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Faster, Safer, Cheaper, Better: The Growth of Minimally Invasive, Image-Guided Therapies

– By Matt Skoufalos

Interventional radiology [IR] dates back to 1964. In 2020, it is routinely employed in the diagnosis and treatment of an ever-increasing number of health conditions. By combining advanced image-guided techniques, the specialty offers physicians a variety of treatment alternatives to traditional approaches that can take a heavier toll on the patient.

“The catchphrase that we used to use a lot was ‘faster, safer, cheaper, better,’ and that’s not always true,” said Scott Trerotola, associate chair and chief of interventional radiology at the Hospital of the University of Pennsylvania.

“A lot of the things we do these days are actually more expensive than the alternative,” Trerotola said. “But that can be offset because interventional radiology offers lower complications, shorter hospitalizations and less mortality. It helps move a lot of care into the outpatient setting that previously would have required prolonged hospitalization.”

IR techniques have the potential to make significant differences in the lives of patients who would otherwise have received more painful, more invasive or less effective procedures. Among its more common applications is uterine artery embolization (UAE) for the treatment of fibroids: non-cancerous growths that can cause women heavy, prolonged menstrual bleeding and pelvic pain. Prior to the adoption of UAE, the only treatments available for this condition were myomectomy or hysterectomy – surgical removal of part or all of uterus.

For some women, “hysterectomy in particular may lead to [feelings of] loss of womanhood,” Trerotola said; “it’s a big procedure: six weeks-plus of recovery, very expensive and the potential for a lot of complications.”

“Now women have the option to have embolization on an outpatient basis,” he said. “It’s just a needle puncture; we put a tube in the arteries, and block off blood flow, and the fibroids shrink on their own. [There’s] usually no hospitalization, and a faster return to work.”

Despite awareness of IR treatment for uterine fibroids, however, Trerotola said, the vast majority of such patients are still treated surgically.

“Hysterectomy is one of the most commonly performed surgeries worldwide,” he said. “And although uterine fibroid embolization isn’t a panacea, a large number of patients seen for the condition it’s employed to resolve.”

Yet, only a “tiny fraction” of women are offered the option of a minimally invasive alternative even though that option is ensconced in national guidelines.

“The vast majority of patients who come to us come from knowledgeable and collaborative gynecologists, or they are self-referred from the Internet,” Trerotola said.

Uterine fibroids are non-cancerous, but image-guided embolization is also employed to starve the blood supply to cancerous tumors, both primary and metastatic, and is frequently used to halt the progression of cancer in patients awaiting a liver transplant, said Trerotola’s colleague, Deepak Sudheendra, founder and director of the DVT and complex venous disease program at the Hospital of the University of Pennsylvania.

“You’re going to be on that transplant waiting list for 18 months to two years,” Sudheendra said. “What’s going to happen to that tumor while you’re waiting? With tumor embolization, we can kill 98 percent of the tumor and keep it under control as a bridge to transplant.”

“In the patient who’s not a transplant candidate, you’re their only option for controlling the tumor,” he said.

Interventional oncology “has really grown by leaps and bounds” since its inception, Sudheendra said, and he foresees techniques on the horizon in the areas of “all kinds of cancers,” including pancreatic and breast cancer. Trerotola agreed.

“The last frontier in our world was thought to be lymphatics, and Penn is Ground Zero for lymphatic interventions,” Trerotola said. “There aren’t that many body parts left to study, but people come up with new things.”

“People are exploring minimally invasive treatments for hemorrhoids, arthritis, and there’s even a research study going on with embolization of the stomach to treat morbid obesity,” he said. “Every time we think we’ve done it all, we keep finding new and interesting areas that are potentials.”

Another common application of minimally invasive, image-guided techniques involves dealing with an enlarged prostate. The same embolization techniques that can be used to help women with uterine fibroids to avoid hysterectomy can also help men avoid a more invasive transurethral resection of the prostate, or TURP procedure. In addition to the longer recovery time, TURP can cause residual bleeding, urinary tract infections, retrograde ejaculation and erectile dysfunction. Conversely, prostate artery embolization (PAE) shrinks the prostate over weeks and months by restricting blood flow to the organ without destabilizing its tissue. Like the vast majority of IR procedures, it’s done under moderate sedation instead of general anesthesia,

As America’s baby boomers continue to age, Sudheendra believes more of them will rely on minimally invasive, image-guided procedures like PAE, or similar interventional radiology techniques to deal with chronic conditions such as arthritis.

“Imagine you’ve got a 55-year-old person with arthritis, but who doesn’t want to undergo a knee replacement,” he said. “You can get an IR treatment that may either cure it, or give you another 10 years before you need a knee replacement.”

Similarly, patients suffering from peripheral arterial disease can often avoid amputation with an IR procedure. And more often than not, Trerotola said, “the vast majority of this care is done on an outpatient basis or a single, overnight stay in the hospital,” which reduces costs for insurers, even if “it’s a mixed blessing” for hospitals that don’t earn diagnosis-related group (DRG) payments for inpatient services.

“You rob Peter to pay Paul,” Trerotola said – but that’s the price of advancing the quality of the work and improving patient outcomes.

As popular as minimally invasive, image-guided therapies and techniques are becoming, practitioners, whether in private practice or employed by a health system, should be considerate of what it takes to perform them, said Raymond Lanzafame, executive director and scientific chair of the Society of Laparoscopic and Robotic Surgeons.

