CIRSE Fellowship report: Dr. Adeniyi Wasiu

By Dr. Adeniyi Wasiu

I am a 2nd (final) year fellow of interventional radiology at Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania. The training takes place at Muhimbili National Hospital (MNH), the National referral hospital in Tanzania. It is the first structured IR training in Sub-Saharan Africa and has produced thirteen IR specialists from across Tanzania, Rwanda, and Nigeria, since its commencement four years ago. The programme is supported by Road2IR, a non-profit organisation through which training is provided by volunteer visiting doctors from USA, UK, Germany, Canada, and, recently, Brazil. There are now four in-house doctors at MNH, all of whom are graduates of the programme.

Interventional radiology services are relatively new in Tanzania and in the majority of Sub-Saharan Africa. In MNH, services offered range from basic to complex procedures, such as:

• Image guided biopsies, mainly using ultrasound and CT
• Aspirations and drainages, especially nephrostomies and biliary drainages
• Image guided insertion of dialysis access catheters (temporary ones are still inserted by nephrologists)
• Management of dialysis AV fistula including angioplasty, declotting, and stenting,
• Central vein recanalization and stenting
• TIPS
• Ultrasound focussed sclerotherapy for varicose veins and vascular malformation embolization
• Routine arterial procedures including uterine fibroid/artery embolization, TAE/TACE and PSAE. Recently, we added BAE to our embolization lists
• Occasionally, peripheral arterial disease- angioplasty.

Dr. Adeniyi Wasiu

Aintree Hospital

My major drive to apply for CIRSE fellowship grant was to see how things are done in other places. I wanted to understand the breadth of available endovascular kits and their specific uses, particularly as we sometimes improvise in our practice due to the high cost of IR consumables. I also wanted to observe more procedures, especially UFE, and treatments for vascular malformations, and see the work culture in a European institution. It was my belief that the visit would enhance my training by allowing me to gain insight into the latest techniques and technologies in IR and further equip me with required knowledge for IR practice especially, as I’m rounding up my training and planning to contribute to establishing IR practice in my hospital in Nigeria.

The one-month observership at Liverpool University Hospital NHS Foundation Trust under the supervision of Dr. Shemin Mehta and his team of amazing interventional radiologists offered me a great learning experience. The IR department operates mostly in two centres of the hospital – Royals and Aintree – and it boasts of a state-of-the-art facility equipped with advanced imaging equipment, including four angiography suites with CT scanners and ultrasound machines. They also operate in hybrid theatres in conjunction with vascular surgeons. The department offers a wide range of procedures, such as image-guided biopsies, image-guided drainages (including nephrostomies, biliary and abscess drainage, among others), other non-vascular interventions (like tumour ablations) and vascular interventions (like peripheral arterial disease management by angioplasty and stenting), uterine fibroid embolization (UFE), transarterial chemoembolization (TACE), dialysis access management, vascular malformations sclerotherapy, aortic procedures in hybrid theatre, gastrointestinal bleeding management, and transjugular intrahepatic portosystemic shunts (TIPS) among others.

From left: Dr. Rim, Gareth, me, Dr. Michael, and Tom

One thing I found fascinating is the workflow of the department. The day usually starts with a brief involving every member of the team; doctors, IR nurses and radiographers. The procedures and required equipment are discussed at the brief. Important clinical information about the patient that may impact the procedure is also mentioned. This ensures that every member of the team is not just aware of the number of procedures, but also the peculiarities of each case. I believe this contributes significantly to the success of most procedures. This is something I hope to introduce in my centre, where patient discussions involve only the doctors most of the time. Thereafter, doctors go to the waiting area in the ward to seek the consent of the patient. The IR nurses prepare the patients for the procedure. Team members are introduced to the patient, patient identity is reconfirmed, important clinical conditions like drug allergies are confirmed from the patient, and lastly, the patient confirms the type of the procedure and willingness to proceed. At the commencement of the procedure, the entire process of the WHO checklist is repeated and patient consent to proceed with the procedure is sought again.

