Heroes of Medicine | Issue 1

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ISSUE 1

JUST LC

What is IFMSA: The International Federation of Medical Students’ Associations (IFMSA) is an independent, non-governmental and non-political federation of medical students’ associations throughout the world. IFMSA was founded in 1951 and now it is recognized as a Non-Governmental Organization (NGO) within the United Nations (UN) and the World Health Organization (WHO). IFMSA now has 124 National Member Organizations in 116 countries around the globe, representing more than 1.3 million medical students worldwide.

In 2006, the Jordanian National Member Organization has joined this global entity and ever since we, at IFMSA-Jordan, have committed ourselves to serving our community through multiple activities, divided into four main global health areas: public health, medical education, human rights and peace and sexual and reproductive health. One of the aims of IFMSA-Jordan is to motivate medical students in all medical schools around Jordan to get involved in their communities through active participation in voluntary work, and to provide them with the necessary tools and skills to become successful future doctors and health leaders.

IFMSA-Jo: IFMSA-Jo was established in pursuit of providing a platform for medical students to harness their skills and unleash their hidden potential. Driven and led by medical students, this provided a new level of motivation and dedication, and this was reflected by the active participation in community service.

The long journey of IFMSA-Jordan started in 2006, from Jordan University of Science and Technology, and joined the ranks of IFMSA. From there, IFMSA-Jordan grew bigger with every family member: University of Jordan (2007), Hashemite University (2011), Mutah University (2014), and Yarmouk University (2017). IFMSA-Jo is recognized as a Non-Governmental Organization (NGO) within the Jordanian Associations System, and now approximately has five thousand medical students as registered members.

It is guided by the vision of serving our community and reinforcing Jordan’s national health through igniting and uniting the knowledge and potentials of medical students.

Our mission is to serve the society and medical students in Jordan by empowering our members in using their knowledge and capacities, and providing a link between members, medical students associations, and national and international organizations to encourage the cooperation between them for the ultimate benefit of the society.

IFMSA-Jo’s work is built and executed through six Standing Committees: Standing Committee on Public Health (SCOPH) Standing Committee on Medical Education (SCOME) Standing Committee on Research Exchange (SCORE) Standing Committee on Professional Exchange (SCOPE) Standing Committee on Human Rights and Peace (SCORP) Standing Committee on Reproductive health (SCORA)

CONTENTS CONTENTS

3

CHARLES THEODORE DOTTER

4

DIAGNOSTIC USES OF INTERVENTIONAL RADIOLOGY

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OTHER PIONEERS IN THE FIELD OF INTERVENTIONAL RADIOLOGY

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DAILY ENCOUNTERS FOR INTERVENTIONAL RADIOLOGY

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GIANT RIGHT GASTROEPIPLOIC ARTERY PSEUDO-ANEURYSM WITH

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AN IVC FISTULA A GLANCE INTO THE HISTORY OF INTERVENTIONAL RADIOLOGY

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THE STATUS OF INTERVENTIONAL RADIOLOGY IN JORDAN

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HOW TO BECOME AN INTERVENTIONAL RADIOLOGIST?

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AN UNUSUAL CASE OF TUBEROUS SCLEROSIS (TS)

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THERAPEUTIC USES OF INTERVENTIONAL RADIOLOGY

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AN INSIDE LOOK ON INTERVENTIONAL RADIOLOGY

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INHOUSE ACHIEVEMENTS IN THE FIELD OF INTERVENTIONAL RADIOLOGY

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NEW DEVELOPMENT IN THE INTERVENTIONAL RADIOLOGY

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(AN INTERVIEW WITH DR. MOHAMMAD AMARNEH)

4

CHARLES THEODORE DOTTER By: Mariam Al-Masri

Imagine how they used to practice medicine, perform surgeries, treat, and diagnose only based on the physical examination and the Doctor’s assumptions. Yes, this was the case until Charles dotter (1920 – 1985) pioneered the use of interventional radiology in the 20th century, which was a revolutionary development in invasive procedures and surgical techniques.

In his early years, Dotter was highly interested in mechanical tools, and in finding other uses for them. This interest didn’t diminish after he went to Cornell medical college in New York City, he then developed his interest in Angiocardiography while he was a resident at New York Hospital. He developed an automatic X-Ray Roll-Film magazine which gives images at 2 per second rate, this fact reveals his exceptional way of thinking.

His most important contribution was on January 16th 1964, the day in which interventional radiology gave real tangible results. It was a case of Laura Shaw; an 82 year old woman who came with a femoral arterial stenosis, gangrenous ulcers in the toes, and with risk of amputation. Dotter then suggested that instead of just imaging the blockages and performing an open surgery to remove them, why won’t they just reopen these blockages during the imaging procedure with the catheter? And this idea led to what’s called percutaneous transluminal angioplasty (PTA). After this minimally invasive procedure, the patient’s symptoms improved and the ulcers were healed completely.

It should be noted that the surgeons’ attitudes towards what he did weren’t that good, some surgeon wrote him a note that says: “VISUALIZE BUT DO NOT TRY TO FIX”, but dotter dealt with this wisely till his ideas were accepted after a couple of years.

Dotter also published hundreds of papers and made 20 scientific exhibits, which with his greatest contribution, had a better effect on the clinical care and how they replaced harmful procedures to the patients.

Charles dotter is known as the “Father of Interventional Radiology” for his pioneering work. He received the gold medal several times and was nominated for the Nobel Prize for Physiology or Medicine in 1978. And the dotter interventional institute was made in his honor.

Medicine has now become beneficially stronger thanks to such ideas, and lots of procedures nowadays depend totally on radiology.

Although it became nearly rare among physicians to step up and dare to change things to the best, but we hope the world can earn more of these contributions in medical innovation.

References: ___________________ (Payne 2001, Friedman 2015, Deora 2016) Deora, S. (2016). “The story of ‘STENT’: From noun to verb.” Indian Heart J 68(2): 235-237.

Friedman, S. G. (2015). “Charles Dotter and the fiftieth anniversary of endovascular surgery.” J Vasc Surg 61(2): 556-558.

Payne, M. M. (2001). “Charles Theodore Dotter. The father of intervention.” Tex Heart Inst J 28(1): 2838.

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DIAGNOSTIC USES OF INTERVENTIONAL RADIOLOGY

By: Hassan Abu-Shuqair

As of recent, groundbreaking advancements in the field of medicine have been achieved, it goes without saying that this has been mainly possible due to the revolutionary field of radiology. Not so long ago, radiology was referred to as simply; diagnostic imaging.

This definition was valid at a time when treatments were carried out separately from diagnostic procedures which were done mainly by radiologists. Until one day, a radiologist named Charles Dotter(1) asked a question that would go on to reshape medical practices; is it possible to use the same diagnostic imaging tools to guide the real-time treatment of disease?

