Dr. Angle is an Associate Professor of Radiology in the Department of Radiology, University of Virginia Health System, Charlottesville, VA. He is also a member of the Editorial Board of this journal.

There has been an ongoing debate about the future of interventional radiology (IR). As the number of other specialists interested in performing minimally invasive procedures has increased, radiologists and radiologists-in-training have voiced increasing concern that IR cannot survive these encroachments. They argue that as other specialists take over procedures previously done in IR, they hinder IR not only by their pattern of taking the procedures with the highest reimbursement, but by also by leaving IR with the costly and fatiguing after-hours cases and money-losing procedures.

To some degree these events are true, but there are plenty of indications that IR will adapt and grow. The most compelling argument that IR is actually thriving is the rate at which new procedures are being introduced. From its beginnings in the early 1970s, the rate of growth of IR has been rapid; there are now hundreds of different procedures that a typical IR lab can perform. In the last 10 years, many exciting procedures have been brought into everyday practice; and other specialists are unlikely to copy these new procedures in the near future. Examples include chemoembolization of liver tumors, radiofrequency ablation of tumors, uterine fibroid embolizations, and, most recently, endovenous ablation of the saphenous vein. Its huge capacity to innovate will keep IR thriving and exciting.

Research in the field of IR will continue to provide a constant stream of new procedures. The Society of Interventional Radiology (SIR) meeting this year included more than 415 abstracts and posters. This number has doubled since 1997. Even if only a very small portion of these original ideas represent a potential for new procedures and even if only a small portion of these new procedures make the translation to practice, the field of IR will continue to see rapid expansion in the breadth of procedures it offers.

Although IR is suffering from competition, a problem this very young specialty has never faced before, it has won some battles. Twelve years ago, IR started performing tunneled line and port placements, a procedure long the mainstay of general surgery. The superior safety and success rates for these central line placements in IR provided new business; and IR now performs the majority of vascular access cases. On the other hand, no one was concerned about the death of general surgery during this transition, and general surgery has refocused on other procedures. Surgery has been dealing with competition from IR and other specialties for years. Cardiac surgery has had intense competition from cardiology, but the demand for cardiothoracic surgeons has never been higher.

For IR, competition is most evident in renal and peripheral angioplasty. For more than 20 years, IR has been doing iliac angioplasty; we have perfected the procedure to a point at which nearly any physician can perform it with relatively little training. We turned a fine art into an exact science, which has made these procedures safer for our patients, but now we must deal with competition. There will always be a need for highly skilled interventionalists, particularly for complex cases, but it is also time for IR to learn how to compete.

Interventional radiologists may have more expertise than other operators, but that advantage is minimal when it comes to routine peripheral angioplasty cases. In that arena, IR must face the advantages that cardiology and vascular surgery have, namely, access to new patients; IR can compete by garnering direct referrals. Radiologists are opening clinics so they can see new consults, they are making daily rounds so they have a presence on the floors of their local hospitals, and they are following up on the patients they treat. These practices allow referring physicians to send their patients to IR with the confidence that they will be treated and be followed. When they send their patients to IR, referring physicians cannot help but have increased respect for radiologists who provide nearly a comprehensive package.

Interventional radiologists must also screen patients to get more self-referred patients into their clinics. Interventional radiology is redefining noninvasive testing with computed tomography (CT) and magnetic resonance imaging (MRI) of the vascular system. Vascular surgeons have benefited for years from their noninvasive vascular laboratories and there is no reason IR cannot use CT and MRI to expand their patient population.

There is no question that the number of arterial interventions that many IR practices perform is shrinking. Yet, practices that adapt and compete for direct referrals may see their peripheral vascular disease population grow. Through the development of new procedures, by involvement in the clinical management of patients, and through noninvasive vascular imaging, IR can continue to thrive as a specialty.