The programme gave me the opportunity to observe different procedures, including diagnostic and interventional angiography for peripheral arterial disease, transarterial chemoembolization for HCC, uterine artery embolization, vascular malformation sclerotherapy, angioplasty and stenting for superior mesenteric artery stenosis, pre-op embolization of renal artery, internal iliac artery embolization, tranjugular intrahepatic portosystemic shunt, CT-guided biopsy of lung nodules, and many drainages. I also participated in pre-procedure patient evaluations and consent processes, multidisciplinary team meetings and case discussions, post-procedure documentation, and patient follow up when required.

With Drs. Shemin and Hannah.

With Dr. Rob

With Dr. Shemin at dinner

One of the highlights of my stay is the realisation that everyday simple procedures still constitute the majority of cases even in the UK, and it’s these procedures which perhaps make the most significant difference in the patients. Biopsies, aspirations, and drainages are important to patients’ care- ‘small’ procedures, but big clinical impact! This is indeed reassuring, as we do a lot of these procedures in our centre at MUHAS, and we do get positive and appreciative feedbacks. Even though I didn’t scrub or assist in any procedure due to regulatory provisions which I was already aware of before the visit – thanks to CIRSE and Liverpool University Hospital (LUH) for comprehensive pre-visit information – I learnt a lot about procedures and equipment. In UFE, which was one of my major focuses, I noticed a few differences in the practice. The embolization agent of choice in LUH is PVA particles of 355-500 microns as against 500 – 700 in our practice at MUHAS. According to my findings, there hasn’t been any documented event of necrosis and abscess formation, which is the major fear with small particles in our centre. I noticed most patients started experiencing significant pain right on the operating table, though, it is not clear if this is due to the particle size or pain tolerance of the patients. Also, one learning point was the use of a 4Fr RIM catheter for embolization without need for microcatheter by one of the consultants. According to her, she gets a very good result with the 4Fr and she hardly records any incidence of spasm. This shows allowable flexibility in the procedure, which is important to know in case the routine consumables are not available.

Dialysis access management here is incredible. I saw a lot of dialysis fistula angioplasty and stentings for stenotic lesions as well as declotting procedures. I also observed some cases of balloon-assisted maturation of fistula. The procedures are very similar to what is done in MUHAS except for some differences in the consumables. I observed at the dialysis fistula surveillance clinic where I learnt more about ultrasound features of different fistula abnormalities. A dedicated sonographer is responsible for scanning the fistula at LUH. She documents her findings and sends the patient to the appropriate clinic based on her findings. She can independently send a patient for angiography and angioplasty if she notices anything concerning on the ultrasound in the appropriate clinical condition. This is something I would like my centre to incorporate into our service. This way, many abnormalities can be picked before becoming symptomatic, closely followed up, and promptly managed once they become symptomatic.

The work culture of the entire team is amazing. The procedures are well explained to the patients before starting and patients are talked through every step during the procedure. The patient is made comfortable as much as possible. Premium attention is paid to patient safety and minimising pain in the patient. Also, the department places emphasis on radiation dose reduction to both the patient and staffs. In addition, there is effective communication and collaboration among the IR team and other healthcare professionals. This is demonstrated by the synergy of IR and vascular surgery teams in the hybrid theatre, and calls from other physicians requesting for urgent procedures for some of their patients which the IR team is always willing to take.

My observership in the IR department at the Liverpool University Hospital offered me an incredible learning experience that broadened my understanding of many procedures as well as appreciation of the breadth of IR consumables. For instance, I saw how a swiftNINJA steerable catheter could make engagement of an otherwise difficult to catheterise vessel easy, and how a Navicross support catheter could help in reaching and crossing complex lesions in challenging anatomy. I also had the opportunity to attend the British Society of Endovascular Therapy conference as a complementary candidate, thanks to Dr. Shemin Mehta and Mr. Simon Neequaye, a vascular surgeon at LUH. The one-day hands-on training and two days of the conference proper were packed with a lot of learning..

I extend my profound appreciation to CIRSE for considering me as one of the recipients of 2024 fellowship grants in order to complement my interventional radiology training. I look forward to applying the knowledge gained in my future practice. I thank the management of Liverpool University Hospital NHS Foundation Trust and the Department of Interventional Radiology for hosting me. I appreciate the guidance and support provided by the amazing IR team and all staff of the department. My special appreciation goes to Dr. Shemin for being such an amazing host. He also created a great schedule for me that enabled me learn from many of his colleagues. I also appreciate his time in going to dine with me and his recommendation of good places I could visit at the Liverpool city!