The answer was yes, and later on this would set the foundation for the field of Interventional Radiology (IR). What distinguishes IR from other radiology subspecialties, is that it provides both diagnosis and treatment of disease through minimally invasive image-guided techniques.

The term image guided refers to the fact that any procedure done in IR mainly depends on real-time taken preoperative or intraoperative images. These images are generated via imaging techniques such as MRI (magnetic resonance imaging) scans, X-rays, fluoroscopy, CT (computed tomography) scans and ultrasounds.

Most of these techniques are commonly used in other radiology subspecialties, for instance: neuroradiology, pediatric radiology, etc. However, their application in other subspecialties is mainly for diagnostic purposes, unlike IR which counts on their outputs in treatment procedures.

Nevertheless, there are other diagnostic methods which are more exclusively used by interventional radiologists such as: 1. Angiography: a technique which produces images by visualizing the internal lumen of blood vessels and body organs, mostly concerned with arteries, veins, and heart chambers (2). This technique has several uses including: coronary angiography, fluorescein angiography, micro-angiography, neuro-vascular angiography , etc.

2. Biopsy: a test that involves the extraction of sample cells or tissues for inspection to determine the presence or dimensions of a disease (3).

3. Cholangiography: an x-ray procedure that includes the injection of a contrast substance directly into the bile ducts inside the liver to produce pictures of the bile ducts(4).

4. Cardiac catheterization: a procedure that involves the insertion of a thin catheter into a chamber or vessel of the heart. This technique is widely used for both diagnostic and interventional purposes.

Recent studies have indicated that various IR techniques are found to be clinically efficient in diagnosing and managing a very rare splanchnic venous abnormality; which is the congenital extrahepatic portosystemic shunt (CEPS)5. These methods include the plasticity of the intrahepatic portal system in type 1 shunts, while in type 2 shunts they are traditionally treated by endovascular treatment by coil or plug embolization. The main evaluation procedure in portomesenteric vasculature is conventional angiography.

Considering that currently CEPS lacks standard treatment guidelines due to its rarity, IR relatively limited-risk methods will significantly help enhance the lives of CEPS patients5.

Moreover, IR may be a promising turning point in the field of breast cancer interventions and diagnostic procedures. As previous studies have outlined that the opportunity exists for new research in ultrasound-guided biopsy of micro calcifications, stereotactic-guided lumpectomy, and ultrasound-guided ablation of breast cancer6.

To conclude, Interventional Radiology without a doubt offers an excellent option for cases which would previously require critical surgical interventions. Whereas, nowadays IR with its minimally invasive procedures provides low risks, less pain and less recovery time in comparison to open surgeries. Further achievements are yet to be expected form IR and its wide implementations in the future.

References: ___________________ 1- Payne MM. Charles Theodore Dotter. The father of intervention. Tex Heart Inst J. 2001;28(1):28– 38. (paper) 2- Uberoi, Raman (2009). “4 Imaging”. Interventional radiology. Oxford New York: Oxford University Press. pp. 49–77. ISBN 978-0-19-157556-3. (book) 3- Uberoi, Raman (2009). “19 Biopsy and drainage”. Interventional radiology. Oxford New York: Oxford University Press. pp. 387–402. ISBN 978-0-19-157556-3. (book) 4- Ahmed O, Mathevosian S, Arslan B. Biliary Interventions: Tools and Techniques of the Trade, Access, Cholangiography, Biopsy, Cholangioscopy, Cholangioplasty, Stenting, Stone Extraction, and Brachytherapy. Semin Intervent Radiol.

2016;33(4):283–290. doi:10.1055/s-0036-1592327(paper).

5- Mathai SV, Kondray V, Salloum E, Kukreja K, Tavri S. Role of interventional radiology in the diagnosis and management of congenital extrahepatic portosystemic shunts: Two case reports. Indian J Radiol Imaging.

2019;29(2):219–222. doi:10.4103/ijri.IJRI_461_18 (paper).

6- Tomkovich KR. Interventional Radiology in the Diagnosis and Treatment of Diseases of the Breast: A Historical Review and Future Perspective Based on Currently Available Techniques.

American Journal of Roentgenology. 2014;203(4):725-33. (paper)

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OTHER PIONEERS IN THE FIELD OF INTERVENTIONAL RADIOLOGY By: Nadine Absy

It is well established that Dotter fathered the concept of interventional radiology, with that being said, it is noteworthy to mention that many other physicians who have carried forward the idea and developed it more intricately, this section will tackle some of their contributions.

The first to coin the procedures as ‘interventional’ was Alexander Margulis, who also highlighted that these procedures required special training and extensive knowledge in certain topics.

Dotter’s ideas paved the way for many inventive angiographers to develop new interventional techniques; amongst those a German physician named Werner Porstman who developed a technique that involves the percutaneous closure of the patent ductus and John Doppman who was the first to use embolization to treat vascular malformations and tumours. Kurt Amplatz and Caesar Gianturco also helped radicalise IR by developing vital new tools used till this day for intervention.

Notably, Andreas Grüntzig, a german radiologist and cardiologist introduced the major revolution in PTA by developing successful balloon angioplasty, and you can be left to imagine how many patients’ lives were affected by the development of this procedure.

An essential pivot in the expansion of IR was the relationship between interventionists and device manufacturers, amongst the latter were Bill Cook and John Abele.

DAILY ENCOUNTERS FOR INTERVENTIONAL RADIOLOGY By: Faris Jamal The introduction of Interventional Radiology (IR) as a minimally invasive technique alternative to surgery, has lower morbidity and mortality rates in comparison to surgery. This image-guided procedure treats patients with a wide variety of common disorders, which were treated by open surgery.(1) One of the most common pathologies encountered in the field are vascular diseases which require vascular interventions. E.g. Peripheral vascular diseases (Atherosclerotic plaques, stenosis, dissections, and aneurysms) are treated by Angioplasty and vascular stenting, which widen the vessel and increase the blood flow while the latter helps the vessels remain patent and support their walls. Moreover, IR is used in thrombolysis by administering pharmacological agents to break down clots thus improving the blood flow (e.g. Lower limb ischemia from DVT, and pulmonary embolisms). Also, it has been used for Vascular access procedures in which a catheter is placed within blood vessels to provide a route for delivering medications (e.g. chemotherapy, antibiotics, blood transfusions or nutrition), taking blood, dialysis or central pressure monitoring. However, non-vascular interventions include: Biopsy and FNA, drainage of abscess, and Renal interventions (Nephrostomy, and renal artery stenosis). IR has been most importantly used in Catheter angiography which has an advantage over CT/MRI angiography as it allows simultaneous diagnosis and treatment (e.g. angiography preceding the intervention) and shows improved anatomical detail during the imaging.(2)(3) References: ___________________ 1- Ciarallo, A., Nguyen, C. T., & Stein, L. (2007). Interventional radiology: from idea to device to patient. McGill journal of medicine : MJM : an international forum for the advancement of medical sciences by students, 10(2), 144– 148.

