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SIR 2021: Extreme-IR and More

Op-Med is a collection of original articles contributed by Doximity members.

Progress in percutaneous image-guided interventions was once again on full display at the 2021 Annual Scientific Meeting of the Society of Interventional Radiology (SIR). As with most other medical meetings over the past year, it was entirely virtual. With nearly 16,000 logins and 27,000 presentation views, focus remained on the evidence for new and existing minimally invasive therapies for cancer, pain, and vascular diseases. Evidence continues to build for new interventional treatments for joint arthritis, deep venous disease, various malignancies, and prostate embolization. Latest data on the controversial subject of drug-coated devices for peripheral arterial disease was also in the lineup at various sessions. 

Among the newsworthy abstracts included the study by Dr. Padia of UCLA on non-surgical treatment of moderate to severe knee pain due to osteoarthritis. The study showed that embolization of geniculate arteries is a durable intervention that improves function and quality of life. A series of previously reported preliminary studies had suggested positive therapeutic impact of embolization on shoulder, elbow, as well as knee pain. This study documented durability of results up to a year after the procedure. The unexpected role of embolization in inflammatory joint disease is certain to attract much attention in the coming years. The likely mechanism of action is the reduction in inflammation by cutting down abnormal blood flow to the inflamed tissues in the joint.

Traditionally, the most popular sessions at the annual meeting of the SIR have been the Dotter lecture (this year given by Dr. Ziv Haskal), the film panel (not done this year), and Extreme-IR. The Dotter lecture is usually given by luminaries in IR who share their perspectives on issues relevant to the IR community and the field. The film panel consists of teams of physicians competing to diagnosis and treat of diseases chosen by the moderators. A panel of usually well-recognized practitioners are given minimal clinical and imaging information live onstage to arrive at the correct diagnosis and propose appropriate treatment. As one could imagine, the logistics of this type of presentation make it difficult to conduct virtually and was hence postponed to next year. 

Almost 10 years ago, a new plenary session was added to the roster of the Annual Scientific Meeting under the title of Extreme-IR. This was inspired by a similarly-named free standing meeting of the early 2000s that focused on presentation of highly unusual cases treated with rarely seen interventional approaches. As the name implies, the presenters are expected to focus on cases where they take heroic or extreme measures previously not tried or rarely attempted to treat patients who often have no other options. 

Over the years, the Extreme-IR has turned into one of the most popular sessions at the annual meeting of the SIR. Although virtual, it was no different this year, being the opener of the meeting. Moderated by its usual masters of the ceremony, Drs. Ziv Haskal, Michael Dake, and yours truly, the online sign-on rivaled the previous years’ in-person attendance. Although the virtual format appeared to detracted somewhat from the excitement of the live interactions between the panelists and the presenters, the discussions remained both lively and entertaining. 

The fast-paced session remained focused on clinical situations with high-impact learning experience for the audience. An international panel of experts and presenters from Japan, Singapore, Greece, Ireland, and the U.S. discussed their one-of-a-kind interventional approaches to a series of cases that included ascending aortic ruptures, chronic splanchnic venous thrombosis, impossible to treat tumors, lymphatic disease, persistent pulmonary arteriovenous fistula, and creative treatments of major complications. 

Although there was no shortage of innovative approaches to a variety of common and uncommon disease entities, two of the cases presented could potentially expand applications of IR procedures and deserve further discussions. First is the topic of lymphatic interventions. Although not entirely new, application of balloon angioplasty to open clogged lymphatic channels is not well described nor known. Dr. Max Itkin from the University of Pennsylvania showed the successful treatment of a thoracic duct obstruction resulting in relief of intractable abdominal pain in a patient with few signs pointing to the lymphatics as the etiology. Frankly, most of us would have been at a loss as to the cause of the patient’s symptoms. After the presentation, discussions surrounding other pathologies that could be helped by lymphatic interventions ensued. Areas under investigation include the role of lymphatics in heart failure, adenitis, unexplained abdominal pain, and fluid collections. 

The second case that will likely open a new arena for image-guided interventions was percutaneous stabilization of a pathologic fracture of the wrist in a patient with metastatic disease. Dr. Alexis Kelekis from National University of Athens inserted stabilizing rods through a needle into the fracture site followed by cement injection, which eliminated the patient’s pain and reestablished her hand mobility and grip. Everyone agreed that the non-surgical treatment of pathologic or traumatic bony fractures deserves further studies to determine the best candidates. 

Overall, despite the virtual nature of this year’s meeting, the initial feedback has been positive with rich content and outstanding speakers. 

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