IR has come a long way since its humble beginnings in the 1960s and the wide spectrum of minimally invasive image-guided therapies offered by interventional radiologists are now an essential part of modern medicine. However, even the venerable Charles Dotter, father of IR, cautioned in 1968 that radiologists need to assume clinical responsibilities for their practice or risk becoming “high-priced plumbers” and losing out to competing specialties (Rosch et al. 2003). Indeed, trends in the United States at the turn of the twenty-first century have shown an exponential increase in the volume of endovascular peripheral arterial procedures performed by Vascular surgery and Cardiology compared to IR (Levin et al. 2005). Although this is largely due to the move towards an endovascular-first approach to the treatment of PAD and the corresponding increase in volume of endovascular work, the lack of clinical presence by IR, upskilling of competing specialties and diversification of IR practice to other emerging fields such as IO have undoubtedly contributed to this trend (Choke and Sayers 2015).
Nevertheless, the results of our survey show that the majority of European IRs remain clinically active in endovascular peripheral arterial interventions and that in over two-thirds of European centres, IR remains the main provider of endovascular peripheral arterial procedures. Similar to previously observed trends by Levin et al. in the United States, Vascular surgery is the largest competing specialty in Europe with Cardiology and Angiology following behind.
In Europe, IR also remains the leading producer of research in the field of endovascular PAD therapy particularly in the studies related to infrapopliteal and pedal interventions and drug-eluting technology (Asadi et al. 2017). However, it is imperative that interventional radiologists continue efforts to maintain our presence in the endovascular field and produce meaningful academic contributions to advance and lead the way forward in the next generation of endovascular therapies. Current interventional radiologists and IR trainees need to embrace the role of an “IR clinician” who understands the current evidence-base and gaps in knowledge where future research can be directed, is able to clinically assess and manage their patients in a holistic manner to ensure that best clinical care and evidence can be individualized to each specific situation and is technically proficient and safe in performing and delivering minimally-invasive therapies. In addition, the challenging and evolving landscape of endovascular practice requires IRs to be able to work in a multidisciplinary setting and develop partnerships with other referring specialties to ensure that patients continue to benefit from the added value of IR. The setting up of outpatient clinics to take direct patient referral and the attainment of clinical skills during IR training are vital ingredients for the future of our specialty. Teaching IR to medical students in dedicated curricula is also important to educate future referrers and to attract students to IR. Mentoring students, setting up IR electives and fostering research with students in IR are also significant factors in engaging medical students and stimulating an interest in IR.
Since our previous IR clinical practice survey a decade ago, there has been substantial progress in the development of clinical practice within the specialty. More respondents are now dedicating the majority of their clinical commitment to IR, supported by dedicated IR nurses and technologists and the majority also provide a 24/7 IR on-call service. European IR is fortunate to have a large proportion of experienced practitioners, with over two-thirds of respondents having practiced for over 10 years in the field. The proportion of respondents who run IR outpatient clinics has increased from 26% in 2007 to 42% in the current survey, but there remains room for improvement. The number of dedicated IR inpatient beds (17% in 2007 vs 28% currently) remains low. The proportion of inpatient admission privileges has also decreased from 86% in 2007 to 55% in the present survey. However, as many of the procedures we perform can be delivered in an ambulatory setting, respondents had greater access to day-case beds which has increased from 31% in 2007 to 61%. Indeed, the practice of day-case peripheral angioplasty has been established over the past decade and emerging experience with the transradial access technique will facilitate the further expansion of an ambulatory approach to other endovascular therapies (Spiliopoulos et al. 2016; Posham et al. 2016; Huang et al. 2008). Just over one-third of respondents (36%) perform ward rounds in their clinical practice, however this component of practice was not previously surveyed in 2007 to allow accurate comparison. Nevertheless, as interventional radiologists continue to embrace clinical responsibilities, the requirement for presence in both outpatient clinics and wards will undoubtedly follow.
A majority of respondents practice in large tertiary or university teaching hospitals and many have trainees in their unit. The development of IR outpatient and inpatient clinical services should continue to be encouraged to ensure that future generations of IRs have exposure to these essential components of training. Understandably, development of clinical practice varies from institution to institution and progress is commonly hampered by a combination of shortages of manpower, funding and competition for access to limited inpatient beds and support from hospital management or national health service providers. As many respondents are also practicing in larger teaching units, there is a possibility of selection bias in our survey reflecting responses from those who are more active in the endovascular field. Therefore, the results related to endovascular practice may not accurately reflect “real world” practice in all centres. Nevertheless, it does provide a valuable insight into the present state of practice and will serve as a baseline for future comparisons.