2- Shaw, A., Speirs, A.J., & Howlett, D. (2010). Current applications of interventional radiology. British journal of hospital medicine (London, England : 2005), 71(11), 619-25.

3- UCSF Radiology. 2020. Interventional Radiology: Minimally Invasive Alternative To Surgery. [online] Available at: <https://radiology.ucsf.edu/patient-care/ sections/ir>

GIANT RIGHT 10 GASTROEPIPLOIC ARTERY PSEUDOANEURYSM WITH AN IVC FISTULA By: Suzan Al-Hawwash

An 81-year-old Caucasian woman presented to the emergency department (ED) for evaluation of abdominal pain. She reported sharp epigastric pain that radiates to her back, along with intermittent abdominal pain for 5 days. She stated the pain was 10 out of 10 in severity and denied any other symptoms.

Upon physical examination, the patient had superior epigastric abdominal tenderness to palpation with guarding. A computed tomography angiogram (CTA) of the thorax, abdomen, and pelvis was performed for concerns of an aortic dissection. This demonstrated a giant pseudoaneurysm measuring 10 cm x 4.8 cm within the gastroduodenal artery distribution with associated active extravasation secondary to pancreatitis.

IMAGING FINDINGS: The CTA demonstrated a multi-lobulated, large, sub-hepatic pseudoaneurysm arising from the gastroduodenal artery/right gastroepiploic artery distribution with adjacent active extravasation, these findings were secondary to pancreatitis.

Interventional radiology was consulted for further evaluation. Catheterdirected angiography of the gastroduodenal artery demonstrated a giant pseudoaneurysm with active extravasation arising from the right gastroepiploic artery with fistulous communication with the inferior vena cava (IVC).

DISCUSSION: A pseudoaneurysm of the right gastroepiploic artery (RGEA) is rare and potentially life threatening due to risk of rupture. And even rarer in the development of venous fistula. This can occur from pancreatitis, although it is uncommon, it is more common in men occurring at an average age of 65 years.

The process and products of inflammation, along with the high-pressure flow from arteries, weakens the vessel walls resulting in pseudoaneurysm formation, The greatest risk is rupture of the pseudoaneurysm and it increases with size, if rupture happened this will lead to shock.

Definitive diagnosis must be made with catheter angiography. Treatment options include surgery and endovascular procedures, and the treatment depends on whether the pseudoaneurysm has ruptured or not, and on the patientâ&#x20AC;&#x2122;s vital signs. In this case, coil embolization was the best treatment option, given the size and high probability of frank rupture, Endovascular treatment with coil embolization not only resolved the giant pseudoaneurysm, but prevented a more invasive treatment option such as laparotomy.

Axial CT angiogram demonstrates a giant subhepatic pseudoaneurysm. (B) Coronal CT Angiogram again demonstrates the giant pseudoaneurysm with active extravasation.

Catheter-directed angiography of the common hepatic artery demonstrates the giant pseudoaneurysm arising from the right gastroepiploic artery with a fistula to the IVC.

A GLANCE INTO THE HISTORY OF INTERVENTIONAL RADIOLOGY

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By: Sarah Khassawneh

To understand the concept of interventional radiology, you have to look at it as a 3 steps process, with Radiology being the first, Angiography being the second and Interventional Radiology being the third. So, easily speaking, it’s the application of image guidance and minimally invasive techniques in order to gain access to the vessels interwining the body.

But, was it that easy to reach this level of comfort while dealing with vessels?

Actually, the magnificence behind the concept of interventional radiology makes it unfair to describe it as being simple, but on the other hand, the actual creativity of it lies in its simplicity!

Let’s take an interesting journey through the history of interventional radiology back from the beginning until today.

Imagine that the first arteriograms were performed by surgeons by direct cutdown until 1927 when the Portuguese physician and neurologist Egas Moniz who is recognized as the pioneer in angiography provided a contrast x-ray cerebral angiography in order to diagnose several kinds of nervous diseases, such as tumors, artery diseases and arteriovenous malformations. Physicians continued to use this technique in a wide range of procedures.

- In the late 1940s, Stig Radner in Sweden had introduced catheter angiography of the vertebral, subclavian artery and thoracic aorta via exposure of the radial artery.

- In 1941, Pedro Fariñas in Cuba performed catheter angiography of the abdominal aorta through the femoral artery using a trocar for puncturing and then introducing the catheter through the trocar.

- In 1951, In Cuba, Ponsdomenech and BeatoNunez performed direct punctures of the heart to visualize the ventricular chambers.

- In 1951, after the introduction of thin walled polyethylene catheter

by Helmsworth, McGuire and Felson was for the first time able to percutaneously puncture the femoral artery.

- In 1956, Nobel was awarded to Cournand with Forssmann and Richards, for introducing heart catheterization.

We know that the “catheter” is used in a wide range of medical procedures, but are you aware that there is an interesting story behind bringing it into usage? This question takes us to speak more about Seldinger and his development of a new technique that was called after his name.

According to Seldinger “It felt natural to find a way to use a thinner needle to reduce arterial trauma and a catheter of larger caliber to increase inner diameter and thereby higher injection rates”.

Initially, Seldinger technique depended on using 3 simple instruments; a polyethylene catheter, a guide wire and a needle inserted through a side hole of the catheter as the illustration demonstrates: Seldinger was able to use this technique in a few angiographies, but the technique was still imperfect, with a possible risk of catheter break at the side hole.

After another failed attempt, Seldinger found himself confused with the three items in his hand, the needle, catheter and the guide wire. Then he was stroked by what he himself described as a “severe attack of common sense”! Within a split of a second he realized how to use the three items: needle in, guidewire through the needle, needle out, catheter over the wire and finally removal of the guide wire.

This happened in April 1952.

A GLANCE INTO THE HISTORY OF INTERVENTIONAL RADIOLOGY - CONT.

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In the January issue of American Journal of Roentgenology, 1984, the 30-year anniversary of the Seldinger technique was celebrated with the following citations: T. Doby: “It is almost impossible to imagine life without things we grew up with, so it is a little hard for us to feel the thrill of angiographers when they first heard about the Seldinger technique. Present-day radiologists cannot even guess how angiography could have been done without it”!

Charles T. Dotter: “His technique has by now served as many as 50 million patients. How many unnecessary cut downs, how many cold hands, how much pain and infection, have been avoided as the result of a moment’s insight on his part?”

Along the way to truth, we question ourselves constantly, but we don’t necessarily find answers to all of our questions. Imagine how incredible it would be to easily have our questions answered. This is actually what happened for Charles Dotter in 1963 when he first proposed the idea of interventional radiology by just asking himself “Is it possible to use the same diagnostic imaging tools to guide the treatment of disease?”

