Well it’s a new year, and though it may feel like groundhog day most of the time with the ongoing pandemic, medical innovation continues and Interventional Radiology is at the forefront of that innovation.  I personally find it nearly impossible to stay current on all the new products and most IRs can agree that a close relationships with industry reps is important (I would argue crucial) in order to stay current and help decide what may be best to help our patients.  I had a chance to sit down (yes we sat down together and had lunch!) one of the first reps I met when I moved back to Saskatoon.  Mike Remo is an Associate Territory Manager-Vascular, Western Canada for Penumbra, Inc. and a great person to have lunch with.

CAIR: Hey Mike, thanks for taking the time to talk to us.  As we enter a new year, what devices/equipment are you most excited about from Penumbra in 2022 and why? 

MR: That’s truly a difficult question. I am so fortunate to have an amazing portfolio in Thrombectomy and Embolization in both the Neuro and Peripheral vascular space. The innovation pipeline is rich and ever changing so I feel like I am in constant “launch mode” with Penumbra.

I must say that our Lightning Technology from our Thrombectomy line is what gets me most excited. There is nothing on the market like our Intelligent Aspiration. Lightning Technology coupled with our State-of-the-Art Aspiration catheters allows interventionalist from various specialties such as Vascular Surgeons, Interventional Radiologists and Interventional Cardiologists to treat clot burden, from both the arterial and venous systems safely and effectively with little to no use of TPA in single sessions. This benefits the physician, their patients and keeps patients out of ICU’s, while vastly reducing the bleeding risks.  This technology is used with our proprietary Engine Pump that creates near perfect vacuum and has a very efficient streamlined set up which is key in acute settings.

Secondly, our Ruby Coils for embolization are incredible. They do not rely on fibers for Thrombogenesis but Penumbra platinum coils mechanically embolize target vessels thanks to their very dense packing. Ruby coils are unique as they are extremely soft, high volume and have long lengths (60cm) and are fully retractable. This is important as less coils will be used in each case. This is better for the patient, less exposure to radiation, shorter procedure times and is cost effective for the healthcare facility. The different product families allow for versatility for various case types.

CAIR: I haven’t had a chance to try out your thrombectomy line yet, but I am hoping to soon, and I will concure that those Ruby coils are very soft and easy to pack! How do these technological advances impact patient care?

MR: The innovation from Penumbra always has the patient in mind first! Penumbrians collectively make it a mission every day to partner with our physicians to ensure our medical devices are used appropriately for the right patient to better their outcomes. Thus provide the best potential outcomes and quality of life for Canadians.

We all know how this current COVID-19 Global Pandemic has negatively impacted our health care system. One of the greatest concerns is running out of ICU beds in our health care facilities. The system is emergently flooded with patients that have clot burden, a known side effect of Covid. It could be stroke, myocardial infarction, DVT or Pulmonary Embolism. One of the main treatment options is the use of TPA which we know is associated with a high bleeding risk and requires a team to monitor these patients over a few days in the ICU. This negatively impacts an already tired medical team let alone the valuable ICU bed.

Our Penumbra Indigo mechanical thrombectomy  device is a great option for all the disease states I mentioned earlier. It is effective, safe, and easy to use. The Lighting Technology available with our newly approved CAT7, CAT 8 and CAT12 aspiration catheters in Canada help mitigate blood loss intra-operatively while the new sizes and design allow for excellent tracking. These newly approved products also now carry the indication for use in PE, which is especially exciting given the lack of tools available up to this point and the current desire to develop effective PERT teams. Most importantly for the patient is single session, little to no TPA use and can keep them out of the ICU. The procedures are endovascular therefore they are less invasive vs surgical options.

As for our embolization Ruby Platform, the mechanism of action for creating a  mechanical occlusion has shown to provide lower recanalization rates vs the fibered counterparts that rely on thrombogenis for occlusion. This is important because recanalization means bringing the patient back for further care. Retractable coils like Ruby allow for better control in the procedure which is safer for patients as well.

CAIR: You are correct that we are all trying to find ways to keep patients out of the ICU, we got pretty creative in Saskatchewan with our thrombolysis patients particularly during a time when we were sending ICU patients to Ontario because we had no ICU capacity (quick shout out to any IRs in Ontario who helped treat the patients sent from Saskatchewan, thank you). Mike, how does Penumbra support IRs hoping to learn more about this? 

