The story behind this year’s CIRSE Gold Medallist

September 10, 2024

By Prof. Francisco Cesar Carnevale, CIRSE 2024 Gold Medallist

I got the idea of becoming an IR after observing a TIPS procedure.

At the time, I was at the beginning of my career, doing a residency in general surgery and liver transplantation, but I wanted to do something slightly different. I went to speak to my teachers here in Brazil, and told them this thought of “surgery, but different.” One of the suggestions they gave me was laparoscopy, because at the time it was the 90s and laparoscopy was just emerging as a new, minimally invasive surgery that they thought would be interesting to me. I had this thought in mind, and then I had to follow a patient to be treated by Dr. Renan Uflacker during a TIPS procedure.

When I saw this, I felt it was crazy! How can you have a physician puncture a vein in the patient’s neck, pass through the heart, get into the liver and do another puncture? It was so interesting and I was incredibly excited to witness it. After that procedure, I spoke to Dr. Uflacker and asked him “what was that, what was that specialty?” And he told me: it’s Interventional Radiology.

From that moment, I started reading and trying to learn all I could about IR. It was fascinating, and I started to reach out to physicians in other countries to learn more. We had some procedures being done here in Sao Paolo at the time, but IR was not officially established as a department or even a discipline. Nestor Kisilevsky, one of my first mentors, had started to do the first cases at the University of Sao Paolo Medical School.

Prof. Carnevale speaking at CIRSE last year

Prof. Carnevale has previously won the Award for Excellence and Innovation in IR for his work on PAE

Prof. Carnevale with his wife of 20 years, Ana Maria, who is a prominent endocrinologist, at the CIRSE presidents dinner

So, I decided to better understand that specialty with a “strange name” and travelled to my first IR (former SCVIR, now SIR) meeting in 1995 in Fort Lauderdale, FL. During the meeting, I had the opportunity to meet several IRs in person who, years later, became some of my mentors. I travelled to several university centres in the US (South Carolina, MD Anderson – Houston, California, Pittsburgh, Chicago) and Europe (San Sebastian, Canary Island, and Zaragoza) to learn new skills, further extend my knowledge, and build strong relationships with well-known interventional radiologists. I’m grateful to my mentors during this time – Renan Uflacker, Sydney Wallace, Albert Zajko, Horacio D’Agostino, Wilfrido Castaneda, James Donaldson, Mariano de Blas, Manuel Maynar, and Miguel Angel De Gregorio, among others.

I did my research fellowship in the United States, and it was there that I met Prof. Manuel Maynar, who invited me to come to Spain to work with his team. I moved to Spain in 1995 and completed my PhD there under the supervision of Dr. Mariano de Blas and Prof. Maynar. My thesis was on chronic iliac artery occlusion, and it was published in CVIR.

I returned to Brazil in 1997, but quickly relocated once more to Spain upon an invitation to work as staff in Barcelona. While there, I received a call from the chairman of the Radiology Department at the University of Sao Paolo, Prof. Giovanni Cerri. He’d become aware of me and wanted me to come back to Brazil, because they wanted to start a paediatric liver transplantation programme and needed someone to do paediatric IR. I told him “I have never treated children – how can I come back and perform IR in children?” He told me that if I came back and accepted the position, that he would support me in training anywhere I liked. So, I did just that. I returned home to start to organize the paediatric IR unit at the University of Sao Paolo, and then I went back to United States to be trained in paediatric IR and complete a fellowship in paediatrics in Pittsburgh and Chicago. This proved to be a significant time for what was to come. The skillset needed in treating small children with IR was an ideal background to have for prostatic artery embolization.

One of the pieces of advice that I received and learned from one of my mentors in Spain was to work as a team and in collaboration with vascular surgeons. So, I was introduced to Dr. Felipe Nasser by a friend of ours and we started to work and learn together. It was an amazing personal and professional experience and relationship! Another physician who was my fellow, colleague, and became great friend during difficult and amazing moments in my life, was Ricardo Augusto (Ricardinho).

After returning from the States, I settled into my job alongside my team in Sao Paolo. I split time between the University of Sao Paolo and the Syrian Lebanese Hospital. These two hospitals have several departments to work together, and I’m the head of the interventional radiology department at both. Two great former fellows who became my partners and friends, Airton Mota and Andre Assis, gave me all the support to build a strong IR department at the University of Sao Paulo and take care of our patients. It’s been an honour and pleasure to lead these great teams. I always say “every star has to shine” – it’s really important to have a great team and to be able to collaborate and support each other while learning from the expertise and experience of others.

