CIRSE Fellowship report: Dr. Tiago Paulino Torres

My name is Tiago Paulino Torres, and at the moment I’m in the fifth and final year of my radiology residency at Unidade Local de Saúde de Trás-os-Montes e Alto Douro (ULSTMAD), Vila Real, Portugal. I have focused on interventional radiology since the beginning of my residency, and I have a passion for interventional oncology.

My fellowship goals were to improve my skills in the whole spectrum of IR (vascular and non-vascular) and to focus on learning novel interventional oncology and pain management procedures.

The 2^nd Department of Radiology at University General Hospital “Attikon” (Medical School, National and Kapodistrian University of Athens) in Athens, Greece, led by Prof. Nikolaos Kelekis, proved to be the perfect fit for my learning goals. It was an honour to be able to learn from their IR team every day during my two-month stay.

Overview of University General Hospital “Attikon”.

With part of the team in Athens.

Main entrance hall of University General Hospital “Attikon”.

Prof. Stavros Spiliopolous (head of the IR Department), Prof. Alexis Kelekis, Prof. Dimitris Filippiadis, Prof. Konstantinos Palialexis, Prof. Stavros Gregoriadis, Dr. Ornella Moschovaki-Zeiger, Dr. Thanassis Giannakis, Dr. Fotis Anagnostopoulos, and all of the radiology residents as well as the dedicated team of radiographers and nurses welcomed me with open arms and made this fellowship an unforgettable learning and life experience.

This department is certified by the International Accreditation System for Interventional Oncology Services (IASIOS), providing high-quality IO and IR care with patients receiving the best possible treatment for an optimal clinical outcome.

The IR department includes two angiosuites (one biplanar, one uniplanar; both with cone-beam), ultrasound, and CT rooms for interventional procedures; these rooms run daily with multiple procedures occurring simultaneously. There are also IR clinics which receive patients almost on a daily basis (mainly, but not exclusively, for pain management procedures).

The team also participates in weekly vascular and oncologic multidisciplinary team meetings.

The team at work, managing an acute pulmonary embolism with mechanical thrombectomy. From left to right: Associate Prof. Stavros Spiliopoulos; Consultant Konstantinos Palialexis; Fotis Anagnostopoulos, IR fellow; Nikolaos Papagiannis, resident on his 6-month rotation in the IR department.

Selfie with Prof. Dimitris Filippiadis at the 14th Panhellenic Congress of Interventional Radiology.

Hands-on workshop during the European School of IR (ESIR) course, “Spine interventions: Established indications”.

This fellowship allowed me to learn and participate in many procedures in different areas of IR, and I would point out the following areas and highlights:

Pain management is an essential skill set for all IRs, and the team in Athens does excellent work in carrying out these procedures. I was able to witness (among others):

• Cryoneurolysis (celiac plexus, splanchnic nerves…) in the context of intractable cancer pain (mostly pancreatic cancer);
• Cryoneurolysis of medial branch nerves for facet joint pain;
• Vertebroplasty/vertebral augmentation;
• Discectomy/disc decompression techniques;
• Infiltrations (epidural, nerve roots, facet joints, sacroiliac joints…);
• Pulsed radiofrequency nerve ablation.

I also had the chance to improve my knowledge and skills in the area of pain management as well as other spine and musculoskeletal procedures, during the European School of IR (ESIR) course, “Spine interventions: Established indications”, with local host Prof. Dimitris Filippiadis. Fortunately for me, this course was held in “Attikon” Hospital during my stay. It was a successful event with great lectures and amazing hands-on workshops, allowing participants to explore techniques like epidural injections, facet joint and sacro-iliac joint therapies, intervertebral disc techniques, percutaneous bone biopsies, vertebroplasty, vertebral balloon augmentation, ultrasound-guided spine injections, and navigation systems (electromagnetic, robotic, combined endoscopy).

