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What will it take to bring interventional radiology to these areas?
Imagine a motorcycle rider crashes his bike on his way to work. He hits his head on the road. He is taken to the hospital, but the CT scanner is broken. The patient feels fine and leaves the hospital. Later he becomes obtunded and passes away. If access to a CT scanner was available, the epidural bleed would have been seen. And, his life would have been saved.
The World Health Organization (WHO) estimates that two-thirds of the world’s population, such as this patient, lacks access to basic radiology care. Interventional radiology is even more inaccessible, and the influence this field can have on patient care is just as remarkable. Interventional radiology is challenging to implement in resource-limited settings because of difficulty maintaining and acquiring radiographic equipment, as well as a dearth of trained practitioners. Fortunately, these are not insurmountable challenges. Through adaptation and education, interventional radiologists can bring their services to populations throughout the world.
The first challenge is physical capital. Interventional radiology relies on equipment that is expensive to purchase and expensive to maintain. A CT scanner can cost up to $2.5 million, and an MRI scanner can cost up to $3 million. The average cost of an angiography system is $1.5 million. The WHO estimates that donations account for 80 percent of the medical equipment in developing countries.
When equipment is acquired through a donation, it is often misallocated in resource-limited settings(1). A clinic in rural Africa may receive a CT scanner. However, if the CT scanner malfunctions, there may be no nearby technician to fix the machine. The CT scanner will quickly become dormant. A reliable power grid and climate-controlled settings are also uncommon, yet essential, for interventional radiology equipment. Fluoroscopy, CT, angiography, MRI, nuclear medicine, and advanced ultrasound equipment are often found in “medical equipment graveyards.” While 1 percent of medical equipment is out-of-service in high-income countries, 40 percent of medical equipment is out-of-service in low and middle-income countries(2).
Human capital is another challenge that faces the practice of interventional radiology in resource-limited settings. For example, there were fewer than five practicing interventional radiologists in Nigeria in 2019. With a population of 200 million people, supply cannot meet demand(3). The training paradigm for interventional radiology in the United States incorporates four years of training in diagnostic imaging. A foundation in image interpretation is essential for the safe practice of interventional radiology.
Unfortunately, diagnostic radiologists and imaging educators are also few in number in resource-limited settings. For instance, prior to RAD-AID, a non-profit organization serving imaging needs worldwide, Guyana had no radiology training program. In the 20 francophone countries in Africa, there are 117 radiologists. Some Asian countries have one radiologist per million population(4). To increase the number of interventional radiologists, the number of trained diagnostic radiologists also needs to increase. Though the current number of radiologists is inadequate, continued growth is likely and will promote better access to interventional radiology.
Adapting procedures is one mechanism that can be used to overcome the challenges associated with the practice of resource-limited interventional radiology. When certain equipment is not available, many procedures can still be performed effectively and safely through alternative protocols and techniques. For instance, portal vein embolization through a trans-ileocolic approach has been successfully performed with hysterosalpingography catheters(5). Percutaneous nephrostomy using only a trocar catheter is a viable alternative to the typical needle/wire/dilator/catheter combination(6). Gastrostomy tube placements and vascular malformation corrections have been successfully performed with ultrasound(7,8). Ethanol ablation of hepatocellular carcinoma has been shown to be an alternative to thermal ablation(9). Adaptations to “high cost” interventional radiology procedures indicate hope for the practice of interventional radiology throughout the world. With continued innovation, interventional radiology procedures can be practiced in settings outside of the typical modern procedural suite.
Training initiatives can also aid the spread of interventional radiology to resource limited regions. Through offering webinars and open-access training documents, interventional radiologists can teach basic procedures to providers in remote settings. Simple biopsies and drainages, vascular access, and embolization procedures are excellent opportunities for low-cost, minimally invasive, treatments.
Ultrasound and fluoroscopy are relatively inexpensive, ranging $10,000-to-$200,000 and $20,000-to-$80,000, respectively, and can be used for many procedures(10). Though the needs of communities in North America are very different compared to places, such as Sub-Saharan Africa, re-evaluation and assessment of local needs can be met through tailored teachings in more advanced procedures(11). Volunteer-based efforts led by non-profit organizations, such as RAD-AID, have focused on developing a global interventional radiology curriculum. Collaborations with Ethiopia, Ghana, Guyana, Kenya, Nigeria, and Vietnam have resulted in regular webinars and workshops. Through volunteerism, there is ample opportunity for interventional radiologists to contribute to efforts such as these initiatives.
The practice of interventional radiology faces several hurdles to becoming a global practice. Through the adaptation of procedures and the education of practitioners, the spread of interventional radiology to resource-limited settings is possible. Interventional radiologists will continue to display ingenuity through creative procedural adaptations and teaching modalities. In the future, maybe a rider will, again, fall from his motorcycle. Not only will he be able to receive high-quality and timely imaging, but he will also be able to receive a high-efficacy percutaneous procedure for treatment: a radiology procedure that has yet to be realized!
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