QUICK CASE. Have you met your interventional pathologist or interventional neurologist or interventional oncologist?

Health care disruption has become so complex that there are few, if any, up-to-date case studies. So I have been developing a method of “raw” contemporaneous cases studies (CCS) each prepared by curating news articles into a coherent thread, after a topic has called out to me. Topics come from navigating the system news feeds, and friends and family.
As health care transformation takes place on an ever steeper and faster trajectory “real time” QUICK CASES can play an increasing “rapid response” role in the classroom. Each QUICK CASE CCS ends with a “challenge” for immediate discussion, debate, a group project, and/or homework assignment.

My first experience with clinical turf competition was in 1968 as administrator of the Department of Surgery at Wilford Hall U.S.A.F. Medical Center. The Chiefs of general surgery, E.N.T., and Oral Maxillofacial Surgery each needed Head & Neck surgical cases for their residents. Time and time again protocols were agreed upon to rotate the cases but they always broke down when residents in one specialty or another needed the required number of H&N cases before they graduated. Interestingly I never recall that any of the Chiefs thought the patients had a role in the decision-making.

Several months ago my GI physician ordered a “rule out” MRI. On my next visit my doctor clicked on the images and went over them with me; it was clear he had gone down to the radiology suite and gone over the “films” with the radiologist. In fact since the senior MRI radiologist was on vacation, he reviewed the images with him too when he returned.
While I did get copies of the MRI reports, I never spoke directly to the radiologist. No one usually does, perhaps with the exception of women talking to their breast radiologist.

Fast forward to another MRI and x-rays for chronic back pain. In each case I asked to meet the radiologist and in both cases the radiologist went over the images with me, before I went back to the referring physiatrist. WOW!!
Now the back MRI and x-rays were outpatient in a free-standing imaging center, and the radiologist was right there. Not so easy if you are in an ER, or a hospital bed, or if the images are read “off-site.”

Recently I met a physician who said he was an interventional gastroenterologist. I didn’t know what that meant.
Back in the day vascular procedures were the domain of vascular surgeons. So I started Googling and found that besides cardiology, stenting has expanded to GI, neurology, oncology, radiology, urology, nephrology, pulmonology, and pain management.
So now as an educated patient you should know more about interventional procedures and who is performing them on you. Some questions: Is the procedure evidence-based? Does the physician have special training in the procedure, and certification if this is the gold standard? Does the physician do enough of the procedure to ensure proficiency and good outcomes?

But first…
“A new study has found that while stents can be lifesaving in opening arteries in patients having a heart attack, the devices are ineffective in relieving chest pain.
A procedure used to relieve chest pain in hundreds of thousands of heart patients each year is useless for many of them, researchers reported on Wednesday.
Their study focused on the insertion of stents, tiny wire cages, to open blocked arteries. The devices are lifesaving when used to open arteries in patients in the throes of a heart attack….
When the researchers tested the patients six weeks later, both groups said they had less chest pain, and they did better than before on treadmill tests.
But there was no real difference between the patients, the researchers found. Those who got the sham procedure did just as well as those who got stents.
Clinical guidelines in the United States say stenting is appropriate for patients with a blocked artery and chest pain who have tried optimal medical therapy, meaning medications like those given to the study patients… “ (A)

Now let’s look at ever expanding interventional medicine.
“A vascular surgeon diagnoses, treats, and manages conditions in your arteries and veins, also called your blood vessels. These specialists treat a range of health problems, from spider and varicose veins to life-threatening aneurysms, and can help patients manage chronic conditions throughout their lives.
A vascular surgeon treats many conditions that affect the blood vessels in every part of your body except for your heart and brain. This can include: Aneurysm, a bulge or weak spot in an artery; Atherosclerosis, or hardening of the arteries, where plaque builds up on your artery walls; Carotid artery disease or peripheral artery disease (PAD), where the arteries that bring blood to your neck or limbs become narrow or blocked; Compression disorders like nutcracker syndrome and thoracic outlet syndrome; Dialysis access, or the placement of a graft or fistula that allows you to receive dialysis treatment for kidney disease; Deep vein thrombosis (DVT), a blood clot in a vein deep below your skin; Spider veins, or small webs of veins just below the surface of the skin; Trauma to arteries and veins caused by accidents or injuries; Varicose veins, or large, swollen, twisted veins that can cause pain or aching in your legs; Venous ulcers and arterial and diabetic (neuropathic) wounds, which are nonhealing wounds that result from poor blood flow, especially in the legs” (B)

“Interventional Cardiology represents advanced training in cardiovascular disease and focuses on the invasive (usually catheter-based) management of heart disease.
Clinical issues usually managed by interventional cardiologists include: Ischemic heart disease (percutaneous coronary intervention (angioplasty), stent placement, coronary thrombectomy; Valve disease (valvuloplasty, percutaneous valve repair or replacement); Congenital heart abnormalities (repair of atrial and ventricular septal defects, closure of patent ductus arteriosus, angioplasty of the great vessels).” (C)

