Yenepoya Medical College

Preamble

The purpose of fellowship program is to create specialists who would provide high quality health care and advance the cause of science through research & training.

Interventional Radiology is a subspeciality of radiology in which minimally invasive procedures are performed using image guidance. Some of these procedures are done for purely diagnostic purposes (for example, Angiography), while others are done for treatment purposes.

Interventional radiology procedures are life-saving and cost-effective. Ranging from the treatment of acute stroke to tumors, technology coupled with innovations in interventional radiology is bringing significant changes to traditional treatment options with better outcomes for patients and shorter stays in hospitals. It is important, therefore, with limited resources and increased demand for healthcare in India, interventional radiologist can play vital role in bridging the gap. This will increase the overall efficiency of our health care system. Currently, fellowship training program in Interventional radiology are not available in most parts of India.

Though interventional radiology is very much part of the MD or Diplomate of National board (DNB) radiology curriculum in India, the 3-year training may only provide an overview of the field. Further training is necessary to learn the skills required to be a competent and safe Interventional radiologist. With limited number of training posts available in India, there is a shortage of interventional radiologists to cater to the rising need.

Yenepoya Medical College provides comprehensive care through 1268 bedded tertiary care facility through broad and super specialty departments. Department of Radiodiagnosis is running postgraduate program from 2009. We have all the expertise, clinical material, infrastructure to offer fellowship program in Interventional Radiology.

PROGRAM CODE -IR04

Eligibility for admission

MD, or DNB in Radiology

Aim of the Program/Course:

The aim of the course is to train specialists in radiology to acquire comprehensive knowledge of the imaging modalities used in Interventional radiology and develop the skills to do both diagnostic and therapeutic interventional procedures

Program Outcomes

At the end of the course, the student should be able to acquire the following competencies.

Knowledge domain

PO01. Demonstrate comprehensive knowledge about radiologic and gross anatomy, relevant to vascular and non-vascular interventions.
PO02. Gain thorough knowledge of the essential and advanced tools and equipment for vascular and non-vascular procedures to safely and effectively perform the required intervention.
PO03. Acquire comprehensive understanding of vascular pathologies and indications/ contraindications/ complications for radiological interventions.
PO04. Demonstrate ability to perform detailed clinical examination and evaluation of patients referred for interventional procedures.
PO05. Appreciate to comply with legal and ethical standards in carrying out clinical, procedural and post procedural patient care.
PO06. Be aware of indications and contra indications for vascular and non-vascular interventional radiological procedures.
PO07. Be conversant about hardware/ instrumentation involved in interventional radiological procedures.

Skill domain

PO08. Assist/ Perform and interpret non-invasive and invasive imaging evaluation of disease of the vascular systems and of other regions amendable to Interventional radiology therapy.
PO07. Demonstrate ability to deliver periprocedural care and follow-up in patients who undergo interventions.
PO08. Assist/ Perform under supervision undertake the vascular techniques including access, cannulation, angiography, angioplasty, stent placement, embolization, intra-arterial drug administration, vascular closure, and hemostasis.
PO09. Demonstrate ability to undertake the non-vascular approaches such as percutaneous drainage, biopsy, or ablation using different guidance methods, including ultrasound, Computed Tomography, etc.
PO010. Acquire necessary skills to perform imaging, therapeutic and interventional procedures as required in all neurological diseases.
PO011. Demonstrate ability to integrate knowledge and skill for conducting common procedures in simulated environment.
P012. Attain basic skills in biomedical research including critical analysis of medical literature and generating research questions, hypothesis and undertake research projects.

Attitude/Communication Domain

P013. Acquire skills to communicate effectively with patients and primary care givers by providing empathic, compassionate, confident and evidence-based counselling with respect to the interventions planned as a part of diagnosis or therapy.
PO14. Demonstrate ability to practice according to ethical principles of providing or withholding of clinical care, confidentiality of patient information, obtaining informed consent and general practice of medicine.
P015. Demonstrate ability to explain the risks and benefits of diagnostic or therapeutic proceduresand listen compassionately patient's preferences and expectations.
PO16. Acquire essential communication skills to effectively interact with specialists in a wide range of other disciplines in the hospital and other hospitals, to deliver state of the art clinical care by multi-disciplinary patient care approach.