MR: Educating in this pandemic at the end of 2020  was a challenge! Fortunately, most hospitals that were locked down at this time had a virtual option such as ZOOM for education. Fast-forward to today and we are still in a pandemic but we are starting to see some normalcy in what I typically do.

My passion is to partner with my IR’s and present them options that will help them in their procedures, in turn providing better care for their patients. Each IR’s needs are different, and I like to tailor my support for their needs. I take pride in what I do and support my partners through face-to-face meetings, in-services for the entire team that are essential to get a hands-on understanding of how our devices work and troubleshooting tips. I take my support seriously therefore I am available 24-7 for case support. I even have my home number on my voicemail if there happens to be a time I miss a call on my mobile. In my absence my teammates across Canada are also available for case support. We further support cases by bringing our own medical device stock for hospitals that currently do not have our devices or consignment.

Last, we provide on going webinars, host PEER meetings, attend all the critical conferences where our IR’s may be, and communicate and support the latest relevant clinical studies. We always include educating Fellows to ensure they have the most current information about Penumbra devices and have the opportunity to learn beyond the doors of the hospital, so they remain on the cutting edge and can receive a global perspective.

Mike Remo is an industry professional with almost 20 years of experience beginning his career in Pharmaceuticals and quickly transitioned to Medical Devices.

His passion for medical innovation and being a clinical consultant is what brought him to Cook Medical and specialized in Aortic Intervention (EVAR/TEVAR). This allowed him to create relationships with Cardiac/Vascular Surgeons and Interventional Radiologists around the country. His business acumen led him to the Medical Start up Ascyrus Medical which had developed an Ascending Dissection Stent (AMDS) to treat Type 1a Dissections. The success of this team to penetrate the market let to the sale of their company to CryoLife Inc. (Artivion) in 2020.

Today, Mike consults for Penumbra Inc., a leader in Thrombectomy (Indigo) and Embolization (Ruby). Mike has developed many friendships with his physicians and is considered an essential partner to help with patient care.

Mike is based out of Winnipeg, Manitoba with his lovely wife Candess and daughter Pepper who also has an interest in Medicine when she graduates in 2024.

Contact info: mremo@penumbrainc.com  | 431-996-9000

*This content was created by CAIR editors on behalf of Penumbra as a CAIR industry partners.  CAIR makes no claims, promises, or guarantees about the accuracy, completeness, or adequacy of the content, and expressly disclaims liability for errors and omissions in the contents of this article. Reference to any specific commercial product, process, or service, or the use of any trade, firm or corporation name is for the information and convenience of the public, and does not constitute endorsement, recommendation, or favoring by the CAIR.

Dr. Jason Wong, MD, FRCPC, FSIR, FCIRSE

Dr. Jason Wong: The Man, The Myth, The Baby-Faced Legend

Jason Wong wasn’t always a famous Canadian IR, at one point he was just a kid, growing up in Calgary, Alberta, the youngest of 3 siblings.  Just how much younger was he then his siblings?  Almost 2 decades, leading some to believe he was a (happy) accident.  He was a straight A nerd (in a good way!), also excelling at volleyball and lacrosse. He attended the University of Calgary undergrad, where he was exposed to and mesmerized by MRI physics…as an undergrad (I said nerd!).  Though he always had his sights set on medicine, it was that exposure that got him thinking about radiology as a career. Once at the University of Calgary he met Dr. Robin Gray and Dr. Benny So, who became early mentors; they were instrumental in making his training interesting and fostering his love for procedures, which eventually led to an IR fellowship at Stanford University.

Once fellowship was complete, Jason took a job at Foothills Hospital in Calgary, and so began his illustrious career.  Over the years Jason’s practice has evolved to include complex endovascular cases and heavy interventional oncology, specifically Jason enjoys liver intervention, getting his kicks with TACE, TARE and TIPS.

It was in 2012 that Jason was somehow bamboozled into joining the CAIR board.  Actually he was voluntold by Dr. Richard Owen, and he had no idea how far down the rabbit hole he would tumble. Dr. Wong thoroughly enjoyed his time on the CAIR board and cherishes the friendships he made over the years. His involvement in CAIR showed him how many dedicated and passionate IRs there are across the country, working to deliver high quality care to patients as well as dedicating their free time to advance the visibility and credibility of our organization. It all culminated in 2017 when Dr. Wong became the Association’s 10th President.

