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
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
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.