|Year : 2021 | Volume
| Issue : 2 | Page : 43-47
Setting up a sustainable interventional radiology practice in a resource-limited environment: Steps to note, challenges, and strategies
Omodele A Olowoyeye1, Kofo O Soyebi1, Olubukola Omidiji1, Adekunle Adeyomoye1, Nicholas Kayode Irurhe1, Hammed Ninalowo2
1 Department of Radiation Biology, Radiotherapy and Radiodiagnosis, College of Medicine, University of Lagos, Nigeria
2 IRDOC Interventional Radiology Consulting Limited, Euracare Multispecialty Hospital, Lagos, Nigeria
|Date of Submission||04-Jun-2021|
|Date of Decision||17-Aug-2021|
|Date of Acceptance||27-Sep-2021|
|Date of Web Publication||30-Nov-2021|
Omodele A Olowoyeye
Department of Radiation Biology, Radiotherapy and Radiodiagnosis, College of Medicine, University of Lagos, Idi-Araba, Lagos
Source of Support: None, Conflict of Interest: None
Interventional radiology (IR) is a developing sub-specialty in Nigeria. Although IR equipment and consumables are expensive, the benefit to patients on the long run compensates for the financial costs. There are various measures that should be put in place to ensure a safe IR practice. There are associated challenges that may be peculiar to different types of hospitals in our environment. This paper focuses on the steps to consider when setting up an IR practice in a resource-limited teaching hospital setting. It also highlights possible challenges and strategies to overcome such challenges.
Keywords: Dotter, fluoroscopy, interventional radiology, preprocedure, time out
|How to cite this article:|
Olowoyeye OA, Soyebi KO, Omidiji O, Adeyomoye A, Irurhe NK, Ninalowo H. Setting up a sustainable interventional radiology practice in a resource-limited environment: Steps to note, challenges, and strategies. J Radiat Med Trop 2021;2:43-7
|How to cite this URL:|
Olowoyeye OA, Soyebi KO, Omidiji O, Adeyomoye A, Irurhe NK, Ninalowo H. Setting up a sustainable interventional radiology practice in a resource-limited environment: Steps to note, challenges, and strategies. J Radiat Med Trop [serial online] 2021 [cited 2022 Jun 26];2:43-7. Available from: http://www.jrmt.org/text.asp?2021/2/2/43/331520
| Introduction|| |
Charles Theodore Dotter stumbled on interventional radiology (IR) when he unintentionally recanalized an occluded right iliac artery during angiography. Subsequently, he tested this technique on his first patient, who had declined amputation for a leg ulcer and gangrenous toes. Dotter noted that the patient had short segmental stenosis of the superficial femoral artery. He was able to percutaneously dilate the narrowed segment. Soon the foot was warm and hyperemic with subsequent resolution of the leg pain and ulcer. Follow-up angiograms months later showed the vessel to be patent. Since Dotter's discovery, IR has grown in leaps and bounds. Despite the radiation exposure to patients associated with IR, it still offers an overall benefit to patients compared with surgical alternatives, and in some cases endoscopy.
IR is fully developed in many countries outside Africa. However, the development in some African countries has been stalled by socioeconomic challenges. Various attempts have been made to stimulate the interest of sub-Saharan Radiologists in IR over the years. For example, RAD-AID, an international nongovernmental organization (NGO) has organized IR annual outreaches to some of our teaching hospitals since their first visit in 2015. One of the challenges faced when the IR team visited was that there were no IR structures in place on which to build on. Therefore, a lot of time was often wasted trying to set up for each procedure and not all the patients scheduled for procedures got to benefit from the expertise of the visiting IR team. Setting up a sustainable IR practice requires a lot of expertise and groundwork. These shall be explored in this paper.
| Personnel-The Interventional Radiology Team|| |
An area of need previously identified by the hospital was the necessity to build an IR team with a collegial spirit. The consultant radiologists at our hospital requested that the Radiology NGO should focus on this on subsequent visits. Therefore, the visit by the NGO, which occurred in February 2020, just before the COVID-19 pandemic global lockdown, was particularly designed to showcase the role of each health professional in ensuring that IR procedures are safe and successful. [Figure 1] shows members of our department and the NGO team. The team included an IR attending, IR fellow, IR nurse, and an IR technologist. The visit highlighted what is needed from team members regarding coordination set up and peri-procedure care.