Charles Dotter opened a new era of percutaneous angioplasty marking the formation of interventional radiology. The technique depended on using coaxial or dilating catheters. However, since the diameters of these catheters were large, there was a limitation in the size of the vessels that could be treated. Because of these limitations, the technique never gained a great deal of popularity in the United States. However, it continued to be performed in Europe.

In the early 1970s, polyvinyl chloride balloon catheters were introduced. The small diameter, balloon compliance, and dilating force of these catheters addressed almost all of the limitations of the previous techniques.

Since then, the practice of medicine had changed completely, and interventional radiology made it possible to easily treat some conditions that were risky to deal with.

For example; selective mesenteric arteriography contributed to the identification of the site of gastrointestinal bleeding. To put this exciting development in perspective, one must remember that flexible endoscopic techniques were not available in the 1960s.

There was very rapid growth of interventional radiology in the 1970s and 1980s, and angiographers started performing image-guided procedures that were outside of the vascular system and involving almost all organ systems of the body.

The range of conditions that can be treated by interventional radiology is continuing to expand, thanks to those who tried to think differently and never lost their passion to change.

References: ___________________ - Richard A. Baum , Stanley Baum, Interventional Radiology: A Half Century of Innovation, 2014.

- Timothy P. Murphy, M.D., F.S.I.R., F.A.H.A., F.S.V.M.B.1 and Gregory M. Soares, M.D.1 , The Evolution of Interventional Radiology, Semin Intervent Radiol. 2005 Mar; 22(1): 6â&#x20AC;&#x201C;9 - Tang Z1, Jia A2, Li L1, Li C1., Brief history of interventional radiology] Zhonghua Yi Shi Za Zhi. 2014 May;44(3):158-65.

- 2020. [online] Available at: <http://www.seldinger.se/ gallery/seldinger%20biography.pdf>

THE STATUS OF INTERVENTIONAL RADIOLOGY IN JORDAN

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By: Mishleen Awabdeh

Jordan has achieved various accomplishments in the medical field over the past fourty years despite the harsh times it has been through.(1) In 2006, it was said to have one of the most modern health care infrastructures in the Middle East by the WHO.(2) The Ministry of Health in Jordan aims to improve the health care system on all levels, thatâ&#x20AC;&#x2122;s why it ensures that the medical sector is always up-to-date with the technological advancements, especially in the field of radiology.

Accordingly, many hospitals have expanded the radiology departments to include special units for modern devices of interventional radiology. Al Khalidi Hospital and Medical Center being one of them offers a full range of interventional techniques as ultrasound and CT guided biopsies and drainages, peripheral angioplasties, tumor ablation with radiofrequency, a wide range of embolization including chemo-embolization to treat tumors and fibroid embolization, and endovascular treatment of intracranial aneurysms and arteriovenous malformation just to name a few.(3) Jordan Hospital has its own interventional radiology services as well; including biliary dilation, stenting and drainage, arteriography and venography, abscess drainage and nephrostomy.(4) Besides making sure that the hospitals are fully equipped with the latest machinery, Jordan has participated in a regional workshop in Dubai. Its main purpose was to develop a regional program on radiation protection in the interventional radiology field by training health professionals from Jordan and 6 other countries.(7) Not only that, but Jordan was home for multiple other workshops. One of them took place in June this year about Computed Tomography (CT). It focused mainly on the needs of medical personnel concerned with medical imaging professionals and improving the quality of radiographic techniques.(6) Another workshop was hosted by King Abdullah University Hospital in April over a period of four days. It was conducted by the International Scientific Exchange Program (ISEP) of the American Association of Physicists in Medicine (AAPM) in collaboration with the International Organization of Medical Physics (IOMP).

It discussed many topics regarding radiotherapy such as Image-Guided Radiation Therapy, Stereotactic Body Radiation Therapy, clinical Brachytherapy, and Quality and Safety in Radiotherapy.(5)

How to Become an Interventional Radiologist? By: Marah Abu-Muhsen Interventional radiology (IR) was established as a unique speciality in medicine in 2012 by the American Board of Medical Specialties, and a dedicated interventional radiology residency was approved by The Accreditation Council for Graduate Medical Education (ACGME) in 2014. So it is considered a new speciality.

The traditional pathway for the IR is one year of IR fellowship after graduation from a diagnostic radiology residency (The diagnostic radiology (DR) is known to be a 4 year residency program) a total of 5 years after finishing the internship year. This is offered until June 30, 2020 then itâ&#x20AC;&#x2122;s anticipated to be ceased, and your way to train in IR will be through the IR residency: either the Integrated Residency or the Independent one; which differs from the traditional pathway in the years spent in DR, IR, and clinical rotations.

For the integrated residency, it is a 5 year training program after finishing the internship year and it includes 3 years in DR and 3 years in IR. While the independent residency consists of 1-2 years after having completed a diagnostic radiology residency, that is; 5-6 years after the internship year.

So if you are a 3rd year DR resident or younger and wish to become an interventional radiologist, then you have to go through the independent pathway.

References: ___________________ 1: 2020. [online] Available at: <https://jordan.gov.jo/wps/portal/Home/GovernmentEntities/Ministries/ Ministry/Ministry%20of%20Health?nameEntity=Ministry%20of%20Health&entityType=ministry> 2: 2020. [online] Available at: <http://apps.who.int/medicinedocs/documents/s17296e/s17296e.pdf> 3: 2020. [online] Available at: <http://khmc.jo/en/specialized-units/diagnostic-interventional-radiologydepartment/> 4: 2020. [online] Available at: <http://www.jordan-hospital.com/Contents/Radiology_Imaging_Department. aspx> 5: 2020. [online] Available at: <https://www.mefomp.com/Workshop-on-Advances-in-Radiology-andDiagnostic-Physics-in-Amman-Jordan_a6930.html> 6: 2020. [online] Available at: <https://www.mefomp.com/Computed-Tomography-Workshop-andQuality-Control-in-Amman-Jordan_a6931.html> 7: 2020. [online] Available at: <https://www.zawya.com/mena/en/press-releases/story/UAE_Ministry_of_ Health__Prevention_to_organize_regional_workshop_on_Interventional_Radiology_IR_and_Radiation_ Protection_RP-ZAWYA20190716110908/> 8: Northwestern University, Feinberg university of medicine, 2019: feinberg.northwestern.edu/ 9: Society of interventional radiology, 2019: sirweb.org/ 10: Review Committee for Radiology ACGME: 415InterventionalRadiologyFAQs2018.pdf

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AN UNUSUAL CASE OF TUBEROUS SCLEROSIS (TS)

By: Obada Al-Jayyousi

Case: A 37-year-old female with mild abdominal pain performed a routine abdominal ultrasound that showed multiple, nodular and mainly hyperechoic renal lesions with regular margins and vascular signal on color Doppler indicating multiple angiomyolipomas, â&#x20AC;&#x153;AMLsâ&#x20AC;? (Fig.1). The upper pole of the right kidney had the largest lesion with a diameter of 60mm. Physical examination revealed six rounded, reddish papules at the right nasal wing corresponding to the relapse of angiofibromas that have been surgically removed three years earlier. Neurological symptoms as well as personal and family history were negative. An MRI was then performed where several lesions were detected on both kidneys supporting the diagnosis of multiple and bilateral renal angiomyolipoma with the largest lesion on the upper pole of the right kidney showing some extent of hemorrhagic content (Fig.2). Furthermore, a contrast-enhanced brain MRI was performed that showed a single lesion in the cortical-subcortical side of right parieto-occipital cerebral cortex consistent with a cortical-subcortical tuber (Fig.3).