As I force Jason to reflect on all of his accomplishments to date (and I realize I am making him sound old and about to retire, let me assure you he is not, and as anyone who has met him can confirm, he doesn’t look a day over 30) he hopes to be remembered as an IR who contributed to the specialty and fostered a collaborative, team based environment focusing on excellent patient care. Dr. Wong is excited about where IR is heading in Canada, with official subspecialty recognition by the Royal College of Physicians and Surgeons of Canada we have demonstrated to our colleagues in other specialties our special clinical knowledge that sets us apart.  In addition, IR is becoming more and more popular for medical students and residents, leading to many high quality applicants who will soon join the ranks of the hardworking IRs across the country. The technology is always evolving and Dr. Wong isn’t done expanding his IR repertoire as Foothills Hospital recently acquired an IRE generator for clinical use.

It would be unfair to highlight all Jason has contributed to IR in Canada without acknowledging the support he receives from his family.  None of Jason’s accomplishments would have been possible without the love and support of his wife, Seline, and their two sons Logan and Luke.  Though Jason’s volleyball days may be over, the family enjoys getaways to the mountains in the winter and wakesurfing in the summer. I am trying to acquire a video of him wakesurfing to show at the next CAIR meeting, stay tuned.

Jason’s advice to IR fellows or new in practice IRs is that this place (the hospital/IR suit) will exist without you; opportunities for leadership, research, and teaching will always be there, so be selective and deliberate with what you agree to. This is a marathon, not a sprint, so take care of yourself and don’t burn out. The relevance of this advice has been highlighted by the events of the past 2 years and I suspect there are many of us who need to hear it.

For anyone who would like to talk to Dr. Jason Wong, he will be at the CAIR Annual Scientific Meeting in Montreal, May 26-28, 2022. See you all there!

Residents and Fellows Day (#RFD22) is back!

May 25, 2022 | Hotel Bonaventure, Montreal, QC

Who can submit a case : Residents and fellows enrolled in a radiology program across Canada and who are members in good standing with CAIR.

• Successful applicants must bring a PowerPoint to present, a draft of which must be submitted at the time of application.
• Unsuccessful submissions may be considered for inclusion in the Cases of the Month circulated by the CAIR, along with the cases selected for presentation at the Residents & Fellows Day.

Submission criteria:

1. A letter of intent explaining why you would like to attend.
2. A short, updated CV (maximum 2 pages) that must include contact info (email address and phone number).
3. A letter of recommendation signed by your program director.
4. A draft presentation including relevant sample images (jpg/png, max 10MB). The draft presentation must be anonymous, your name and your institution should not appear.
5. The submission needs to be complete to be considered.

Complimentary registration, and a bursary for transportation and accommodation will be provided to 20 residents and fellows selected to present the best cases.

Send your complete submission at cairservice@cairweb.ca , deadline: March 31^st, 2022!

Corporate Partner

CAIR programs are made possible through unrestricted education grants from our corporate partners and sponsors and are planned to achieve scientific integrity, objectivity, and balance.

Based on casual conversation with Canadian endovascular specialists, it seems as though when compared to Europe and the US, Canada is behind in addressing veno-occlusive disease. One of the world leaders of venous interventional medicine is Professor Gerry O’Sullivan from University Hospital Galway in Ireland. We had the pleasure of interviewing Professor O’Sullivan. 

Professor O’Sullivan is a consultant interventional radiologist at University Hospital Galway, Ireland. Previously, he held a consultant radiologist position at Rush University Medical Center in Chicago. Prof. O’Sullivan completed his basic medical training (MBBS) at University College Cork, Ireland.

CAIR: Veno-occlusive disease in Canada is under explored compared to the EU and US with many patients being left untreated. I understand this may have been the case in Ireland, where you saw a need. Can you elaborate?

GS: I think this represents a significant opportunity for Vascular positions and particularly interventional radiologists.