|Figure 1: Showing members of Department of Radiology, Lagos University Teaching Hospital (LUTH) with the RAD-AID team that visited in 2020|
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The IR nurse is primarily concerned about the patient's welfare. They receive patients into the IR suite and document preprocedure vital signs. Patients with severe hypertension may be discovered during preprocedure check-up by the IR nurse, and the blood pressure may be controlled prior to commencement of the procedure to prevent excessive hemorrhage. It is important for the IR nurse to obtain from the clinical notes of the interventional radiologist and the patient's case note in general, history of allergies, relevant medical conditions, previous procedures done and history of previous sedatives. The IR nurse or any other person designated is expected to verbalize all this information during time-out. This is a procedure that will be described in further detail subsequently. IR nurses may also monitor the vital signs during and after the IR procedure. These include parameters such as pulse rate, blood pressure, oxygen saturation, and respiratory rate. In diabetic patients, there may be a need to monitor blood glucose levels also, depending on the procedure.
The IR nurses administer drugs for moderate sedation such as fentanyl, midazolam, or Hydromorphone through a preestablished intravenous line. These drugs may affect respiration and other vital signs which is why having nurses with prior critical care expertise is preferable. However, those without prior knowledge of critical care could be trained on the job. In some centers, IR nurses ensure that required consumables for procedures are available in stock.
IR technologists are usually those with prior training as radiographers. They assist with preparing the procedure tray, patient positioning on the table, preparation of a sterile field for the procedure, and image acquisition during IR procedures.
Interventional radiologists are responsible for the patient. They are expected to have reviewed the patient's history and relevant imaging studies during the consultation visit, which is described further below. They are also expected to explain the procedure to the patient and obtain written informed consent.
| Preprocedure Work-up|| |
This is the most important aspect of the IR procedure. Some parts of the preprocedure work-up occur at the consultation visit, while some occur on the day of the procedure.
The consultation visit: Some IR centers run consultation clinics where the patient's clinical notes are reviewed along with any additional information provided by the patient. The patient may undergo a physical examination. The radiological imaging will be actively reviewed with the patient to better understand their disease.
Laboratory work-up: Previous laboratory investigations should be reviewed, and the patient is requested to provide recent international normalized ratio (INR) and platelet count results. These are reviewed, and the threshold for laboratory values for each procedure is gauged based on complexity either minor, moderate or complex. The patient's anticoagulant profile is typically reviewed, and patients are asked to stop or hold anticoagulants based on recommendations for each anticoagulant profile and in conjunction with the referring physician. Drugs such as rivaroxaban and antiplatelets are withheld. Patients may be converted to low molecular weight heparin, which is then withheld a day before the day of the procedure. It is preferable that the INR should not be more the 1.5 and the platelet count should not be <50,000/μL. In centers without a readily available critical care set-up and/or blood for transfusion, a Packed cell volume (PCV) check may be performed, and patients with values <30% declined.
Consent form: Written informed consent should be obtained from each patient scheduled for an interventional procedure or their legal representative. This can be obtained during the consultation visit or just before the procedure. During this process, the patient is educated in layman's language about their condition, the proposed IR procedure, and possible complications.
| Day of Procedure|| |
Baseline image acquisition: Preprocedure imaging is usually performed prior to opening expensive, sterile consumables. The imaging confirms that the pathology is still present on the day of the procedure. This is important because there may be a delay between when the diagnostic images were obtained and the IR procedure scheduled. The delay may be due to fear of the procedure by the patient or financial constraints, as patients often pay out of pocket in our environment. During this delay, it is possible that nature will have taken its course. For example, when a patient who was diagnosed with a loculated pleural effusion in the upper lung zone and scheduled for an ultrasound-guided chest tube insertion finally presented 18 days later for the procedure, no fluid was seen in the pleural space sonographically. The procedure was converted to a CT-guided intervention, but no empyema was seen, as shown in [Figure 2].
|Figure 2: Two axial CT scans of the same patient within 18 days interval. (a) A loculated pleural effusion is seen in the right upper lateral chest wall of the patient lying supine. (b) A preprocedural CT scan done 18 days later with the patient lying in the right lateral position was not able to demonstrate the pleural effusion so the procedure was canceled|
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Pre-procedure imaging is also done for site marking or to determine the access route. For example, ultrasound assessment of the radial artery is used to decide if the radial artery is suitable for arterial catheterization. If not suitable, the good old femoral artery will be used. Baseline ultrasound is also useful in determining which internal jugular vein (IJV) is suitable for a tunneled central venous line placement. Although the right is preferable due to its straighter route to the heart, if it is stenosed or thrombosed, the left IJV may be more suitable. In some cases, the femoral vein may be used.
