On being a radiology endovascular fellow

Created - 02.08.2009

I have spent the last year as an endovascular fellow at the Sheffield Vascular Institute, consolidating and advancing skills learnt during my basic 5 year Radiology training in Hull. The populations are quite similar, with poor lifestyle, a high smoking incidence and, in addition, a large Asian population with high prevalence of diabetes, creating a large cohort of vascular patients locally, supplemented by national and international referrals.

The team of 5 consultant radiologists works closely with 8 vascular surgeons across 2 sites – the Northern General and the Hallamshire – and liase with various other specialties, including neurology, diabetology, renal medicine, cardiothoracic surgery, cardiology, urology and Obs&Gyn. The working week consisted of up to 10 elective angiography sessions, with additional emergency lists thrice a week. 

The majority of elective patients were day cases, accommodated in a high throughput 4-bedded day ward. However, with Radiology 'beds' on the vascular wards and weekly combined ward rounds, patient care did not stop once groin haemostasis was achieved, and I was encouraged to regularly review patients on the ward. Patient care actually started in the weekly out patient clinics – a novelty in radiology circles! 

It was fantastic, being in a dedicated vascular radiology clinic, being able to assess patients myself, stratify their management and investigations, monitor various aspects of disease modification, consent and list them, and during followup, the satisfaction of seeing patients I had treated myself, describe how it felt 'like having a new set of legs', or the heart-sink of the occasional treatment failure.

The rest of the week was mostly spent in the angio suites, where I was given free rein, doing as much as I wanted. While I had done straightforward angioplasties and stents before, I now started dealing with more complex cases – long SFA recanalisations, iliac occlusions, crural interventions, upper limb interventions, consequently my skills repertoire expanded rapidly.

Add to this specialist interest skills such as the treatment of the failing dialysis fistula, uterine fibroid embolisation, pelvic congestion treatment and managing various vascular malformations, supplemented by CT and MR experience, and I was learning new procedures almost every week. My logbook numbers were exploding. 

Sheffield has been at the forefront of EVAR for a while and I too was soon actively involved in aortic stent grafting, mostly below but a few above the diaphragm as well (not forgetting the spinal drain!). I even learnt to do part of the procedures percutaneously and look forward to the day when EVARs are done entirely without surgical cutdowns. Of course I also had to learn how to plan the EVARs, order the grafts and provide the “before and after” service – embolise internal iliacs and treat endoleaks. 

Sheffield probably leads the country in carotid stenting and this meant discovering a new world of monorail technique, protection devices and reverse-flow systems (wear wellies when using them!). Cases were discussed at weekly carotid MDTs, and patients recruited for the ICSS trial. The weekly vascular MDT was always a lively forum and with everyone presenting their own cases, I had to be ready for both the usual brickbats and the rare plaudits.

The other aspect of working in Sheffield was getting to know the technology. Various company reps were forever traipsing through the door and offering groundbreaking technology and equipment allegedly before most of the world had heard about it, and whether it be new generation stent grafts, new stents and balloons, detachable coils, occlusion plugs – it felt at times like I used them all. 

Apart from me there were other trainees at various stages – ranging from course attendees, visiting consultants brushing up their skills, other senior fellows, some fellows doing short term attachments, trainees from the Sheffield rotation coming to grips with their first angio to medical students stuttering over aortic anatomy – and I was encouraged to get involved in their training as well. 

I did a 1 in 6 on call with one of the consultants covering, and that week could be a very mixed bag, from a minor phone consult with a neighbouring hospital to adrenaline surging middle-of-the-night embolisations – including the occasional stabbing or shotgun blast.

While I had developed basic wire skills before coming to Sheffield, the past year has equipped me to deal with vascular patients as a whole. Not only have I picked up advanced technical skills, but I now feel confident making clinical decisions, and can deal with a greater range of vascular problems. It has been an invaluable learning experience, and a thoroughly enjoyable one and I thank Professor Gaines and Dr Cleveland for giving me the opportunity. I've worked with a great bunch of colleagues and made new friends – and it has been an experience that I can wholeheartedly and without reserve, recommend to anyone wanting to expand their endovascular experience.

Ramita Dey Endovascular Fellow Sheffield Teaching Hospitals