During this time, I read a paper on prostatic artery embolization in JVIR, it was a case report published by John DeMeritt et al. from New Jersey, who is today a very good friend of mine. His case report specifically detailed a case of a patient suffering from urinary obstruction and bleeding. I was contacted by a colleague Salomão Faintuch from Harvard in Boston, and we hatched the idea of replicating the study in PAE, but instead of treating a patient that was bleeding due to benign prostatic hyperplasia (BPH), the idea was to try to better understand the anatomy of the prostate and to use PAE as an alternative treatment for patients suffering from lower urinary tract symptoms.

It was a busy time for me in 2007 – work was busy and my daughter was only eight months old! But I went to Boston, where we had an interesting start, because we didn’t know exactly where the prostate arteries were in dogs. We did arteriograms, angiograms, CTs, and were able to identify the prostate arteries and treat the dogs (Picture 1)

We presented our study at the SCVIR meeting in Washington, D.C., in 2008 (SIR was called SCVIR back then), and it was selected as one of the best abstracts of the year (Pictures 2, 3, and 4).

After this success, I talked to the chairman of Urology Department at the University of Sao Paolo, Prof. Miguel Srougi, and to Prof. Cerri, and we decided to start a study with the idea of treating patients with urinary obstruction with PAE. Shortly after, we treated the first patients (Picture 5).

Picture 1: Prof. Carnevale doing PAE in dogs with his colleague from Egypt Mostafa EM, MD

Picture 2: Experimental study with dogs at Harvard in 2007 and presented during the SIR 2008 in Washington DC

Picture 3: Experimental study with dogs at Harvard in 2007 and presented during the SIR 2008 in Washington DC

Picture 4: Featured abstract of the experimental study with dogs presented during the SIR 2008 in Washington DC

Picture 5

Both patients were too high-risk to operate on due to comorbidities, and had had Foley catheters in place for nearly a year. After writing the protocols and assembling a team which included radiologists, pathologists, urologists, radiologists and IRs, we offered prostatic artery embolization to the patients. They accepted the idea, we treated them, and they were able to remove the Foley catheters after treatment. Now, we had proved that PAE was safe and effective to treat patients suffering from complications related to the BPH-enlargement.

We submitted our results to CVIR, and it was a huge honour for myself and my team at the University of Sao Paolo that they were accepted and published in 2010. I presented on PAE at CIRSE for the first time that year, in Valencia 2010. One year later, we published the mid-term results in CVIR, and we started to develop a programme for treating patients with PAE. With teamwork, and under the supervision of the urology department, we started to get really good results. Even with the urology chairman’s support, you can imagine there was a huge resistance from the urology community, and I made a few enemies.

I started to travel around giving talks on PAE, and also training physicians in this technique. I had physicians from the world over come to me in Brazil, and travelled to other hospitals in the endeavour to replicate this procedure across the globe. It was surreal, to begin teaching internationally known IRs. I was used to going to medical meetings, to CIRSE and SIR, watching these great physicians presenting and teaching everyone. Then one day, I was teaching them in my life, in my patients, and they were there doing the procedures with me. It was an honour and a pleasure to host them at the University of Sao Paolo. It was also wonderful because they were able to give their valuable inputs on the procedure to me.

Thanks to the attention that sprang from teaching so many great physicians, I got the invitation to do a live case. It was one of the greatest things that happened in my life – and then it was really terrible. Soon you’ll understand why!

I was invited to transmit a live case from the Syrian Lebanese Hospital in Sao Paolo to New York City for that year’s GEST meeting, organized by Jafar Golzarian and Mark Sapoval. It would be the very first PAE procedure transmitted live. I was in New York alongside my urologist, and my team, coordinated by Airton Mota, MD, did the procedure at home in Sao Paolo.

My team talked to the most important TV channel in Brazil and asked if they would like to cover the case. A Brazilian surgery was going to be transmitted, live, to New York, USA!  They were interested, and so the TV channel went to the hospital, and during the live transmission to New York, they were also transmitting the story to Brazilian TV and – wow. It was great!

After the live case and the subsequent discussion, my cell phone rang. It was the CEO of Syrian Lebanese, and he told me “Hey, Francisco, we have 1000s of calls to our hospital. The entire population was watching TV, and they want to be treated by this procedure.” BPH is a very common disease. Around 50% of men will have BPH symptoms of urinary obstruction after their 60s. The telephone lines of the hospital were completely blocked, but that night I told the CEO, let’s try to set these patients in the ambulatory clinic of the hospital. It’s important. We’ll see these patients with urologists.

Later, while still in New York, I got an email. “Dr. Carnevale, as soon as you get back to Brazil, we urgently need a meeting with the board of the hospital and with urologists of the hospital. There was a movement from some urologists in the hospital telling us that you have done a procedure that was not allowed in the country. It seems you have done something illegal.”

