Key words
education - interventional radiology - curriculum
Key words
education - interventional radiology - curriculum
Introduction
Interventional radiology is an integral part of clinical radiology. Image-guided diagnostic
and therapeutic procedures are at the core of this specialty. In addition to minimally
invasive interventions, important elements of interventional radiology include pathology,
various imaging techniques and particularly patient management [1]. There are significant overlaps with other clinical specializations that use image
guidance techniques and catheter techniques primarily developed in radiology. Since
image guidance based on radiological techniques is a core element of interventional
radiology, fundamental knowledge of radiation biology and radiation protection is
essential for interventional radiologists [2]
[3].
Interventional radiology has developed rapidly over the last decades. The type of
procedures, the increasing number of procedures and in particular the growing complexity
of procedures have resulted in special requirements regarding the training of radiologists
[2]. In addition to knowledge of the type, implementation, and results of interventional-radiological
procedures, the manual aspect must also be taken into consideration. In light of the
increasing complexity and the necessary level of specialization, interventional radiology
recently became established as its own specialty in the USA, for example. In 2015,
a residency program for interventional radiology was introduced by the “Accreditation
Council for Graduate Medical Education” [4]. In Europe, the European Union of Medical Specialists (UEMS) recognized interventional
radiology as an independent subspecialty of radiology in 2009 [5]. A particular objective of the “UEMS Specialist Division – Interventional Radiology”
has been to establish standards for the education and training of interventional radiologists.
CIRSE created an interventional radiology curriculum ending with a certification examination
(European Board of Interventional Radiology – EBIR) [2]
[6].
In Germany, interventional radiology has grown since 2008 from a working group within
the German Roentgen Society (DRG) into the German Society for Interventional Radiology
and Minimally Invasive Therapy (DeGIR). As an affiliated society, the DeGIR is firmly
rooted in the DRG. Since specialist training in radiology already includes extensive
requirements, the DeGIR does not see a need to create a separate core area. Analogously
to the "UEMS Specialist Division – Interventional Radiology", a main goal of the DeGIR
is to establish training standards for interventional radiology including highly specialized
interventional procedures. This objective is pursued in close cooperation with the
German Society for Neuroradiology (DGNR). The aim is to establish a uniform standard
regarding the knowledge and skills required by interventional radiologists. It must
be taken into consideration that the broad spectrum of interventional radiology includes
many areas, such as revascularization procedures and oncological and neuroradiological
interventions.
To this end, a two-level modular concept was developed based on the qualification
initiative of the DeGIR. Using two levels and six modules, this concept represents
the requirements for interventional radiologists and neuroradiologists ([Table 1]). Training is concluded with an examination [7].
Table 1
Modules of the DeGIR/DGNR module and level concept.
|
name
|
short description of the module content
|
|
module A
|
vessel-opening procedures, incl. lysis, PTA, stent, endoprosthesis, thrombectomy,
etc.
|
|
module B
|
vessel-closing procedures, incl. coils, liquid embolic agents, particles, plugs, etc.
|
|
module C
|
diagnostic punctures, drainages, PTCD, bile ducts, TIPPS, gastrostomy, port, etc.
|
|
module D
|
oncological procedures, incl. TACE or other tumor-specific embolization procedures,
ablation, percutaneous tumor treatments
|
|
module E
|
vessel-opening neuro-interventions (PTA/stent of the extracranial supraaortic arteries,
PTA/stent of the intracranial arteries, mechanical recanalization in stroke, local lysis
and spasmolysis in stroke)
|
|
module F
|
neurovascular embolization treatments (embolization and comparable procedures for
intracranial aneurysms, embolization of intracranial and spinal vascular malformations,
other embolization procedures in cerebral vessels, vessels supplying the brain and
vessels supplying the spinal cord)
|
The creation of this modular program was accompanied by the establishment of a network
of training and internship centers. In the future, specialist training in interventional
radiology is to be performed at certified training centers. These centers must be
able to show a documented minimum number of procedures for the individual modules
via the DeGIR quality assurance software. Moreover, a trainer with corresponding proof
of the highest certification of the DeGIR must be present.