Program Specific Outcomes

PSO1	To make a diagnosis	Demonstrate ability to use all modern diagnostic imaging modalities including fusion imaging, ultrasound, DSA, CT, MR, SPECT, CT SPECT, PET, CT-PET and radionuclide scans. Demonstrate ability to decide on the various image-guided interventional procedures to be done for diagnosis and therapeutic management. Demonstrate ability for clinical judgment and technical skills in diagnosis and comprehensive management of patients requiring interventional radiology procedures
PSO2	To formulate a treatment plan	Demonstrate scientific approach in evaluating the patient, discussing with multidisciplinary team and formulating appropriate diagnostic or therapeutic treatment plan keeping in mind the patient needs.
PSO3	To counsel the patient	Acquire Counselling skills to help patient and primary care provider understand about rationality of all imaging and interventional procedures, possible contrast reaction, complications of anesthesia and interventions and how it may affect the overall outcome. Demonstrate ability to explain the procedure and answer all related questions and concerns raised by the patient and family.
PSO4	To Perform appropriate Procedures	Acquire skills to perform simple, common non- vascular procedures under ultrasound and fluoroscopy guidance e.g.abscess drainage, drainage catheter placement, nephrostomy, biliary drainage etc. Assist/ Perform under supervision common vascular interventions e.g stricture dilatation using balloon catheters, embolization with gel foam and other agents. Assist/ Perform transfemoral puncture and insert catheter, help in angiographic procedures both diagnostic and interventional
PSO5	To Manage or prevent Complications	Acquire knowledge about the relative and absolute contraindications for each individual procedure and apply clinical skills to weigh the risks versus benefits for each patient. Demonstrate ability to properly recognize procedural complications and manage them using pharmacological or procedural interventions, or by timely consulting proper services.
PS06	To acquire basic skills in research	Develop the expertise to perform a scientific study including formulating hypothesis, research questions, designing appropriate study, analyze and interpret the results. Demonstrate competence in presentation of case reports, short study findings at institute level, regional, or national professional and scientific society meetings.

Program structure: Weekly schedule

Duration of the course	13 months
Theory	4 hours per week
Practical and Clinics	12 hours per week
Contact hours	42 hours per week
E-learning hours	4 hours per week
Research Work	2 hours per week
Self-Directed Learning	6 hours per week
Clinical services/ Diagnostic services	18 hours per week

Attendance

After completing 13 months of course with 80% minimum attendance is required to appear for the University exam.

Syllabus / Course contents

A.PATIENT SAFETY AND OCCUPATIONAL HAZARDS:

Selection and evaluation of patients before Interventional radiology procedures
Identify high risk factors for procedures and anesthesia
Importance of consent taking before procedures
ALARA and its applications in Interventional radiology
Patient education and follow up

B.PHYSICS RELATED TO INTERVENTIONAL RADIOLOGY PROCEDURES

Basic DSA physics
Types of DSA equipment
Various advanced application of DSA such as 3D rotational angiography, Xper CT etc

C.TECHNICAL ASPECTS RELEVANT TO INTERVENTIONAL RADIOLOGY (BASIC KNOWLEDGE OF HARDWARE)

Sheaths, wires and catheters
Micro guide ware and Micro catheters
Balloons, stents and stent grafts
Embolizing agents
Other products: Stroke intervention, IVC filters, sclerosants, DE beads
Basic technique: Seldinger and Pigtail etc

D.PHARMOCOLOGY RELEVANT TO INTERVENTIONAL RADIOLOGY

Local anesthetic agents: Lignocaine, Bupvacaineetc
Heparin/ Heparin induced toxicity
Other anticoagulants including newer agents
Anti-platelet agents
Thrombolytic agents
Contrast agents and their effects
Emergency/ important drugs: Adrenaline, Non Adrenaline, Steroids, Anti histamines, Dopamine, Labetalol, Mitroglycerine, Abciximab, Tirofiban, rtPA, Urokinase, Nimodipne and other drugs used in ICU
Common antibiotics – doses, adv effects used in peri-procedure period
Drugs used for sedation/ analgesia for short procedures: Midazolam, Fentanyl and Tramadol etc