Blood tests were normal besides an initial mild proteinuria. Otherwise, no remarkable findings were found (1).

Discussion: Tuberous sclerosis is a rare inherited autosomal dominant disorder (with around 2 million cases worldwide) (2) with many manifestations in multiple organs, mainly hamartomas. It can be defined as a triad of: sebaceous adenoma, mental retardation, and seizures. CNS involvement is very common in the context of TS, occupying 85% of the cases (1). As mentioned earlier, the patient had a cortical-subcortical tuber in the right parieto-occipital side which is a hamartoma.

Moreover, cutaneous involvement is one of the common manifestations of TS. This includes, pigmentation defects of the skin and nail fibrosis.

Other manifestations could include liver and kidney manifestations. AMLs are the most common urinary system manifestation of TS. In fact, AMLs in female patients with TS are mainly found in those in their thirties and forties. In addition to that, AMLs show a higher female prevalence than males possibly suggesting hormonal influence to some extent.

The diagnostic criteria of TS were finalized in a 1998 conference held by the Tuberous Sclerosis Association and the National Institute Of Health followed by a Consensus conference in 2012 (3)(4).TS definitive diagnosis requires at least two major criteria or one major criteria followed by two or more minor criteria.

Regardless of that being said, a mutation in TSC1 or TSC2 genes alone is sufficient for a TS definitive diagnosis. The patient in this case meets two major criteria: multiple and bilateral renal AMLs and at least six cutaneous angiofibromas with a corticalsubcortical tuber.

Most TS cases are diagnosed during childhood due to early cutaneous and neurological symptoms. However, this case shows a late presentation due to the manifestations being primarily dermatologic, which makes this case unusual.

Interventional radiology has provided a convenient treatment option for such cases including: angio-embolization, cryotherapy, and radiofrequency ablation. Studies have shown that symptomatic patients or those with masses larger than 4 cm are excellent candidates for arterial embolization as prophylaxis for rupture (5). Whatâ&#x20AC;&#x2122;s more, percutaneous ablation devices for the primary management of AMLs is possible depending on tumor size and location. However, more studies should be done to assess it fully. Another study also showed that, thirty-nine angiolipomas in 19 patients were successfully treated with selective arterial embolization (92% with primary success and 8% with secondary success) (6).

Conclusion: This is an unusual case of Tuberous Sclerosis (mainly concerning the late presentation of the disease) that has been diagnosed and can be successfully treated with interventional radiology including arterial embolization and radio ablation. This field is expected to show promising results with the diagnosis and treatment of many disorders in the future as it is doing currently.

References: ___________________ 1: 2020. [online] Available at: <https://jordan.gov.jo/wps/portal/Home/GovernmentEntities/Ministries/ Ministry/Ministry%20of%20Health?nameEntity=Ministry%20of%20Health&entityType=ministry> 2: 2020. [online] Available at: <http://apps.who.int/medicinedocs/documents/s17296e/s17296e.pdf> 3: 2020. [online] Available at: <http://khmc.jo/en/specialized-units/diagnostic-interventional-radiologydepartment/> 4: 2020. [online] Available at: <http://www.jordan-hospital.com/Contents/Radiology_Imaging_Department. aspx> 5: 2020. [online] Available at: <https://www.mefomp.com/Workshop-on-Advances-in-Radiology-andDiagnostic-Physics-in-Amman-Jordan_a6930.html> 6: 2020. [online] Available at: <https://www.mefomp.com/Computed-Tomography-Workshop-andQuality-Control-in-Amman-Jordan_a6931.html> 7: 2020. [online] Available at: <https://www.zawya.com/mena/en/press-releases/story/UAE_Ministry_of_ Health__Prevention_to_organize_regional_workshop_on_Interventional_Radiology_IR_and_Radiation_ Protection_RP-ZAWYA20190716110908/> 8: Northwestern University, Feinberg university of medicine, 2019: feinberg.northwestern.edu/ 9: Society of interventional radiology, 2019: sirweb.org/ 10: Review Committee for Radiology ACGME: 415InterventionalRadiologyFAQs2018.pdf

THERAPEUTIC USES OF INTERVENTIONAL RADIOLOGY

20

By: Yasmeen Dhaher

Interventional radiology is a minimally invasive and image guided diagnosis as well as treatment of various diseases, many of which are life threatening. Venous thromboembolism, one of the diseases which has significantly high mortality rates according to statistics which suggest that 60,000-100,000 Americans die of Deep vein thrombosis and pulmonary embolism. With 10 to 30% of people dying within one month of diagnosis.(1) Therefore due to the frequency of venous diseases and its influence on quality of life quality, we chose to draw attention to the interventional radiological procedures that can provide fast and complete recovery from venous thromboembolism if applied in time.

The most important radiological interventions applied in the venous system are: ●Interventional radiological invasive treatment of massive pulmonary embolism. ●Treatment of acute lower extremity deep vein thrombosis. ●Treatment of deep vein stenosis (balloon dilatation, stenting). Inserting a temporary or permanent vena cava filter. ●Embolization of enlarged, inadequate venous networks (varicocele, embolization of large haemorrhoidal veins, embolization of dilated gastric, perigastric venous networks). ●Development of TIPS (transjugular intrahepatic shunt system shunt). ●Embolization of arteriovenous malformations. ●Sclerotization, laser treatment of superficial veins, varicose veins.(2) The indication that allows the use of interventional radiological techniques is massive pulmonary embolism which is decided according to clinical classifications or the previously used Greenfried and Erbel-Meyer severity grouping, depending mainly on the severity of dyspnoea, tachypnea, syncope and chest pain, reduction in systemic blood pressure.