Interventional radiology curriculum
A standardized curriculum is needed to define uniform training content in Germany.
With the "European Curriculum and Syllabus for Interventional Radiology", the "Cardiovascular
and Interventional Radiological Society of Europe" (CIRSE) created a basis for standardized
training in Europe in 2013 [10]. However, the structure and parts of the content do not correspond with the requirements
and reality of training in the field of interventional radiology in Germany. Therefore,
the DeGIR created an interventional radiology curriculum that complements the DeGIR/DGNR
module and level concept. This curriculum builds on and further develops diagnostic
and interventional radiology/neuroradiology content already taught during specialist
training in radiology. This curricular catalog presents the possible scope of each
module without weighting the individual topics.
The DeGIR curriculum for interventional radiology is comprised of cross-module topics
([Table 2]) and specific module-related requirements. The latter are consistently structured
for the different modules according to technique, material, image guidance, and procedural
considerations as illustrated in the example of [Table 3] on the basis of catheter angiography as part of module A.
Table 2
Cross-module topics of the DeGIR curriculum in interventional radiology.
|
General knowledge and radiation protection
|
|
general knowledge
|
-
anatomy of the arteries and veins, vascular territories (functional brain areas)
-
basic principles of hemodynamics and vascular physiology
-
basic principles of analgesia and sedation
-
basic principles of blood coagulation and the pharmacology of anticoagulants and their
antagonism
-
basic principles of pathology, pathophysiology, and clinical assessment of module-typical
diseases
-
pharmacology, risks and complication profile of contrast agents
-
alternative and complementary diagnostic and treatment methods (value of noninvasive
diagnostic methods, standard vascular surgery treatments, hybrid procedures, conservative
therapy approaches, etc.)
-
basic principles of peri-interventional monitoring
-
basic principles of interdisciplinary indication determination and collaboration
-
basic principles of quality assurance (DeGIR QA, legally required QA)
|
|
radiation protection in interventional-radiological procedures
|
-
active radiation protection (pulsed fluoroscopy, last image hold, recording of fluoroscopy
series, collimation, exposure geometry)
-
passive radiation protection (protective clothing, leaded glass goggles, radiation
protection attached to equipment, radiation protection shield), special considerations
in CT interventions with high kV values
-
dosimetry, dose structure report (DSR).
|
Table 3
Example of a module-related theme of DeGIR Curiculums Interventional Radiology.
|
Aortic, visceral, and peripheral catheter angiography
|
|
Technique
|
Cross-over technique, selective and superselective catheter techniques
|
|
Materials
|
Plain and selective catheters, manual and automated contrast injection. Advantages
and disadvantages of different contrast agents (e. g., iodine-containing contrast
agent, CO2, etc.), medication (butylscopolamine, vasodilators, etc.)
|
|
Guidance
|
Fluoroscopy (pulsed, high-dose), DSA
|
|
Special considerations
|
Patients with renal insufficiency, intolerance to contrast agents
|
This curriculum is a living document and should be modified and supplemented according
to developments in interventional radiology. This curriculum makes it possible for
the first time in Germany to teach interventional radiology and neuroradiology in
a structured manner. The curriculum can be used as a basis for the individual structuring
of training at the training centers for interventional radiology and/or neuroradiology.
It also provides the basis for the level-2 examinations "specialization in interventional
radiology and/or neuroradiology". In the future, holders of level-2 certificates will
be able to refer to themselves as "certified interventional radiologists of DeGIR
(level 2)" or "certified interventional radiologists/neuroradiologists of DeGIR/DGNR
(level 2)". Depending on the modules in which level-2 certification is acquired, various
additional qualifications such as vascular medicine or interventional oncology are
possible.