At the present time, venous ulcer patients are probably the most underserved and underrepresented portion of any vascular disease space, despite the fact that they suffer, often needlessly, and absorb huge taxpayer dollars and resources and clinic time and nurse time and bandages and dressings and wound care clinics etc. etc.

Interventional radiologists and other vascular experts can certainly help with these patients, and they are incredibly grateful; and with the skill set that most IRs already have, they are in a position to profoundly and positively affect patients’ lives.

After my initial IR training in England, I went to Stanford in California where I was exposed to, at the time, some very forward thinking people back in 1998. I then spent 3 1/2 years in Chicago and realized that my future lane was not so much an aortic dissection, which is what I had intended, but more so venous disease.

When I came back to Ireland in 2002 I could see that, frankly, it was pretty neglected. Acute thrombotic events patients at that time were simply offered anticoagulation, and we have managed to change this to some extent.

I now offer the full gamut of venous interventions apart from arteriovenous malformations which I referred to a colleague in Dublin, two hours away. Apart from that, I do venous reflux disease, SVC obstruction, IVC obstruction, acute DVT, chronic venous obstruction, venous ulcer treatment, varicocele embolization, pelvic vein embolizations, and cancer related embolization, the list is endless. By and large I have given up arterial disease apart from embolization – I’m not saying it’s the only way to do things, it’s just the way I’ve done things and it’s work for me.

CAIR: Management of veno-occlusive disease has evolved over the years. Can you highlight some of the more significant breakthroughs and how they have changed your practice?

GS: Venous thrombosis techniques are now very efficient for removing large volumes of thrombus thanks to pharmacomechanical thrombolysis and very low-dose thrombolytics, so the days of five days of catheter directed thrombolysis are well and truly over. Around 90% of patients can be treated by thrombectomy device and occasionally in the remaining 10%, we put them on catheter directed thrombolysis overnight. After their thrombectomy Venous stents are a big help. Better diagnostics are a big help to, as we have gotten much better at MRV thanks to help from some European centres.

I think venous disease is under-represented on the diagnostic radiology and interventional radiology curriculum and I certainly have learnt a great deal after my training.

CAIR: A loaded question: How would you recommend starting up and maintaining a veno-occlusive service?

1. Educating other physicians
2. Recruiting patients
3. Multidisciplinary clinic
4. Patient follow-up

GS: All of the above. I frankly am a “vein lover” as opposed to a “vain lover”!!  I have no hesitation in making sure that the vascular lab contacts me first for acute deep vein thrombosis management, they generally do. The Vascular Surgeons are quite happy to dump all of this on me, I gladly except, be it acute events, chronic or acute on chronic thrombosis. Most interventional radiologists already have their foot in the door of the Nephrologists with AV fistula maintenance and HD line induced central veno-occlusive disease, and so it naturally leads from one to the other and there’s absolutely no shortage of work.

CAIR Express – your Canadian Interventional Radiology newsletter at your fingertips. Feel free to pass it along to others in your network, and most importantly, enjoy the content that is developed with you in mind.

Dr. Taylor Loon MBBChBAO, PGY-1 Diagnostic Radiology, SUNY Upstate Medical University

I was once in a patient handoff where the resident doctor had a transgender male patient on their service. While discussing the patients care with myself, they frequently stated the patients deadname (calling a transgender person by their birthname when they have changed their name as part of their gender transition)¹ and commonly referred to the patient as “she” rather than “he”. After multiple attempts to correct this resident’s comments, I felt unsuccessful in trying to change their outlook towards transgender patients in their care. Being a member of the LGBTQ+ community myself, I began to wonder despite commitments to patient care equity, how do we be better regarding care of our transgender and non-binary patients? 

Barriers to Access of Care

Lesbian, gay, bisexual, transgender and queer or questioning + (LGBTQ+) experience higher rates of healthcare disparities compared to their heterosexual or cisgender counterparts.  Identifying factors contributing to these disparities have included perceived discrimination from health care providers and denial of healthcare, in addition to racial identity and geographic location². Published in 2020, the Trans PULSE Canada project collected survey data from 2873 trans and non-binary people in Canada in 2019. 45% of the participants reported having 1 or more unmet healthcare needs in the year 2019.² This is compared to 4% of the general Canadian population in the year 2015.² In addition, 12% of patients avoided going to the emergency department altogether due to their trans identity, despite needing care. Past history of harassment, or fear of harassment was reported to be a major contributor to resistance to healthcare access by those patients in the study. ²

How Can We Improve?