In the treatment of cardiac embolism with interventional radiology catheterization, we should primarily alleviate the severe hemodynamic catastrophe, which can be achieved most rapidly by cleavage and mechanical removal of thrombi (Figures A and B). The method can dramatically reduce the pressure in the pulmonary artery, which is critical to the success of therapy in gaining time. By rapidly relieving pressure, the patient is prevented from hearing in the acute first few

The function of selective fibrinolytic therapy following thrombus fragmentation is to optimize the thrombus-free pulmonary vascular system.(2) Selective fibrinolysis is not sufficient to render major vessels thrombus-free, and efforts should also be made to repair capillary circulation to prevent late pulmonary hypertension and all its consequences. Therefore, the duration of therapy can last from 12 hours to 5 days.(4) Secondly, The advent of interventional radiology enabled remarkable advances in diagnosis and treatment of several situations in obstetrics and gynecology. The non-tubal ectopic pregnancy, either cervical, abdominal, ovarian or in a cesarean scar, often represents a major therapeutic challenge, especially when there exists a desire to maintain fertility. Despite the systemic methotrexate therapy and surgical resection of the ectopic gestational sac be the most used therapeutic options, the interventionist approach of non-tubal ectopic pregnancies, direct injection of methotrexate in the gestational sac and intra-arterial chemoembolization of uterine arteries constitute in the currently literature viable, safe, effective modalities with low morbidity, shorter hospital stay, and rapid clinical recovery.

Because of little variety of materials used, and the increase in training of specialists in the area, the radiological intervention as a treatment option in ectopic pregnancies is financially viable and present considerable accessibility in the world and at most of Brazilian medical centers.(3) Finally, the therapeutic uses of IR do not end on the cases listed above. But in addition to them, interventional radiology nowadays has found treatments for Intrahepatic Cholangiocarcinoma and Gastroenteropancreatic neuroendocrine tumors (GEP-NETs).

To conclude, interventional radiology nowadays has broad therapeutic uses that can save lives, decrease mortality and morbidity rates as well as improving the quality of life for many patients who have always been seeking minimally invasive and considerably faster treatments.

References:

___________________

(1): Beckman MG, Hooper WC, Critchley SE, Ortel TL. Venous thromboembolism: a public health concern. Am J Prev Med. 2010 Apr;38(4 Suppl):S495-501. doi:10.1016/j.amepre.2009.12.017.

(2): Battyáni I, Dósa E, Harmat Z. [Interventional radiology treatment of extensive pulmonary embolism and thromboembolic diseases]. Orv Hetil. 2015 Apr 26;156(17):674-9. doi: 10.1556/ OH.2015.30151.

(3): Fornazari VA, Szejnfeld D, Elito Júnior J, Goldman SM. Interventional radiology and endovascular surgery in the treatment of ectopic pregnancies. Einstein (Sao Paulo). 2015 JanMar;13(1):167-9. doi: 10.1590/S1679-45082015MD3168.

(4): Battyány, I., Horváth, L., Sárosi, I., et al.: Local fibrinolytic treatment in subtotal pulmonary embolism. [Lokális fi brinolytikus kezelés subtotalis tüdőembóliában.] Orv. Hetil., 1999, 140(16), 873–879.

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AN INSIDE LOOK ON INTERVENTIONAL RADIOLOGY

By: Hanin Lataifeh

AN INTERVIEW WITH DR. MOHAMMAD AMARNEH Dr. Mohammad Amarnehâ&#x20AC;&#x2122;s Education and Training: 1. JUST medical school class of 2008.

Electives: two months of internal medicine at University of Texas Medical Branch (UTMB) at Galveston.

2. Internship, Ibn Al Nafees hospital, Irbid 20082009 3. Transitional Pediatric Residency, KHCC, Amman 2009-2010 4. Pediatric Residency, University of Iowa 20102012 5. Radiology Residency, University of Iowa 2012-2016.

6. Pediatric Radiology Fellowship, University of Iowa 2016-2017, 7. Pediatric Interventional Radiology Fellowship, Harvard University, 2017-2018.

What is your current role and title?

- - - -

Assistant Professor of Radiology at University of Iowa.

Pediatric and Adult Interventional Radiologist.

Director, Pediatric IR program.

Assistant director, IR Residency Program.

Why did you choose IR? I wanted a field that stimulates me intellectually and gives me the opportunity to make a visible impact on peopleâ&#x20AC;&#x2122;s lives on a daily basis. I wanted to perform innovative procedures using cutting-edge technologies, and provide longitudinal patient care. I have always enjoyed working with kids and advocating for their wellness. Therefore, I decided to pursue a career in pediatric IR, one of the IR subspecialties.

What does your typical work day look like?

My typical week consists of one clinic day, three procedure days, and one academic day. In my clinic day, I see new consults as well as existing patient follow ups. Two of my procedure days are general/adult IR, and one is dedicated to pediatric IR practice. My clinic day starts at 8:00 and ends around 4-5 pm.

Typically, I see 4-8 patients in my clinic. My procedure day starts at 7:00 and ends around 5 pm. My academic day is dedicated to residency administrative work, meetings, and academic work/research. I practice with 4 other adult IR attending physicians and we take calls one week at a time (once every 5 weeks). When I am on call, I take over doing scheduled procedures around 4:00 pm and stay in the hospitals until all procedures are done. Depending on the day, this means staying in the hospital anywhere between 6 to 11 pm. After that, I take calls from home along with a resident or fellow and only come back to the hospital for emergent cases such as trauma or GI bleeding or urgent nephrostomy placement in a septic patient (happens 2-3 times per week on average).

What is the thing you like most about your specialty?

IR is a very rewarding specialty in many ways. I love how I can use my skills to treat urgent life-threatening or chronic debilitating conditions. I also love when a patient comes back for a clinic visit and they tell me how easy their recovery was, and how their life has changed after my procedure. This feeling is even more magnified in my pediatric patients, where procedures can be more challenging, and results can be quite dramatic. The other part that I love about my job is teaching. Working with students and residents is very rewarding professionally.

Seeing a trainee being able to perform a simple or complex procedure with little or no help brings unmatched joy and pride.

What are the training pathways to become an Interventional Radiologist?

Traditional Vascular and Interventional Radiology (VIR) fellowship (ends June 30, 2020): The traditional training pathway was one year fellowship training after diagnostic radiology residency (a total of six years: one year internship + four years residency + 1 year fellowship). The VIR fellowship ceased on June 30, 2020 and was replaced by the independent IR residency.

Integrated IR residency: Integrated IR residency is 5 years (a total of six years: one year internship + 5 years IR residency). First three years are focused on diagnostic radiology, and the last two years are focused on interventional radiology.

24

AN INSIDE LOOK ON INTERVENTIONAL RADIOLOGY - CONT.

AN INTERVIEW WITH DR. MOHAMMAD AMARNEH Independent IR residency (starting July 1, 2020): This is the replacement of the traditional VIR fellowship. It is two years in length (a total of 7 years: one year internship + four years residency + two years Independent IR residency).

Early Specialization in Interventional Radiology (ESIR): Total of 6 years (one year internship + four years residency (including ESIR) + one year Independent IR residency). Not all radiology residency programs are approved for the ESIR designation. If your residency program is approved for ESIR, you can complete ESIR training and apply for one year independent IR residency. Without ESIR, you have to do 2 years of Independent residency.

Basically, you save one year of training

What is the most challenging part about your specialty?