The interventional radiologist should always plan carefully and think through each stage of the procedure to reduce the wastage of expensive consumables.
Time-Out: This is a very important step that should be performed once everything is set and the procedure is about to commence. It may be carried out by the nursing staff. During the Time-Out, everybody stops what they are doing and listens with full attention to the person conducting the Time-Out. The IR nurse or whoever is doing the time out reads out, documents, and verifies the following information-
- Patient's name, age, sex, allergies, preprocedure vital signs, patient's diagnosis, IR procedure to be performed, which side of the body (right or left), anticoagulant/antiplatelets have been discontinued, recent laboratory values (INR, platelet count, PCV-<3 days), nil per oral (if required), IV line has been secured, previous images have been reviewed, inform consent obtained, everyone is wearing a lead apron, where applicable.
If the interventional radiologist does not regard time-out with the seriousness it deserves, no one else will. It is important that the interventional radiologist nurtures a culture in which everyone in the IR suite pays attention during time-out. Inculcating time-out as part of the regular routine in the IR suite will protect the team from potential mistakes.
Pain control and vital signs should be monitored by the IR nurse. An automatic monitor is helpful in this regard. If not available, a portable pulse oximeter should be used and the blood pressure measured frequently. This will ensure early detection of a decline the patient's clinical status and allow for corrective measures to be initiated.
Postprocedure: The IR nurse should verify and document that patient is stable postprocedure. Depending on the procedure, vital signs may be measured every 15 min or 30 min over a few hours before discharge from the recovery room. The interventional radiologist should verify that representative images are saved where possible. Notes on the procedure done, how access was obtained, guide wire used, size of catheter used, image guidance (computed tomography [CT], US, fluoroscopy), technique, findings and possible challenges should also be documented. They should also verify that the biopsy or biological sample containers are correctly labeled and sent to lab. The patient is instructed on how to care for drains or feeding tubes.
It is important to follow up on histopathology results to see if the tissue sample obtained was of diagnostic quality. Patients who had a drain inserted such as nephrostomy or biliary drain should be informed that the drain needs to be changed over a wire within 6–12 weeks to prevent blockage of the tube. Patients with gastrostomy tubes may be requested to come in once a year for a change of the tube.
| Consumables and Equipment|| |
Procurement of suitable consumables such as guidewires and catheters may be a challenge. Companies that produce these consumables are often reluctant to provide wholesale products to developing countries until they see evidence of a high demand for these products. However, an IR facility should be well-stocked with different sizes for guide wires, catheters, angioplasty balloons, embospheres®, etc., because there may be a need to upsize or downsize during a procedure. Unfortunately, in low-resource settings where patients pay out of pocket, this may become an added cost to the patient or facility.
Storage of IR consumables is important. Improper storage may lead to damage of these expensive IR materials. Guidewires may bend or kink if not properly stored. The protective package may get damaged, rendering it nonsterile. Specially designed storages shelves can be purchased for proper storage. Such storage shelves may also be fabricated locally if the imported ones are unavailable.
Appropriate consumables should be used in a resource-limited environment. For example, it is advisable to obtain core biopsies with a 14G-18G biopsy needle rather than a 20 G needle because samples taken with a small-core needle with may be returned as an insufficient sample by low-resource histopathology centers. Cost may limit the use of embospheres® for particle embolization. In some cases, the lesser options of gel foam or polyvinyl alcohol embolization may be considered. Some authors have considered using small fragments of surgical sutures as a safe and cheap alternative in emerging countries. Reducing the cost of the IR consumables may lead to a decrease in the cost to the patients. Donation of IR materials by NGOs or affluent hospitals might help defray the cost of consumables to indigent patients. In this regard, some consumables were donated to our teaching hospital by RAD-AID.