A mini-guide into common definitions

It is without a doubt that we as medical professionals want to provide the highest quality care to our patients in an open and judgmental-free way. However, for many this may be challenging due to lack of familiarity of understanding the correct terminology regarding the patient’s gender identities. The list below is a mini-guide into common terminology.

Transgender or trans: “an umbrella term for people whose gender identity (a person’s internal, deeply held sense of their gender, their ‘maleness’ or ‘femaleness’) and/or gender expression (the external presentation of gender, such as name, clothing, hair, voice, and/or body characteristics) differs from what is typically associated with the sex they were assigned at birth”²

 A transgender patients identity does not depend on physical appearance, if they are taking hormonal therapy, or if they undergone any surgical procedures (gender confirmation surgeries). In addition, make no assumption based on their appearance alone and believe patients when they tell you that they are trans.

 Non-binary, gender non-conforming or genderqueer/genderfluid: “terms used by people who experience their gender identity and/or gender expression as falling outside or somewhere in between what is typically associated with being a ‘man’ or ‘woman’”²

These definitions are much different than transgender and should not be used interchangeably. They should only be used if the patient self-identifies as non-binary or gender non-conforming

 Two Spirit: “Two-spirit” refers to a person who identifies as having both a masculine and a feminine spirit, and is used by some Indigenous people to describe their sexual, gender and/or spiritual identity. As an umbrella term it may encompass same-sex attraction and a wide variety of gender variance, including people who might be described in Western culture as gay, lesbian, bisexual, transsexual, transgender, gender queer or who have multiple gender identities.”³

Cisgender: a term for people whose gender identity matches the sex that they were assigned at birth. ²

Using Preferred Terminology

Very commonly, the name and pronoun of the patient you are caring for may not be what they choose to identify with. Changing names and genders on medical records may often be extremely challenging for patients and thus resulting in the information not being up to date. Calling a patient by the wrong name or “deadnaming” a patient can put them in an incredibly uncomfortable position.

When first meeting a patient, ask them how they would like to be addressed and, if they are comfortable sharing, what pronouns they use. In addition to making sure other staff members in the department use the preferred pronouns and names of patients, check that medical documentation includes this information as well. If unable to change the patient’s name in a medical record, put their preferred name in parentheses beside and only use their preferred and pronouns name when dictating, writing progress notes or procedure notes.

Creating a Welcoming and Supportive Environment

So how exactly can interventional radiologists achieve this? One simple way to make your department or practice more inclusive is the use of signs, stickers, and flags such as the LGBTQ+ pride flag and the transgender and nonbinary flags. It is a small, simple gesture that can help create ease in patients and let them know that your practice is a safe space where they are able to seek care.

Another way to support patients is to avoid unnecessary gendering in forms, procedures, and medical documentation. A first step would be to avoid using gendering language such as “sir”, “maam”, or “miss” when addressing patients.  Providing gender neutral bathrooms and change rooms, having a patient write their gender identity (if needed) on any medical forms rather than a tick box of male vs female, providing patient gowns that are comfortable and covering a range of individuals are a few small steps to decrease unnecessary gendering.

Most importantly, make sure yourself, colleagues and staff are trained in these practices. Every provider in your department from radiologists to nurses to techs should be educated in how to make sure trans, two-spirit and non-binary patients are treated with respect and dignity every step in their care. Colleagues should be corrected if still using incorrect terminology in regards to a patient’s identity. Organizations such as Rainbow Health Ontario and Trans Care BC offer on-demand and scheduled courses for healthcare providers to increase both clinical and cultural competency in treating LGBTQ+ patients and creating an inclusive environment.

Inclusivity is not about creating unnecessary changes and policies to a department or practice nor is it an overnight process. By understanding the needs of our trans and non-binary patients, we can help create a strong patient-provider relationship and provide safe and welcoming interventional radiology departments.