Making a clinical decision that is best for my patients is the most critical part of my job and being trusted with someone’s life is not a little burden. Your patients will develop complications, regardless of how good your clinical judgment and procedural skills are. You have to be able to manage these complications, and address these events honestly with your patients and/or their parents or loved ones.

What are some of the misconceptions about IR? “IR has a difficult lifestyle”: IR can be busy, and you will be called at the middle of the night for emergencies. But that is exactly what makes it rewarding. The adrenaline rush and the satisfaction you get after you stop that bleeding and save someone’s life is the ultimate reward of being a physician. If you are reading this and got excited, you have the personality for IR. “Forget about IR because you are an IMG”: It’s true IR is a very competitive specialty, more so in the last few years. The new integrated IR residency was the most competitive specialty in the 2018 National Residency Match Program (NRMP). However, competitive IMG applicants continue to match into both integrated and independent IR residencies.

“You can’t go into IR if you are female”: Women have been notoriously underrepresented in Radiology and more so in IR. Only 8% of IRs in the United States are women. The truth is women have been in IR since the beginning of the specialty, and display comparable procedural skills and patient care compared to men. There are several hurdles that women face in IR. Research has shown that being married and having a family is more challenging for women than men, and associated with emotional exhaustion. Therefore, working with a supportive spouse is essential for a woman to balance a successful career and family life. Being a female should not stop you from pursuing a career in IR. Lastly, what is your advice for students at JUST who are considering IR as a future specialty?

If you are interested in IR, you should complete such a rotation. Believe in yourself, work hard, follow good advice, and don’t underestimate the power of connections.

INHOUSE 26 ACHIEVEMENTS IN THE FIELD OF INTERVENTIONAL RADIOLOGY By: Rama Alawneh

You may have heard the latest commotion regarding the most recent “Worldly Medical Accomplishment” performed at the King Abdullah University Hospital (KAUH) by a team of Jordanian doctors. Well, this uproar is not out of place. It reflects the current skill and capacity of the Jordanian Doctor, and also the potential that Jordan has to offer to the medical field through its gifted medical professionals.

The paper published recently in The Journal of Craniofacial Surgery is authored by Khaled Alawneh, MD, Bashar Abuzayed, MD, Majdi Al Qawasmeh, MD, and Liqaa Raffee, MD. It proposes the use of a “novel technique of endovascular and surgical devascularization” in the removal of a scalp arteriovenous malformation.

A 26-year-old female patient presented to the emergency department at KAUH with chief complaints of an increasing headache and swelling of the left upper eyelid. The swelling was noticed to be soft and pulsatile upon examination. Consequently, a brain computed tomography (CT) scan was performed along with a brain magnetic resonance imaging (MRI) scan. Following that, brain CT angiography was performed and revealed that there was a vascular lesion. A six-vessel cerebral angiography showed that there was a left frontal scalp arteriovenous malformation (AVM).

An arteriovenous malformation of the scalp is an “abnormal fistulous connection between the feeding arteries and draining veins without an intervening capillary bed within the subcutaneous layer.” The symptoms of an AVM depends on its location.

This particular AVM was supplied by the left and right superficial temporal arteries along with the left supraorbital artery. The superficial temporal arteries and the supraorbital arteries are arteries of the scalp.

“The nidus of the AVM and the direct high flow venous drainage to the superior sagittal sinus through a wide pore (See Figure 1C – black arrow) in the bone carries a high risk of passing the embolizing materials, especially since that the bony pore of the venous drainage does not collapse like the venous vessel wall when there is decreased intranidal pressure.”

In the process of her treatment, the patient was sedated and through her right femoral artery, both superficial temporal arteries were occluded using Onyx 18 – liquid embolic agent used for the occlusion of blood vessels. Post-procedure, cerebral angiography displayed regression of the nidus. There was complete cutoff of the flow from the bilateral superficial temporal arteries. Two days following this procedure, the patient was operated on through a left eyebrow incision. This operation was done in order to expose, ligate, and cut the supraorbital artery.

“The endovascular embolization of the supraorbital artery was avoided due to the high risk of ophthalmic artery occlusion and potential blindness. Therefore, instead, the external ligation of the supraorbital artery via a left eyebrow incision was done. It was a safer option. (See Figure 1B)” With this technique, and without embolization of the nidus, total surgical excision of the AVM was feasible.

This isn’t the first medical achievement performed by doctors at KAUH. Dr. Khaled Alawneh, along with colleagues, performed a rare surgery on a 22-year-old Syrian refugee in 2017. She was referred to KAUH due to constant pain, weakness, and numbness in her right upper arm three weeks following gunshot wounds to the right chest and neck area. The patient was found to have a subclavian pseudoaneurysm – in other words, a hematoma surrounding the subclavian artery. The patient was treated via an endovascular repair by angioplastic ballooning of the stenotic region of the artery. The patient recovered and, on follow-up examination, was revealed to have significant improvement with respect to the neurological deficits previously incurred.

Such a case is considered rare and is associated with a high mortality rate; the doctors at KAUH managed to successfully treat this case. A case report was published on the 13th of June in 2017 in the Journal of Vascular and Endovascular Surgery. This case report was authored by Khaled Alawneh, MD, Liqaa Raffee, MD, and Shadi Hammouri, MD. Progression in the field of interventional radiology has allowed the treatment of highrisk conditions with less-invasive techniques. The progression is well exemplified by the work of doctors at KAUH in Irbid, Jordan.

Figure 1. A) A schematic drawing and B) intraoperative picture showing the site of the left eye-brow incision and the cut of the left supraorbital artery (arrow). C) Intraoperative picture showing the dissection of the AVM in subperiosteal plan and exposure of the draining bony venous pore (arrow). D) Intraoperative picture showing the separation of the draining vein and occlusion of the bony venous pore with bone wax (arrow). E) Intraoperative picture showing the peri-galeal plan of the AVM dissection with noticed very minimal blood oozing from the soft tissues. F) The AVM after resection.

AVM, arteriovenous malformation; OA, ophthalmic artery; SOA, supraorbital artery

NEW 28 DEVELOPMENT IN THE INTERVENTIONAL RADIOLOGY By: Obada Ababneh

Interventional radiology (IR) is a rapidly growing field in medicine. Therefore, new procedures and techniques emerge every once and a while. One of the most rapidly developed specialties in IR is interventional oncology, which deals with tumor treatment by using radiological methods(1). For example, Transarterial chemoembolization (TACE); which is an image-guided and non-surgical procedure, is the first-line treatment for patients with intermediate-stage of hepatocellular carcinoma (HCC)(figure1)(2). This technique uses a catheter to deliver both chemotherapy medication and embolization materials into the blood vessels that lead to the tumor, allowing doctors to treat tumors that are not accessible using conventional surgery or radiation treatments(3).

Transarterial radioembolization (TARE) is another method that uses a radioactive element like Yttrium-90 (Y90) and it is newer than TACE(4). TARE is very similar to TACE, and it is delivered to the cancerous tissue similarly by using a catheter. The two methods aim to block the supply of blood to the cancerous cells and thus eradicate them, (Figure 2) illustrates when TARE and TACE can be used to treat HCC(5).