In countries with government-funded hospital with better healthcare budgets, most of the IR consumables are disposed after a single use. These include disposable sterile surgical gowns, drapes, probe covers, covers for the image intensifier. In our environment, many surgical theatres still use surgical gowns, drapes made of cloth, and these are washed, autoclaved, and reused. Some IR centers also use cloth to make covers for the image intensifier. These cloth covers are also sterilized and reused.
Some people use condoms as covers for the ultrasound transducer while doing procedures. While this may protect the transducer from exposure to the patient's biological material, condoms are not sterile. Neither are they long enough to cover the cable of the transducer. Some others use the palm area of sterile gloves to cover the transducer during procedures. However, this can be clumsy because the fingers of the gloves may get in the way.
Recently, we devised a custom-made probe cover made up of a surgical glove and a cloth sheath with pull strings at the top end, to secure the sheath to the handle of the probe [Figure 3]. The sheaths are of varying length 36” or longer, depending on the type of procedure being done. With this device, the fingers of the gloves may be tucked away within the sheath and secured with the pull strings. In place of disposable CT biopsy grids, we made an autoclavable grid out of a flexible wire mesh basket [Figure 4].
|Figure 3: Showing the custom-made probe covers made up of surgical gloves and 36” long cloth sheaths with pull strings at the top end. (a) Sterile covering for a linear transducer. (b) Sterile covering for a curvilinear transducer|
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|Figure 4: Showing the autoclavable grid made from a flexible wire mesh basket|
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IR is a capital-intensive program. Unless a hospital management sees the profitability of the venture, they may be unwilling to deploy resources to it. Therefore, it is important to capture ultrasound and CT-guided interventional procedures carried out in the department separately from diagnostic imaging procedures. As the number of IR cases done increases, it will encourage more investment in IR. It is also important to document requests for IR procedures that cannot be done in the IR center due to limitations of equipment or personnel. If the requests are many, it will encourage the management to invest in required equipment and personnel training. Equipment rental may be an avenue to explore for reducing costs when starting an IR practice.
| Surgical, Histopathological Collaborations, and Turf Battles|| |
The tricky relationship between surgeons and Interventional Radiologists started with Charles Dotter. However, over time the turf battle has evolved to collaboration. There are patients that are poor surgical risks, for which the surgeon will appreciate a minimal invasive approach to the issue at hand. A good surgeon knows when to refer patients to IR, and a good interventional Radiologist know when to do the converse. Having surgeons as allies means that if an interventional Radiologist runs into trouble, he can readily call for surgical help. It is important to build a relationship with referring surgeons because that ensures that patients get the best of care.
For core biopsies and fine-needle aspirations, histopathological collaboration is vital. Adequate samples for core needle biopsies should be obtained to prevent the unpleasant feedback of “insufficient sample.” Interventional Radiologists should learn how to properly prepare cytology slides from fine needle aspirations. In centers where a microscope is available, a Histopathologist may view the slide immediately and provide a feedback on the adequacy of the samples.
| Marketing and Awareness|| |
IR is a relatively unknown field in our country. Many procedures that could be done under image guidance are sometimes done blindly. These include biopsies, chest tube insertions. Some are done with ultrasound guidance but without fluoroscopy such as nephrostomies and central line insertions. Such procedures may be associated with more pain and other complications. There have been efforts to create awareness of IR in our teaching hospital via hospital grand round presentations and inter-departmental meetings with surgeons or physicians. Medical students are also educated on the scope and benefits of IR during their rotation to the department.
In conclusion, we hope that as we continue to create awareness concerning IR and set up sustainable structures, that there will be increased support from the government and the private sector to enable us provide solutions to diverse patient problems.
- Dr. Farouk Dako, Dr. Scott McLafferty and all members of the RAD-AID teams who have visited the Radiology Department at LUTH over the past five years, to stimulate our interest in Interventional Radiology and to donate IR consumables.
- The University of Toronto Vascular and Interventional Radiology fellowship program and the IR team at Sunnybrook Hospital who provided the corresponding author with firsthand experience of how an IR practice should be run.
- Medivation Health Limited, Nigeria and members of the Department of Radiology, LUTH.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]