“Interventional Radiology” (IR) refers to a range of techniques which rely on the use radiological image guidance (X-ray fluoroscopy, ultrasound, computed tomography [CT] or magnetic resonance imaging [MRI]) to precisely target therapy. Most IR treatments are minimally invasive alternatives to open and laparoscopic (keyhole) surgery. As many IR procedures start with passing a needle through the skin to the target it is sometimes called pinhole surgery!
The essential skills of an interventional radiologist are in diagnostic image interpretation and the manipulation of needles and the use of fine catheter tubes and wires to navigate around the body under imaging control. Interventional radiologists are doctors who are trained in radiology and interventional therapy.” (D)

“Interventional Nephrology is a new and emerging subspecialty of Nephrology that mainly deals with ultrasonography of kidneys and ultrasound-guided renal biopsy, insertion of peritoneal dialysis catheters, tunneled dialysis catheters as a vascular access for patients undergoing hemodialysis as well as percutaneous endovascular procedures performed to manage dysfunction of arteriovenous fistulas or grafts in end stage renal disease patients.” (E)

“Interventional urology provides care for many urologic diseases in the most minimally invasive fashion possible. New approaches include state of the art prostate cancer screening technologies, focal therapies for prostate cancer, minimally invasive kidney cancer treatments, embolization for BPH, non-surgical approaches to treat varicoceles and erectile dysfunction.” (F)

“Interventional oncology uses image-guided technology to directly target solid tumors. It’s a complementary intervention that I hope will eventually be integrated into standard care algorithms. It gives clinicians another focused area of cancer care in which we can collaborate with other specialists. We perform targeted procedures that can be characterized as either arterial or ablative. Interventional oncology, and to some extent interventional radiology, also involves the use of biopsies for genomics analysis, in a similar way as other oncologic specialists use biopsies to help guide their biological therapies or systemic therapies.” (G)

“Interventional pulmonology is a relatively new field in pulmonary medicine. Interventional pulmonology uses endoscopy and other tools to diagnose and treat conditions in the lungs and chest.
These procedures may be offered by pulmonologists (lung specialists) who have undergone extra training. Cardiothoracic and other surgeons also routinely perform interventional pulmonology procedures.
Procedures for interventional pulmonolgy include: Flexible bronchoscopy. Biopsy of lung or lymph node.
Airway stent (bronchial stent). Rigid bronchoscopy. Foreign body removal. Pleuroscopy. Thoracentesis.
Pleurodesis. Indwelling pleural catheter. Bronchoscopic thermoplasty.
Interventional Pulmonary Diagnostics: Endobronchial ultrasound system (EBUS); Electromagnetic navigation bronchoscopy (superDimension) (H)

“Interventional (gastrointestinal) endoscopy is a minimally invasive procedure that involves the use of a thin, flexible tube (or scope) that is equipped with a camera and light at its tip. The endoscope is inserted either in the mouth or rectum and passed through the esophagus or intestines to make color images of the esophagus and intestinal tract. It also can be used to make images of surrounding organs such as the pancreas.
Interventional endoscopy can be used to screen, diagnose, manage, and treat: Colon and rectal bleeding, polyps, and cancer; Complete and colon polyp resection, including large polyps; Complications from bariatric surgery; Diseases of the esophagus; Gallbladder disease; Gastric stomach diseases; Pancreatic diseases; interventional endoscopy also is used to prevent cancer by removing growths (polyps) before they become cancerous.” (I)

“Endovascular neurosurgery is a subspecialty within neurosurgery. It uses catheters and radiology to diagnose and treat various conditions and diseases of the central nervous system. The central nervous system is made up of the brain and the spinal cord. This medical specialty is also called neurointerventional surgery.
Interventional neuroradiology is a subspecialty within radiology. It also involves catheters and radiology to diagnose and treat neurological conditions and diseases.
The term endovascular means “inside a blood vessel.” Endovascular neurosurgery uses tools that pass through the blood vessels to diagnose and treat diseases and conditions rather than using open surgery. The surgeon often uses radiology images to help him or her to see the part of the body involved in the procedure.” (J)

“A variety of interventional procedures can be used to treat a range of pain conditions, from chronic low back pain to migraine headaches. Many of these techniques are performed under X-Ray guidance, which helps the physician deliver the therapy—whether it’s a steroid injection or heat-based remedy—to the exact source of the pain.
The range of interventional pain management treatment options include: Epidural Steroid Injections;
Medial Branch Blocks / Facet Joint Injections; Radiofrequency Nerve Ablations; Major Joint Injections (Knee, Hip, Shoulder); Occipital Nerve Blocks; Kyphoplasty (Balloon kyphoplasty). (K)

