An insight into the Middle Eastern IR landscape

Mohammad Arabi is a consultant interventional radiologist currently working at the King Abdulaziz Medical City and King Abdullah Hospitals (Riyadh, Saudi Arabia). Interventional News sat down with him to explore how interventional radiology (IR) practice varies both within the Middle East-North African (MENA) region and when compared to that of interventional radiologists worldwide. He looks ahead to the challenges this region may be up against from an IR perspective in the future, and also reflects on the advancements that have shaped how he and colleagues care for their patients today.

What are the main differences in terms of IR infrastructure/practice between the MENA region and Europe or the USA?

The practice of vascular IR (VIR) in the MENA region is substantially different when compared to the practice in Europe or North America in many ways, including clinically, academically, administratively, socioeconomically and legislatively.

Healthcare expenditure in the MENA region was estimated at 5.5% of the gross domestic product (GDP) in 2019. This is significantly lower than in Europe (9.9%) and the USA (16.3%) and varies significantly among the MENA countries. The current health expenditure per capita in the MENA region is reported at US$507 (US$275 excluding high-income countries) compared to US$3,476 in the European Union and US$10,317 in North America. This could be, in part, due to the younger and healthier population in the MENA region compared to other parts of the world. The population over 65 years is estimated at 5% of the total population, compared to 17% in North America and 21% in the European Union. This translates into differences in IR clinical practice and the nature of pathologies that prevail in the corresponding regions. The MENA region is densely populated and diabetes, end-stage renal disease, motor vehicle accidents, and some cancers are more common than in other parts of the world. The socioeconomic restraints, poor education and awareness, lack of easy access to healthcare due to limited resources and unavailability of insurance and governmental support, result in late presentations of diseases such as advanced diabetic foot or advancedstage cancer.

In countries with low incomes, governments and healthcare facilities focus on providing essential medical and surgical interventions, and access to advanced VIR procedures remains limited to few centres and those who can afford their high costs. The current economic crisis and associated inflation has made it more difficult and challenging to sustain the supply chain of the expensive IR materials. For example, the local currencies in Syria, Lebanon and Egypt reported record low exchange rates against the US dollar and euro, increasing the burden on healthcare systems.

On a positive note, the geographic location of the MENA region and existing regulations allow easier access to a wider range of supplies from both the Eastern and Western hemispheres, allowing for more flexibility in maintaining the supply chain at relatively low cost.

How does IR in Riyadh compare to elsewhere in Saudi Arabia/elsewhere in the MENA region?

The Saudi capital Riyadh has a population of nearly eight million and is served by numerous governmental healthcare facilities that provide 24/7 VIR services. While the majority of these hospitals provide essential vascular and interventional procedures, advanced VIR interventions are typically offered in tertiary care institutions. These include interventional oncology services, advanced venous and arterial procedures, hepatobiliary and transplant interventions.

In a recent presentation by Zakariya Al-Safran (King Fahad Specialist Hospital, Dammam, Saudi Arabia), former president of the Saudi Interventional Radiology Society (SIRS), the current number of interventional radiologists in Riyadh is estimated at 41% of the entire IR workforce in the kingdom (58/141). Despite the increasing number of interventional radiologists, some provinces remain devoid of IR services, and referrals to higher care centres are required for the simplest interventions.

The Saudi VIR fellowship was established in 2014 and currently, 15 graduate fellows pass through annually. This has helped in covering some of the peripheral areas that did not have access to VIR services before.

The practice of IR in Saudi Arabia is remarkably advanced compared to other parts of the Arab world and MENA region. Data from the Pan Arab Interventional Radiology Society (PAIRS) indicate that members from Saudi Arabia and Egypt constitute nearly 50% of registered interventional radiologists in the database. The available infrastructure and resources in governmental hospitals in Saudi Arabia allow offering a wide range of advanced interventions that parallel the majority of European and North American centres. The private sector, on the other hand, has also witnessed remarkable attention over the past decade due to expansion of the insurance industry and governmental support of privatisation.

How have your IR practices evolved in the last decade? What have the innovations been in terms of devices/procedures?

The increasing number of interventional radiologists in the kingdom was paralleled by expanding the services provided and the increasing complexity of the procedures. Several centres in the country offer advanced interventional oncological procedures including radioembolization and advanced ablation with microwave, cryoablation, and irreversible electroporation. The vast majority of IR services provide peripheral arterial and dialysis interventions, and have access to atherectomy, thrombectomy and intravascular lithotripsy. Recent guidelines and advances in stroke thrombectomy added additional burden onto IR services to provide 24/7 coverage. In addition, the increasing knowledge of IR among other medical and surgical disciplines, along with increasing public awareness, resulted in higher demand on IR services. For example, more women are directly seeking uterine fibroid embolization rather than surgical treatments. Our unit performed nearly 18,000 IR procedures in 2022 compared to nearly 8,300 in 2013, adding many new procedures and techniques such as endovascular arteriovenous fistula creation, peritoneal dialysis catheter placement service, cryoablation, same-admission hepatic mapping and radioembolization, and advanced venous and arterial interventions.

What do you hope to see for IR in your region in the years to come? Do you expect the patient demographic to change in any way?

The incidence of cancer is projected to increase by 47% worldwide by 2040, and the relative magnitude of this increase will be highest in low and medium human development index (HDI) countries. The World Health Organisation reports that the prevalence of diabetes and associated complications has also been rising more rapidly in low- and middle-income countries than in high-income countries. This carries increasing burden on the healthcare systems and creates higher demand on VIR services in the region. PAIRS is working tirelessly to advance IR in the region in collaboration with other regional and global IR societies such as SIRS, the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) and the Society of Interventional Radiology (SIR). Several initiatives were undertaken to further disseminate knowledge about IR among medical students and juniors, as well as several public campaigns to increase awareness about the role of IR in certain conditions such as diabetic foot, uterine fibroids and doing prostate artery embolization.

The ‘I am PAIRS’ campaign was launched in 2019 and runs in Egypt, Saudi Arabia, Morocco and Tunisia and was created by the residents/fellows/students (RFS) section under the umbrella of PAIRS. Since its inception, the RFS section has participated along with other peer societies in global events such as the

Global IR Juniors Summit organised in collaboration with CIRSE, SIR and the European trainees forum. PAIRS’s vision is to further promote and advance IR training in the region, specifically in countries where IR services are not available, scarce, or limited to basic interventions. Interventional radiologists practising in African countries such as Nigeria and Tanzania have reported their early local experience in providing VIR services such as peripheral arterial interventions, percutaneous nephrostomy placement and lung biopsy. These reports highlight the staff shortages, the challenges they have to confront and the opportunities that need to be explored. The role of IR societies such as PAIRS is to establish a network of collaboration and education to enhance local VIR practices and experiences, and provide a platform for volunteering in areas where IR services are not widely available.