In a short span of time, I went from the top of the world to the precipice of being fired from not only Syrian Lebanese, but also from the University of Sao Paolo – as I mentioned, they are very close and work together. I was about to be fired with the idea that I was doing something illegal. But it was not illegal!

We had the code of embolizing a tumour, embolizing haematuria. The hospital was aware of everything. So, I wrote a dossier several hundred pages long and submitted it to the Federal Council of Medicine in Brazil (Pictures 6 and 7), which is the highest level I could escalate to. The dossier had everything, every bit information from the very first experimental and clinical studies up until the present to prove that I had done nothing illegal.

Picture 6

Picture 7

This exhaustive work paid off – we got approval from the Federal Council of Medicine. I had officially done nothing illegal.

From there, we started to get more and more data. We submitted our data, along with data from other centres in Europe and the USA, and we got approved by the FDA to use microspheres in prostatic artery embolization. It’s important to state that Ms. Melodie Domurad was one of the most important people in charge to get this approval. Things sped up considerably from there, and the procedure gained more credibility as other centres started to publish their own data. The National Institute of Health (NIH) invited me to talk to their board, and also to their IRs and urologists.

One of the most important things that happened to me linked to PAE was the opportunity to treat someone really special. My father was suffering so much from LUTs, lower urinary tract symptoms, and his urologist wanted to remove his prostate. So, I talked to my father, I told him, let’s wait five years to understand the results of prostate artery embolization, and if we have good results without complications, I will offer this procedure to you. After the results were clear, I did just that. It was one of the great moments in my life to give something back to my father after everything that my parents had given me in life.

His symptoms improved 100%. His parents were from Italy and he loved to drink wine – but it worsened his symptoms and it had been forbidden for him for a long time. One night sometime after the procedure, he called me and I just heard “Clink! Clink! Clink!”. He was clinking a knife on a bottle of wine! I thought, father, what’s wrong with you? What’s happening? And he answered “I’m drinking my glass of wine! You cannot image what you have offered me in terms of quality of life. I’m calling to say thank you, that I’m really happy with this. And now I can drink my wine.”

I treated him when he was 75, and he remained symptom-free until the end of his life, years later, from other causes.  It was really great to be able to do that for him.

Other notable treatments – I also treated my father-in-law! As to how that procedure went, he’s doing quite well, and I am still married. I also finally did a PAE for a urologist, who told me, “you cannot tell anyone.” I treated his two brothers as well!

I need to say that all the support I have received from my family and friends has been the key in my life. My father, Jose, my mother, Elza, my sister Maria Lucia, my brothers, Rogerio and Ricardo, my wife, Ana Maria, and our two children, Marina and Rafael – they are the key in my life to being strong, developing things, and working with the passion that I have. I have travelled overseas a lot. I have flown across the globe to stay for one day. I’ve taken a red-eye to NYC, performed a procedure at 8am, taken the plane at 17:00 and been back to work in Brazil the next day. It’s been rewarding, but demanding, and would not have been possible without the immense support from my family.

The Carnevale family loves being together at home and at parties, a real “carnival”

Prof. Carnevale with his father Jose, mother Elza, sister Maria Lucia, brothers Rogerio and Ricardo

Prof. Carnevale with his wife, Ana Maria, and children, Marina and Rafael

The four Carnevale siblings celebrating sister Malu’s (Maria Lucia) birthday in September 2024 

I have passion in everything that I do, in my personal life, my job, my relationships. Doing things with passion and determination is the most important way to get a result. If it’s a good or bad result, time will tell! We can take a right, we can take a left, but if we want to go somewhere we need a strategy. We need to have an understanding of what we want to do, what we believe, and follow our instincts and feelings with ethics. Being ethical is important to the meaning of our lives, as well as to medicine.

It’s hard to imagine now the resistance that I faced. There were several urologists who wouldn’t look at me, wouldn’t talk to me, because we developed a procedure that brings quality of life to patients.

As it stands now, PAE is included in urology guidelines. It’s huge, it’s accepted everywhere. I’ve received patients from everywhere, and the physicians I had the opportunity to train are treating patients all over the world and offering quality of life to them.

Along the way I have met the most amazing people. Its one of the great things about CIRSE – community. I feel like it’s a group of friends. They accepted me, someone who was doing research in South America, in the difficult field that is urology, with a technique that is not easy. You can imagine the beginning, when people were reading papers and publications and letters from Francisco Carnevale from Brazil and thinking “Can I trust this? This is from Brazil?”

It was not easy – but with teamwork, we succeeded!

Prof. Carnevale celebrating at a pizzeria with his team of staff, fellows, and residents