References

¹Stowell, J. T., Grimstad, F. W., Kirkpatrick, D. L., Brown, L. R., & Flores, E. J. (2019). Serving the Needs of Transgender and Gender-Diverse Persons in Radiology. Journal of the American College of Radiology, 16(4), 533–535. https://doi.org/https://doi.org/10.1016/j.jacr.2018.12.050
²Trans Pulse Canada. (2020, March 10). Health and health care access for trans and non-binary people in Canada. Retrieved October 26, 2021, from https://transpulsecanada.ca/results/report-1/.
³Fewster, P. H. (n.d.). Two-spirit community. Researching for LGBTQ Health. Retrieved October 27, 2021, from https://lgbtqhealth.ca/community/two-spirit.php.

Dr. Charlotte Yong-Hing

All Canadians have a fundamental right to individual protection from discrimination and bias. Promoting equity and diversity within medicine fosters a just professional and learning culture that cultivates the diverse perspectives within it, reflects the communities physicians serve, and promotes professional excellence and social accountability.  Evidence indicates that when equity and diversity in medicine is achieved patients experience improved care and a more responsive and adaptable health care system.

Given that CAIR is dedicated to improving Canadians’ health and quality of life we thought a discussion about equity, diversity and inclusion in (interventional) radiology was in order.

We reached out to Dr. Charlotte Yong-Hing, who is a Clinical Assistant Professor, UBC Radiology; the Medical Director of Breast Imaging at BC Cancer Vancouver; President Elect of the BC Radiological Society; and President Elect of the Canadian Society of Breast Imaging.  Dr. Yong-Hing also co-chairs the UBC Radiology Equity Diversity and Inclusion Committee and chairs the Canadian Association of Radiologists Equity Diversity and Inclusion Working Group. She founded Canadian Radiology Women in 2018 to advocate for improved diversity in Canadian Radiology practices. Most importantly she is from Saskatchewan originally 🙂  We appreciate her taking the time to answer our questions.

CAIR: Can you describe why equity, diversity and inclusion groups are needed in (interventional) radiology?

CYH: Radiology has been identified as one of the medical specialties with the least diversity of gender and race. We know that patients receive better care when the physician population reflects the diversity of the population as a whole.  Many studies in industry and medicine have shown that increased diversity drives innovation and improves outcomes.

Specifically in regards to gender, there are documented significant positive impacts of increasing the role of women in medicine on the medical culture and practice, the quality of care, and the organization of the healthcare system, with benefits for patients, learners and the system.

In Canada, women currently represent over half the medical student population, yet women remain underrepresented in Radiology. The proportion of women radiologists has changed minimally over decades and current application trends suggest the proportion of women in radiology could decrease.

In addition, there is a marked paucity of women in political, academic and departmental radiology leadership positions across the country. Women represent 36% of Radiology faculty members in Canada.  The Radiology gender gap widens with increasing academic ranks, suggesting that women may not advance at the same academic or professional pace as men. Further, an established gender pay gap may result in retirement and lifetime wealth differences of up to $2.5 million.

In the last census in 2016, 1 Canadian out of 5 was a visible minority.  We know that underrepresented minorities in medicine in Canada include first nations (4.4%) and black people (2.9%).  There is however no data on ethnic diversity in radiology in Canada.  This is important because racial/ethnic representation of medical faculties and residency programs should resemble that of the population served.  Visible minorities are more likely to practice in areas with underserved and minority populations.  When patients and physicians are the same race/ethnicity there is improved overall patient satisfaction and compliance with medical recommendations.  Physicians’ race/ethnicity are the strongest predictors that a physician will care for more vulnerable and underserved communities, irrespective of socioeconomic status.

The Canadian Truth and Reconciliation Commission published a report in 2015 outlining a number of calls to action to increase the number of Indigenous healthcare workers.  While at the undergraduate level, faculties are collecting data on the admission of Indigenous medical students, information on post-graduate residency programs or faculty positions is largely lacking and there are no data in the literature regarding radiology and Indigenous peoples in Canada.  A necessary step in meaningful progress toward Indigenous representation and equity lies in the collection of data around Indigenous residents, faculty members, and community physicians.

CAIR: What can (interventional) radiologists do to support diversity and combat inequality in Canada?

