Interviewer: Apurva Bhavana Challa

Editors: Edna Wang, Andy Moore and Yi Yang

I first heard of the speciality of interventional radiology (IR) during my away rotation in vascular and endovascular surgery in the USA. Even though I went to one of the eminent medical schools in India and I am the eighth doctor in my family, I had never heard of IR during my medical school education. The procedure of stenting an iliac artery in a case of peripheral arterial disease was so fascinating to me that I changed all my away rotations in the USA to IR. After completing my rotations, I started sharing my experience in this new specialty with my medical school classmates.  However, they could not relate to it because most procedures are still performed in an open fashion and rarely endovascularly in India. The practice of radiology is perceived as reading in a dark room with X-ray films, and the idea of radiologists performing procedures endovascularly is beyond one’s imagination. During my rotations, whenever I got asked about IR practice in India, I didn’t have a good answer. This lack of knowledge about IR in my own country motivated me to learn more about IR and its practice in India.

The practice of IR in India started in the early 1970s with 19 physicians practicing at 9 institutions. The Indian Society of Vascular and Interventional Radiology was established in 1997 by 28 physicians practicing at 18 institutions. Even though the number of practicing interventional radiologists has increased from 19 to nearly 500 now, it is inadequate given that the population of India is 1.3 billion. There wasn’t a structured IR training pathway until 2017. The pathway to becoming an interventional radiologist in India now is to join a three year accredited IR training program after completing three years of radiology residency. Currently, there is a limited number of fellowship training positions available in India with 33 institutions offering IR, 10 institutions offering Neuro IR, 2 institutions offering Hepatobiliary IR, 1 institution offering Cardiothoracic and Vascular IR, 1 institution offering Phlebotomy and Venous IR, and 1 institution offering Interventional Oncology IR training.

Practicing a speciality that is not well-established is the biggest career challenge a physician can face. I have interviewed a diverse group of brave physicians who pursued IR as their speciality and are passionately practicing it while trying to expand and develop it further. I hope the interviews below will provide further insight into the practice of IR in India.

Dr. Kumble S Madhusudhan

His subspeciality interest is gastrointestinal and hepatobiliary radiology with special interest in IR for GI bleeding and pediatric Budd Chiari syndrome. He is the principal investigator of two ongoing research projects on embolization for gastrointestinal bleeds and IR interventions for bilioenteric anastomotic strictures. He has authored numerous book chapters and research papers in IR. He was the assistant editor of the IR section of the American Journal of Roentgenology from 2018 to 2020. He is the editor of the hepatobiliary interventions section of the Journal of Clinical and Interventional Radiology (JCIR).

Dr. Shyamkumar Nidugula Keshava

His team has published techniques in the management of Budd Chiari syndrome including the use of trans-abdominal US guidance during Transjugular Intrahepatic Portosystemic Shunt (TIPS) and transjugular liver biopsy and cannula-assisted recanalization of occluded hepatic veins and inferior vena cava. He is a contributor to the IR fellowship curriculum in India and a member for IR faculty selection at the most eminent institute in India. He is the founder and Editor-in-Chief for the Journal of Clinical and Interventional Radiology.

Dr. Mangerira chinnappa Uthappa (Vipin)

His team is the first in South India to perform microwave ablation of a liver tumor and first in India to provide prostate artery embolization for a patient with BPH-related symptoms. His team started an IR education event called Global Interventional Radiology Symposium. He is also part of a motivated group of doctors who are keen to set up a Cancer Village that provides holistic care for cancer patients. He is the editor of the interventional oncology section of the Journal of Clinical and Interventional Radiology.

Dr. Pushpinder Singh Khera

His areas of interest are neurointerventional radiology and emergency IR. His research interests include AI in IR and oncologic IR. He likes to teach students and be involved in academic activities such as CMEs and workshops, which made him choose academia over private practice. He is an editor of the Journal of Clinical and Interventional Radiology for the musculoskeletal IR section, which is an under-represented IR subspeciality in India.