The team has published many papers on the topic of cancer pain management, including a publication (with Prof. Dimitris Filippiadis and Prof. Alexis Kelekis as authors) that was incorporated in the National Comprehensive Cancer Network (NCCN) 2021 guidelines for adult cancer pain. The impact of pain management through IR procedures and importance of ablation in cancer pain relief are evident here, whether it be percutaneous ablation on nerve structures responsible for pain mediation signals (neurolysis), or direct tumour ablation to relieve tumour-mediated inflammation and decompress tumour compression of anatomical structures.

Regarding other IO procedures, I was able to attend multiple transarterial radioembolization (TARE) and transarterial chemoembolization (TACE) procedures for the treatment of liver tumours (including hepatocarcinoma and cholangiocarcinoma).

Also, the team expertly performs numerous CT-guided ablation procedures (with different technologies, and in different organs,) including:

• Liver microwave (MW) ablation (mainly for colorectal cancer liver metastases);
• Lung metastases cryoablation;
• Renal cell carcinoma (RCC) cryoablation;
• Extra-abdominal desmoid tumour cryoablation.

It was a great experience watching the pre-procedural image assessment, planning, execution, and often follow-up of these embolization and ablation procedures.

I also had the chance to watch how adjunctive techniques can be applied to improve the efficacy and safety of ablation procedures, namely, transarterial embolization to decrease the vascularity of renal tumours before performing renal cryoablation, as well as planning thermal protective techniques (hydrodissection) to protect important anatomical structures.

Selfie with Ornella Moschovaki-Zeiger, IR Fellow.

Prof. Alexis Kelekis and Dr. Fotis Anagnostopoulos performing a vertebroplasty under a combination of fluoroscopy/cone beam CT guidance coupled with electromagnetic navigation system.

Lunch after a great day of IR cases with the team and trainees from Portugal and Albania.

In the above-mentioned areas of IR, as well as for image-guided biopsies, I had the chance to see how multiple imaging modalities and navigation systems (electromagnetic and robotic) can play a great role in assisting the guidance and precision of these procedures. The work of this team is a good example of using the most recent technologies to our advantage, and how important it is for interventional radiologists to be at the forefront of technical innovation and application in the realm of image-guided procedures. This refers to not only modern navigation systems but also to combining different image modalities in IR practice. On this topic, I am pleased to announce that our joint paper, “Percutaneous Cryoneurolysis of Splanchnic Nerves Under Combined Computed Tomography and Endoscopy Guidance: Pushing the Boundaries of Hybrid Imaging”, written during this fellowship, has been recently published in CVIR. (https://doi.org/10.1007/s00270-024-03792-z).

Arteriovenous fistulas (AVF) and grafts (AVG) angioplasty procedures in haemodialysis patients were also frequent in this department.

It was interesting to see the importance of using sequential intraprocedural duplex ultrasound for measurement of volume flow to assist AVF/AVG angioplasties (a topic this team has published in the literature and presented in interventional congresses), in order to optimize outcomes and provide a quantifiable, functional endpoint in these endovascular procedures.

Percutaneous transluminal angioplasties to treat peripheral artery disease (PAD) both above and below the knee were also fairly common procedures.

I also was able to observe some emergency cases, including embolization procedures in the context of acute bleeding, as well as a bilateral pulmonary mechanical thrombectomy.

There was also a chance to see some rare/outlier cases, including embolization (with ethylene-vinyl alcohol) of an arterio-venous malformation (AVM) of the tongue, and coil embolization of a cryptogenic splenic arterio-venous fistula in a young female patient.

During my stay in Athens, I was also fortunate to attend the national 14th Panhellenic Congress of Interventional Radiology, a well-organized three-day meeting with excellent presentations and covering a wide range of recent IR topics and technology.

The 2024 CIRSE Fellowship Grant allowed me to achieve my goals of expanding my array of skills in IR, learning from an incredibly experienced team in an excellent academic centre, and getting familiar with and improving technical aspects of different interventional procedures mainly in the scope of IO, pain management and other areas of IR. I can’t wait to bring this knowledge home, share it with my colleagues and implement it in my daily practice to provide a better service to patients.