CYH: An informal online survey of women radiologists and radiologists in training in Canada demonstrated there are many real and perceived barriers to achieving personal, professional, and academic success as a female radiologist in Canada.  The reported barriers were lack of exposure early in training; observation of gender gap; lack of female radiology mentors, lack of female radiology leaders. While some of these are general and would apply to women and men as well as other underrepresented minorities, all barriers could be addressed by increasing the engagement and visibility of the women who are already in radiology.

By increasing visibility of minorities in radiology online and in real life we can improve medical student exposure to radiology.   In particular, as has been documented repeatedly, the Covid 19 pandemic has had a disproportionate effect on women. There need to be proactive strategies to support, mentor and sponsor young female radiologists.

CAIR: How can (interventional) radiologists promote equity, diversity and inclusion in their practice?

CYH: As a radiologist, you can improve equity, diversity and inclusion in radiology. Acknowledge that radiology is not diverse and educate yourself about why this is and what can be done to improve it.  Recognize and reduce unconscious bias in your daily life.  Mentor, sponsor and champion your peers and trainees.

CAIR: How can systemic imbalances be identified in (interventional) radiology and what strategies can be introduced to rectify such imbalances?

CYH: While women are underrepresented within radiology overall, interventional radiology (IR) has the lowest representation of women among Canadian radiology subspecialties (10.6%).   Although IR, like breast and pediatric imaging, where women are well represented, has a great deal of direct patient interaction, several other potential factors have been identified that may deter women from pursuing this subspecialty. These factors include lack of scheduling flexibility and increased radiation exposure.  The risk of radiation exposure during pregnancy has been overstated and exaggerated. To our knowledge, no clear consensus, protocol or guidelines exist for pregnant women in IR.

CAIR: Why do you think diversity is extremely underrepresented in interventional radiology and what actions are being done and can be done by programs and societies to combat this underrepresentation?

CYH: Strategies to improve diversity in radiology in Canada are necessary at the national, institutional, departmental, and individual levels. National organizations can drive improvement through awareness and policy change.  I’m proud of the BC Radiological society where we have more women than men on our executive. However, some provincial radiology organizations have no women leaders at all.  Programs and societies should intentionally create diverse teams.  Look for people who will see things differently. Support junior team members and allow them the chance to grow and develop their skills.  Resist the urge to label people and check boxes.

In summary, diversity is good for patients. Women are underrepresented in Canadian Radiology, particularly in Interventional Radiology.  There is no data regarding ethnic diversity or Indigenous representation in Canadian Radiology. Actionable strategies exist at each level to improve equity, diversity, and inclusion in Canadian Radiology.

This segment will feature a unique pearl learned by a junior VIR staff during residency or fellowship to share with our community. This pearl is written by Dr. Joel Woodley-Cook from Scarborough Health Network.

Exchanging the blocked catheter (usually a gastrojejunostomy). The pull, cut and push technique.

It’s 3 PM on a Friday before a long weekend and the internist calls and says, “I think this patient’s GJ tube is blocked. The nurse keeps trying, but the semi-crushed tablet-apple sauce paste won’t go through. I need a stat change before this patient can go back to their nursing home. And they need to go back today or they will lose their bed at the nursing home and it will be all your fault”.

This exchange procedure typically goes smoothly but can go downhill quickly without a well established tract to re-enter. The technique described below is my go-to for a blocked catheter (usually GJ but sometimes nephrostomy).

I learned this technique from Dr. Martin Simons during my last month as a resident. This “pull, cut and push” technique is one I use often and is performed under fluoro (I sometimes bypass Step 1, but Step 1 does provide improved trackability of the catheter). This example will focus on a blocked GJ exchange:

1. Insert a 0.035” Amplatz through the hub or cut sidehole as far as it will go (obviously if it finds a sidehole, the procedure is likely nearly over and you can ignore steps 2+).
2. Retract the catheter under fluoro such that the pigtail lies within the 2nd segment of the duodenum.
3. Cut a side-hole close to the skin that is large enough to fit the tip of a second Amplatz but small enough such that the tip does not easily pop out. I usually insert the tip approximately 1 – 2 cm.
4. Advance the catheter under fluoro until the side hole is in the 2nd – 3rd segment of the duodenum.
5. Retract the tip of the wire that is in the side hole and voila, you have wire access into the duodenum.
6. Carefully remove the catheter under fluoro after releasing the pigtail as you normally would (don’t pull out your new exchange wire) and proceed with the exchange.