In 2000, the Food and Drug Administration (FDA) approved the first medical robotic system; Vinci, and since then a huge shift in all different fields of medicine occurred(6). In IR, robots are used for multiple goals: mainly to diminish radiation exposure risk, facilitate needle placements and guidance, and enhance image-guided percutaneous procedures. Steerable Robotic Catheter Systems (SRCS) is an example of using robotics in endovascular procedures(7). SRCS helps in stent placement especially in the case of patients with complex peripheral vascular anatomy. Steering the catheter inside the vessels depends on the magnetic field. Figure 3 shows the Robotic cannulation and embolization of bilateral prostatic arteries.

Robots can also help to take a biopsy from deep small tumors or tumors that are closed to sensitive organs like the lungs and the heart by connecting them to either computed tomography (CT), Magnetic Resonance Imaging (MRI) or ultrasound (US). Computed Tomography-Guided Robotic System (figure 4) is composed of a CT scan and a connected robotic arm that will take the biopsy after analyzing the picture.

Benign prostatic hyperplasia (BPH) is one of the most common diseases among me that has an incidence of 50% in men aged 50-60 years. It is due to the increase in the size of the prostate which leads to lower urinary tract symptoms (LUTS).

The incidence increases with age. The old method to treat BPH was done by a surgical procedure which is called Transurethral resection of the prostate (TURP). Interventional Radiologists use the prostatic artery embolization (PAE) method to treat BPH. Although TURP is considered the gold standard to treat BPH, it has a high morbidity rate and 40% of patients have residual LUTS within five years after the surgery. However, PAE new development shows less severe LUTS after the end of the procedure than TURP does. PAE depends on the reduction of the blood flow to the right and left prostatic arteries and thus decreasing oxygen and nutrients to the cells leading to prostate shrinking in size(9). Figure 5 shows the size of the prostate gland before and after prostatic artery embolization(10).

Hemorrhoids are swollen veins in the anorectal region. Hemorrhoids can be internal, in the rectum and upper anus regions, or external, in the lower part of the anus or under the skin. A new method called Hemorrhoid Embolization (or Emborrhoid technique) is used by an interventional radiologist to treat hemorrhoid patients. This technique involves endovascular coil occlusion of the distal branches of the superior rectal arteries arising from the inferior mesenteric artery. Middle and inferior rectal arteries prevent any ischemic damage to the rectum (they are not embolized unless they are the cause of the hemorrhage). This procedure is fast (around one-hour), easy, and successful (95% success rate).

NEW 30 DEVELOPMENT IN THE INTERVENTIONAL RADIOLOGY - CONT. By: Obada Ababneh

Obesity is considered an epidemic problem in third world countries and some first world countries like the USA that result in significant morbidity, mortality, and cost to the healthcare system. A new type of treatment has emerged and it is called Bariatric Arterial Embolization which is still under the clinical trials (figure 6 shows the different surgical options).

This is done by interventional radiologists.

Ghrelin is a hormone secreted from the fundus of the stomach and binds to the central nervous system(CNS) to increase the appetite (figure 7 shows the effect of ghrelin on the brain).

There is a strong association between ghrelin levels and obesity. Bariatric Arterial Embolization aims to embolize the left gastric artery which induces sufficient ischemia to the mucosa of the gastric fundus to inhibit ghrelin production(12).

Therefore, weight loss might occur.

However, it has been suggested that the reversal or slowing of the procedural effect is due to the revascularization of the stomach(13).

In conclusion, IR is considered a rapidly developed field that offers a good alternative from surgeries, reduces X-ray exposure, and the need for iodinated contrast. IR can deal with small and non-complicated procedures to highly severe conditions like tumors. Continuing advances in different technological fields mean that the range of IR conditions that can be treated is continuing to expand.

References: ___________________ 1- British Society of Interventional Radiology n.d., what is interventional radiology?, viewed 9 august 2019, < https://www.bsir.org/patients/what-is-interventional-radiology/?fbclid=IwAR0V032aTjEwFZxMTB_pXINuGM1fH67SlmE-3ykZbjXOgtrswrs-BHJ5zE> 2- Updated use of TACE for hepatocellular carcinoma treatment: How and when to use it based on clinical evidence Raoul, Jean-Luc et al.Cancer Treatment Reviews, Volume 72, 28 – 36 3- Massachusetts General Hospital n.d., Transarterial chemoembolization (TACE), viewed 9 august 2019, < https://www.massgeneral.org/imaging/services/procedure.aspx?id=2267> 4- Kallini, J.R., Gabr, A., Salem, R. et al. Adv Ther (2016) 33: 699. https://doi.org/10.1007/s12325016-03245- Marrero et al. Diagnosis, Staging, and Management of Hepatocellular Carcinoma: 2018 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology, VOL. 68, NO. 2, 2018 6- Rueda, M., et al. (2018). “Robotics in interventional radiology: Past, present, and future.” The Arab Journal of Interventional Radiology 2(2): 56-63.

7- Kassamali RH, Ladak B. The role of robotics in interventional radiology: current status. Quant Imaging Med Surg 2015;5(3):340-343. doi: 10.3978/j.issn.2223-4292.2015.03.15 8- Kettenbach, Joachim and Gernot Kronreif. “Robotic systems for percutaneous needle-guided interventions.” Minimally invasive therapy & allied technologies : MITAT : official journal of the Society for Minimally Invasive Therapy 24 1 (2015): 45-53 .

9- Abt Dominik, Hechelhammer Lukas, MüllhauptGautier, Markart Stefan, Güsewell Sabine, KesslerThomas M et al. Comparison of prostatic artery embolisation (PAE) versus transurethral resection of the prostate (TURP) for benign prostatic hyperplasia: randomised, open label, noninferiority trial BMJ 2018; 361 :k2338 10-INVO n.d., Prostate artery embolization (PAE), < https://www.inova.org/healthcare-services/ interventional-radiology/types-of-services/prostate-artery-embolization> 11- Endovascular today 2018, Hemorrhoid Embolization: Does It Last?, viewed 9 august 2019, < https://evtoday.com/2018/04/hemorrhoid-embolization-does-it-last/?fbclid=IwAR3umILrVC_ jzI8x9A9AmKO5Wd88CgpP6LYK0pO40DbhK0JMlbHKNs2cXn0> 12- Bariatric Embolization of the Gastric Arteries for the Treatment of Obesity Weiss, Clifford R. et al. Journal of Vascular and Interventional Radiology, Volume 26, Issue 5, 613 - 624 13- Endovascular today 2018, Bariatric Embolization: Are Patients Actually Losing Weight?, viewed 9 august 2019, < https://evtoday.com/2018/04/bariatric-embolization-are-patients-actually-losingweight/>