Dr. Shivanand Gamanagatti

He developed new procedures on his own by reading, going through video clips, and attending CMEs. He streamlined and developed many procedures at the All Indian Institute of Medical Sciences including TACE for HCC, revascularization procedures for Budd-chiari syndrome, and embolization for pseudoaneurysms and obstetric bleeds. He also developed IR procedures for post-traumatic bleeds from solid organs, pelvic injuries, maxillofacial injuries, peripheral vascular injuries, as well as non-vascular procedures such as urinary leaks, biliary leaks, and insertion of feeding gastrostomy and jejunostomy tubes. He has published numerous book chapters and research papers. He is the editor of the gastrointestinal interventions section in the Journal of Clinical and Interventional Radiology.

Dr. Deepa Shree

The percentage of women interventional radiologists in India is 2%. Dr. Shree is the head of the IR department at Dr. Rela Institute and Medical Centre. She specialized in hepatopancreaticobiliary IR and conducts CMEs and workshops to create awareness about IR among patients and physicians. She is also the author of the book Art of Balance. Dr. Shree believes in taking passion to work and maintaining a work-life balance.

Through conversations with these physicians, I learned that the practice of IR in India has changed tremendously over the years. In the beginning, angiography machines had little storage space and only basic functions were available, so all studies were printed on films until the arrival and integration of PACS. Vascular procedures were predominantly performed using 5F catheters, since micro-catheters were rarely available given their high cost. Similarly, stents were extremely costly, so they were not used in procedures. Two major challenges in India have been the cost and the availability of equipment. Although there is a drastic improvement in the availability of equipment, the challenge of affordability remains. Hopefully, changing medical insurance policies will improve affordability. The balance between demand and supply has been improved by government schemes which is a welcomed step, but there are still miles to go.

The number of radiologists practicing IR was also once limited. Now more practitioners of IR are available in the Indian private practice sector. Furthermore, with advancement in the equipment and hardware used in IR, an increasing number of procedures are performed by IRs. Many conditions which were previously treated by surgeons, such as non-variceal GI bleed, Budd-Chiari syndrome, collections from acute pancreatitis, and liver tumors, are now referred for IR interventions. These include TIPS, embolization, hepatic vein/ IVC stenting or angioplasty, ablation of liver tumors, and TACE. Advanced procedures like BRTO, pediatric liver interventions, IR for biliary anastomotic strictures, etc. are more commonly performed now. This improvement has a considerably positive influence on the training of residents and fellows as it exposes them to these procedures and improves their knowledge and skills.

Yet, there are a few challenges in training residents and fellows in IR in India. One of which is the limited exposure to IR during radiology residency, because there are only a few institutions that are providing structured training exclusively in IR.  Furthermore, even though the need for a structured training has been recognized and defined, it has not been widely implemented, especially at institutions where the volume of patients needing interventional procedures is low. The practice of IR is different and variable throughout the country. There exists two main types of practices – academic institutions and private hospitals. Smaller institutions may suffer from a shortage of equipment necessary for IR procedures. This puts the burden on the patients to pay for certain equipment which may delay the procedure. Another problem that many of the radiology residents face is the requirement of completing a structured certified training before being employed by big corporate hospitals, despite having adequate hands-on training in most vascular and non-vascular interventions. Although a more uniform and systematic training program in IR is necessary, making the completion of such a program an eligibility criteria to practice IR may not be reasonable until there is a sufficient number of such quality training programs in the country. For these reasons, IR specialists who are trained abroad are often preferred over those trained within the country. The final challenge that physicians face is non-radiology clinical colleagues who are venturing into the practice of IR.

From 2017, when I have started my IR journey, to 2021, I have seen a paradigm shift in the thinking of doctors who have recently graduated from medical school. The awareness about IR has increased in multiple folds that even students who hailed from rural parts of India are becoming aware and are considering choosing IR for their fellowship after completing a radiology residency. The receptiveness for IR as a desirable specialty has increased.  For example, my best friend who planned to choose surgery for residency was enthralled after listening to my IR experience and chose a radiology residency instead with the goal of pursuing IR fellowship. Radiology residency is the toughest to get into in India.  We need to take a nation wide entrance exam which determines which specialty we can choose depends on the marks we score. Only the highest achieving get into a radiology residency, which means the most hardworking and intelligent Indians get to pursue IR. I believe my generation of open minded inquisitive minds will take IR to greater heights in India in the years to come.