The International Day of Radiology #IDoR2021 is celebrated on November 8 with the aim of building greater awareness of the value that radiology contributes to safe patient care and improving public understanding of the vital role radiologists and radiographers play in the healthcare continuum. In 2021, the International Day of Radiology is dedicated to Interventional Radiology and its essential role in treating patients.

As the world continues to face the challenges posed by COVID-19, it is extremely important to acknowledge the key role that medical imaging has in medicine, not only during unforeseen circumstances such as the pandemic, but also on a daily basis in all areas of patient care. Interventional radiology is a unique and growing sub-specialty that helps and protects patients each and every day.

What can you do?

• Follow our social media accounts on Twitter and LinkedIn. We partnered with the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) and the Society of Interventional Radiology (SIR) to share educational resources and information about the Interventional Radiology and to raise awareness about the benefits of minimally invasive treatments with patients, healthcare professionals, decisions makers, and the public at large. Check out our CAIR Initiative on the website for related content and share with your network!
• NEW! We will be creating member profiles to feature on our website and in our CAIR Express – let us know why you chose Interventional Radiology, what a typical day looks like, what are the most challenging and rewarding aspects of caring for patients and anything you’d like to share with our editors by emailing us at cairservice@cairweb.ca.

Why Interventional Radiology?

Dr. Ani Mirakhur, FRCPC (DR), FRCPC(IR), Calgary, AB

How did I become an IR?

I was first exposed to interventional radiology in my second year of medical school during a gastroenterology observership. The GI attending asked me to follow his bleeding patient (after a failed endoscopy) to IR for an embolization. I was hooked! I was fortunate enough to land a good residency and an excellent fellowship program and I have been in practice for over 5 years now.

Why I love practicing as an IR?

Diversity of disease and organ-systems:

Each day I work with a diverse group of patients and physicians. Some days are filled with complex PAD interventions (SAFARIs, DVAs, thrombolysis, etc), organ-sparing visceral aneurysm treatment , fenestrated EVARs (with vascular surgery colleagues) and dialysis interventions. On other days, I treat vascular malformations, do VTE interventions as well as PAVM, prostate, varicocele, pelvic congestion and uterine embolizations. And not to mention, bread and butter IR including venous access, drainages, biopsies and emergent embos/TIPS for bleeding patients. In my experience, very few specialists work with as broad an array of anatomy, and disease as an IR.

Diversity of practice environment:

As IRs, most of us are excited by the prospect of performing life-saving procedures in very sick patients. On the other hand, outpatient interventions to improve a patient’s quality of life can also be fulfilling.  IR is one of the very few specialties, where the practitioner can obtain a balanced exposure to both the acute care and outpatient worlds.

Innovation and collaboration:

IR, in many ways, is the wild west of medicine. You learn a core set of skills and can repurpose your skillset to solve any number of problems in real time.  There are tons of opportunities for academic research and/or working with industry. I personally have had opportunities to work with colleagues from other specialties as well as industry, on projects related to device and procedure development.

Dr. Brad Hnatiuk, FRCPC(DR), FRCPC(IR), Edmonton, AB & family

IR is the perfect combination of image interpretation, hands-on skills, and patient interaction.  Most patients are extremely happy after a minimal invasive procedure that can often greatly improve a patient’s quality of life.  This positive feedback can result in great job satisfaction.  As IRs, we are considered an integral part of many clinical pathways in Edmonton.  These are a few of the reasons why I love being an interventional radiologist.

Do you have a great case to present? Our next Virtual Angio Club (VAC) is now accepting submissions! We want to see cases with the best learning opportunities, so don’t wait and send your case today!

Who can submit a case: Canadian Interventional Radiology physicians who are CAIR members in good standing.

The best six (6) cases will be selected by Dr. Jason Wong and Dr. Amol Mujoomdar  and presented at the next CAIR VAC on November 24, 2021.

Case criteria:

• Presentation must be targeted to the Canadian IR community
• Educational value of presentation will be favored over complexity/rarity of the case
• The recommended file type to be used for presentations is PowerPoint or Portable Document Format (PDF)

A draft presentation of no more than 8-10minutes should be submitted by November 12th, 2021 via email at cairservice@cairweb.ca