Lanzafame, who considers himself “in the pioneer group” of minimally invasive technique practitioners, is a surgeon who has studied photonics for nearly 40 years and minimally invasive surgery for more than 30 years. As his career has traced the emergent arc of IR and minimally invasive surgical practices, he’s also guided institutions in the development and capitalization of such techniques.

Historically, Lanzafame said, minimally invasive techniques tend to be reimbursed at a lesser level than open surgeries, which can make them less financially attractive to institutions. Years ago, when academic hospitals started acquiring GreenLight lasers to perform TURP alternatives, at first, “it took a long while to convince the administrators that this needed to be done,” he said. Once the technology was available, institutions had the option of leasing or purchasing it; deciding which put themselves in a position to either be stuck with an expensive tool they seldom used, or to overpay for a rental that it would be cheaper to own.

“If I’ve got a $2 million robot, 10 percent of that purchase price becomes eaten up by maintenance annually,” Lanzafame said.

Aside from acquisition and upkeep, institutions purchasing high-end IR equipment must credential the physicians who will use it, and train and retain the non-physician staff who support them in its operation.

“If I’ve got this champion who wants to introduce a new technique or technology to the institution, how do I vet that?” Lanzafame said. “Is that individual qualified? Are there clinical studies? Then you get into the various turf wars in the laparoscopic realm – people who attend a course, but don’t have privileges on different parts of the anatomy. You’ve got some smearing and blurring of disciplines and lines.”

“All other issues notwithstanding, from a patient perspective, I want it to be 100-percent safe, I want it to have zero complications, and I want it to be 102-percent effective,” he said.

Not every patient is a good candidate for a minimally invasive intervention, however. Dr. Bret Wiechmann, a private-practice IR specialist with Vascular & Interventional Physicians of Gainesville, Florida, a founding member of the Outpatient Endovascular & Interventional Society (OEIS) and its current president-elect, said that a number of factors can complicate their suitability.

Anatomy is typically one such reason. Wiechmann said some patients with abdominal aortic aneurysms (AAA) “don’t have a good landing zone for these [endovascular] devices” used to treat their conditions. Others “fail less invasive attempts” and must proceed to open surgery, he said; still others select a less invasive option “knowing that there may be a trade in procedural durability or long-term outcomes.”

“When these devices first came out 21 years ago, not everybody was a candidate for a less invasive approach to fixing an aneurysm,” Wiechmann said. “As the devices have improved and the technique has been more refined, then more and more people become candidates.”

Today, almost 70 percent of aortic aneurysms are treated with minimally invasive, image-guided interventions this way, “whereas in the beginning it was more like 30 to 40 percent,” Wiechmann said. Similarly, IR techniques for the treatment of peripheral artery disease can open blood vessels more urgently, delivering faster results “than putting somebody on a blood thinner, or just hoping that they get better on their own,” he said. In addressing stroke, another debilitating illness, he said, “we are able to quickly re-establish blood flow to the brain with the devices we now have available.”

Even for those patients who aren’t well suited for minimally invasive procedures, “one of the beauties of our specialty is that we work so collaboratively with other specialties,” Wiechmann said. “We get exposed to the procedural part of things, and we combine those aspects with managing the patients clinically. One of our specialties is to be able to apply all that knowledge.”

That collaborative ethic has been on display broadly since 2018, Wiechmann said, as IR has become “the most desired formal subspecialty in terms of residency and fellowship numbers,” a claim Sudheendra seconded.

“Worldwide, there are shortages in access to training, but in the United States, IR was the most competitive fellowship to get into last year,” he said. “That being said, no matter what specialty you get into, you will never learn everything in your residency training; the learning doesn’t stop.”

“When it started, IR was a purely diagnostic specialty,” Sudheendra said. “All you did was tell the surgeons what was wrong with the patient. Now, 40 years later, someone comes in with massive internal bleeding, they don’t come to the surgeon, they come to us.”

Dr. Matthew Johnson, Director of Clinical Research and Director of Interventional Oncology in the Department of Radiology and Imaging Sciences at the Indiana University School of Medicine in Indianapolis, Indiana, said that despite its elevated profile and increasing prominence in the health care field, interventional radiology is “tough to conceptualize” and may suffer from a branding deficit.

“We operate on people through pinholes so we can do amazing things to them and have them not know, which is glorious, but makes it difficult for people to understand,” Johnson said. “If you operate on someone and they have a big incision, they have to do rehab, and they have a big scar – and they know something’s been done.”

“[With IR procedures], all they might know is they have a Band-Aid on their neck and on their groin,” he said. “We’re working as a society to get people to understand that almost every patient can benefit from having IR involved in their care. We’re at the forefront, and we’re always there.”

Johnson said the IR “bread-and-butter procedures are things that everybody needs but nobody thinks about,” including installing ports, catheters and gastrointestinal tubes; performing hemodialysis, abscess draining and biopsies. He described these as “a service to the hospital and to patients,” as well as “things that are managed frequently by other doctors.”

To elevate the profile of the specialty means letting the rest of the universe of practitioners know “that we are there, that we want to be part of multidisciplinary care, and we want to be recognized as who we are,” Johnson said.

“There are thousands of us in the hospitals doing these things,” he said. “It’s our identity that we’d like to share.”

“How we grow the field is we grow people’s understanding of it,” Johnson said. “You provide a great mousetrap, and then you provide people of knowledge of your mousetrap and what it can do for them.” •

 

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