“Pathologists use microscopic examination and supporting tests to study tissues taken from biopsies and make diagnosis. In conventional pathology, the samples are taken by a surgeon and then sent away to a pathologist for analysis.
Interventional pathology is a new, less invasive option that allows for preliminary sample testing to be done in-person by the pathologist. It enables the pathologist to directly communicate with the patient and helps the doctor put the biopsy samples in context with the patient as a whole. This achieves faster, more accurate, and more complete diagnoses. With interventional pathology, patients can receive a better diagnosis than is available with conventional pathology, and in fewer trips to the doctor’s office.” (L)

“Over the past decade or so, the trend has been toward less and less invasive treatment—laparoscopic surgery instead of open-body surgery. Now enter so-called interventional cardiologists, who perform angioplasty and deploy stents (small mesh tubes that act as scaffolds inside an artery) to treat coronary-artery disease, in place of cardiac surgeons scrubbing in for a bypass. Indeed, since 1994, such surgeries have fallen more than 20 percent, to fewer than 300,000 annually. And then there are interventional radiologists wielding catheters and stents to deal with, say, carotid-artery disease, in place of vascular surgeons reporting for duty, scalpel in hand.
“It’s like the Wild West, the turf wars with the vascular surgeons,” … “You’ve got interventional cardiologists, interventional neuroradiologists, interventional neurologists all wanting in.”…
The solution, many doctors say, is to develop criteria that carefully spell out which conditions call for which procedures and—this is key—to make certain that the practitioner who first sees a patient is knowledgeable about all treatment options: surgical, interventional, medication, lifestyle modification, the whole deal.” (M)

In summary be thorough when getting care from any interventionalist. One should know who is doing the procedure, and his or her training, experience and performance results.

THE CHALLENGE: More and more hospital based interventionalists serve on “on-call” panels (often in-house 24/7). This means that in “rapid response” situations the interventional procedure is performed by a pre-designated physician. What mechanisms can be put in place so the patient (or family members) more fully participate in interventional clinical decision-making?

“Capital Health Regional Medical Center has become the first hospital in New Jersey to employ the Embotrap II Revascularization Device for treatment of stroke, the Trenton-based facility said.
Neurosurgeons at Capital Health’s Capital Institute for Neuroscience use Embotrap II to remove a blood clot in the brain causing a stroke. The stent retriever features a fine, mesh-like end and is guided through a major artery to trap the clot.” (N)

(A) ‘Unbelievable’: Heart Stents Fail to Ease Chest Pain, by GINA KOLATA, https://www.nytimes.com/2017/11/02/health/heart-disease-stents.html
(B) Learn About What Vascular Surgeons Do, https://www.acponline.org/about-acp/about-internal-medicine/subspecialties/cardiovascular-disease/interventional-cardiology
(C) Interventional Cardiology, https://www.acponline.org/about-acp/about-internal-medicine/subspecialties/cardiovascular-disease/interventional-cardiology
(D) What is Interventional Radiology?, by David Kessel, https://www.bsir.org/patients/what-is-interventional-radiology/
(E) Interventional Nephrology: a new subspecialty of Nephrology, by G Efstratiadis, I Platsas, P Koukoudis, and G Vergoulas, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464263/
(F) Interventional Urology, http://www.mountsinai.org/patient-care/service-areas/urological-conditions-and-surgery/areas-of-care/interventional-urology
(G) Burgeoning Field of Interventional Oncology Is Poised for Takeoff: A Q&A With Dan Brown, MD, by Andrew J. Roth, http://www.onclive.com/publications/obtn/2013/november-2013/burgeoning-field-of-interventional-oncology-is-poised-for-takeoff-a-qanda-with-dan-brown-md
(H) Interventional Pulmonology, https://www.webmd.com/lung/interventional-pulmonology-uses-effects#1
(I) WHAT IS INTERVENTIONAL ENDOSCOPY?, https://www.summitmedicalgroup.com/service/Interventional-GI-Endoscopy/
(J) Endovascular Neurosurgery and Interventional Neuroradiology, https://www.hopkinsmedicine.org/healthlibrary/test_procedures/neurological/endovascular_neurosurgery_and_interventional_neuroradiology_135,39
(K) Interventional Pain Procedures Under X-Ray Guidance, http://www.mountsinai.org/patient-care/service-areas/pain-management/pain-management-services/interventional-spinal-procedures-under-x-ray-guidance
(L) Interventional Pathology, https://sites.google.com/site/pathdiag/upcoming-seminars/our-company
(M) The rise of low-invasion techniques—and the doctors who specialize in them—has made the competition for surgical patients, well, cutthroat, by Joanne Kaufman, http://nymag.com/nymetro/health/columns/strongmedicine/n_9311/
(N) Capital Health first in NJ to employ Embotrap II stroke treatment, by Jessica Perry, http://www.njbiz.com/article/20180822/NJBIZ01/180829948/capital-health-first-in-nj-to-employ-embotrap-ii-stroke-treatment

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