The various procedures, therapies, techniques and mindsets that embody interventional radiology have had many different names over the years. Well before the Society of Interventional Radiology, there were angiographers and procedural pioneers, cardiovascular radiologists and clinical cowboys. In the 50 years since the Society of Interventional Radiology was established, the field has seen unparalleled growth in technology, tools and procedures. Today’s IR suite is almost unrecognizable from its roots, according to the SIR past-presidents, who shared how practice as evolved over their careers.
Tools
Steaming guidewires
“We had very limited tools when I started,” said Katharine L. Krol, MD, FSIR (2006–2007). “We weren’t completely without, but catheters were 7 French, very stiff and had limited choice of curves.”
It was not uncommon for IRs to make their own curves, Dr. Krol said, utilizing a good old-fashioned kettle and steam.
“You had a tea kettle that would produce steam, and you would hold the catheter over the steam to soften it,” said Michael D. Dake, MD, FSIR (2020–2021). “You would shape it with your hands into whatever shape you wanted, and when you removed it from the steam, it would cool in that shape.” As an added bonus, the steam would sterilize the catheter as well.
The problem, Dr. Dake said, is that although steaming would provide more flexibility than commercially shaped catheters, the shaping wouldn’t last long.
“The shape would eventually wear out if you took too long to do your procedure,” he said. “The tools that we have at our disposal are so much more advanced today.”
Inventing stents
Mark Wholey, MD, FSIR, placing a stent.
Dr. Krol was in training when Andreas Gruentzig, MD, performed the first balloon angioplasty in 1977, and so she went into practice having seen balloon angioplasties, but having never performed one. During her early career, Dr. Krol had a front-row seat to arterial and venous interventions, participating in the stent trials with Julio Palmez, MD, to determine safety and efficacy of various stents such as carotid stents, drug-eluting stents and endovascular graft stents.
“All the early TIPS were done with uncovered wall stents,” said James B. Spies, MD, MPH, FSIR (2014–2015). “And so the introduction of covered stents was a huge step forward because it allowed us to have much better outcomes and lower reclusion rates of TIPS.” Those lower reclusion rates enabled IRs to expand treatment to other areas, such as pulling pseudoaneurysms out of vessels, according to Dr. Spies.
When James F. Benenati, MD, FSIR (2010–2011), began his career, vascular stents had just been approved and the only stents available were self- or balloon-expandable stents.
“Stent evolution has just been enormous,” Dr. Benenati said. “I believe that we will soon see the rise of biodegradable stents, which will degrade on their own and not leave a scaffold behind.”
Imaging
According to Curtis W. Bakal, MD, MPH, FSIR (2001–2002), the creation of digital imaging and rotatable C-arms, which fully replaced film, was the most important evolution to happen during his career.
Two IRs wearing lead during a CT-guided procedure.
“The idea that you can rapidly produce angiography images digitally, as opposed to cut film, just utterly transformed the speed and accuracy with which we could do angiography,” said Robert L. Vogelzang, MD, FSIR (1997–1998). The simple act of placing a catheter into an artery and knowing that it would not only reliably catheterize the artery, but also very selectively catheterize into specific branches was unheard of when he began practice.
“I recall struggling to get subselective and into a second-order branch, and sometimes you just couldn’t because of the tools,” he said. “Now, it’s a matter of routine; it can be done very simply and very safely.”
Like the departure from film, the creation of ultrasound imagining changed everything, according to Matthew S. Johnson, MD, FSIR (2021–2022). When Dr. Johnson started as an IR fellow in 1992, jugular access was just beginning to catch on—and it was done without ultrasound.
“We didn’t stick jugular veins, we stuck subclavian veins, and mostly arteries,” he said. “But with ultrasound and the ability to see what we were doing in real time; it changed the way we practice to the extent that I don’t think there are many people not using ultrasound to gain access to veins or arteries today.”
Therapies
The improvement in tools led to the improvement and evolution of procedures and new techniques; with new imaging modalities and catheters to match, IRs were able to refine and expand therapies, constantly making them safer and more efficient.
Douglas Redd, MD, demonstrating pediatric interventional radiology.
“Most of the things I did toward the end of my career were things I never did in my training,” said Anne C. Roberts, MD, FSIR (1996–1997), citing TIPS or IVC placements without surgical cut downs. “We did embolizations, but usually it was for bleeding and trauma. We certainly weren’t embolizing fibroids.”
When Barry T. Katzen, MD, FSIR (1988–1989) was a resident, the most common surgical procedure in the United States was an exploratory laparotomy.
“An exploratory laparotomy is when a surgeon opens your abdomen to see what’s going on,” Dr. Katzen said. “It’s hard for people today when you explain that to them. They can’t even understand how that could be.”
Cryoablation—particularly prostate cryoablation, which used to involve placing an array of 8 mm probes into the prostate under general anesthesia—has also come a long way.
“This was one of the initial percutaneous approaches to ablation, if not the initial approach,” said Brian Stainken, MD, FACR, FSIR (2009–2010). “It involved a lot of equipment. I’ll never forget the cryomachines, which belched nitrogen smoke out as they froze away. It seemed a little bit out of Jules Verne.”
Clinicians
Just as IR tools and techniques have improved and evolved, so too has IR’s role in the healthcare system.
“The internal recognition and external recognition of IR as medical decision-makers and patient care providers—not just people who do a procedure in response to another physician’s request—is the biggest change to IR over my career,” said M. Victoria Marx, MD, FSIR (2018–2019). “We are now actively contributing to the care of patients both in procedural decision-making and planning as well as post-procedural care.”
This has led IRs to firmly establish their fundamental importance to hospitals. From biopsies to port placements to venous procedures, IRs are involved in so many areas that they have become the glue of many hospital practices, Dr. Dake said.
Staff of Miami Vascular Specialists in the IR suite.
“Now, if IRs are not available or there's some epidemic that makes them all stay home, the hospital can't function. That's not true of many other specialties,” said Dr. Dake. “I think it’s becoming increasingly apparent that IR is mission critical to the delivery of healthcare.”
The rise of longitudinal care, combined with the growing awareness of the importance of IR, has opened doors for widespread and deeply innovative IR subspecialization.
“Over the course of my career, we have progressed from being practitioners who dabble in cancer diagnosis and therapy to full-fledged participants in this field,” said Michael C. Brunner, MD, FSIR (2003–2004). “Interventional oncology is an entity that was unknown when I started. But it is now a very respected participant in cancer care and has spawned even a separate society to allow for progression of the field.”
An elegant solution
For Dr. Vogelzang, the growth of IR has been inspiring to watch. “The beauty of interventional radiology is that it’s the most elegantly simple method ever devised in the history of medicine, and we are the inventors, beneficiaries and developers of it,” he said. “We revolutionized medicine. We utterly changed the paradigm of medical and surgical therapy.”
