT ON INTERVENTIONAL RADIOLOGY

Vertebroplasty,

kyphoplasty and

skyphoplasty have all

emerged as viable

therapies.