E.ANATOMY AND PATHOLOGY RELEVANT TO INTERVENTIONAL RADIOLOGY PROCEDURES

Anatomy of important parts of body in brief with emphasis on arterial and venous anatomy and nerve supply or other important applied aspects relevant to Interventional radiology
Pathology of various vascular and non-vascular disorders managed by Interventional radiology
CNS: Aneurysms, AVMs, DAVFs and Venous thrombosis
H&N: Parangliomas, JNF and Thyroid lesions etc
Chest: Common SOLs, Bronchial and Vascular concepts and liver endobronchial/ vascular interventions
Abdomen: Liver anatomy with emphasis on vascular concepts and liver transplant evaluation, Renal anatomy and transplant anatomy etc
Other: Osteoid osteoma and vascular malformations etc

F.SPECIFIC ENDOVASCULAR TRAINING MODULES

Section A: Non-vascular interventions in Chest, Gastrointestinal tract and Hepatobilliary systems

Image Guided Biopsy (Excluding MSK)
Image guided aspiration and drainage of collections and abscess
Gastrointestinal interventions
Enteral Tube Placement (Gastrostomy, Gastro – Jejunostomy, Jejunostomy and Caecostomy)
Gastrointestinal stenting
Hepato-pancreatico biliary (HPB) intervention

Section B: Intervention of the Genito urinary tract and renal transplants

Pelvicalyceal and Ureteric obstruction
Renal stone disease
Renal masses and perirenal collections
Genito – Urinary interventions
Prostatitis (Abscess)
Renal transplant interventions
Section C: Interventional radiology of the musculoskeletal system
Image guide biopsy
Percutaneous ablation of bone and soft tissue lesions
Intra-articular injections under image guidance
Percutaneous osteoplasty
Spinal interventions
Interventions in vertebral body compression fracture (VBCF)
Spinal procedures for disc, Nerves and Facet joints
Section D: Interventional Oncology
Fundamental Interventional Oncology
Vascular Interventional Oncology
Non-vascular Interventional Oncology
Section E: Vascular diagnosis and intervention
Arterial disease
Peripheral arterial disease
Aortic and upper extremity arterial disease
Aortic dissection and aneurysmal disease
Supra-aortic disease
Vascular malformations
Vascular trauma
Visceral arterial disease
Arterial problems in Obstetrics and Gynecology
Prostate artery embolization (PAE)
Priapism
Section F: Venous disorders
Venous thrombosis and insufficiency
Pulmonary thromboembolic disease
Disease of the superior and inferior venacava
Portal and hepatic venous interventions
Portal venous disease and transjugular intrahepatic portosystemic shunt (TIPS) and balloon occluded retrograde transvenous obliteration (BRTO)
Hepatic venous disease and Budd-Chiari syndrome
Gonadal venous interventions
Hemodialysis access
Central venous access
Venous sampling
Section G: Important Neuro interventional procedures
Carotid stenting
ECA territory embolization
Brain aneurysm management
Other brain vascular malformations
Stroke management

PRACTICALS

Physics

Effectiveness of Lead Apron and other protective devices
Physics of DSA / Angiography and Fluoroscopic techniques
Quality control in DSA / Interventional radiology lab
Practical training in DSA / Interventional radiology lab
Basic table movements and DSA / Fluoroscopic controls
Radiographic views used in various interventions
Contrast agents being used for procedures
Post-processing and use of other advanced angiographic techniques Anatomy
Relevant gross and angiographic anatomy for various Interventional procedures

Teaching - Learning methods and Academic Activities

Teaching - Learning method	Academic Activities
Experiential learning	Case presentation
Integrated/Inter-disciplinary learning	Scientific society meetings/ Clinical Meet, Grand round
Participatory learning	Journal club, Seminar and interactive lectures
Problem-solving methodologies	Clinical Audit
Self-directed learning	Research work, Logbook
Patient-centric and Evidence-based learning	Case presentation
Project-based learning	Research work
Any other : Visits to institutes	Visits to other institution of excellence Visit to laboratories, diagnostic facilities, affiliated clinical units and other areas.

Scheme of Examination

Internal Assessment (Frequency, Pattern-Theory and Practical)

Formative assessment: -Assessment of academic activities like journal club, seminar, case presentation, clinical meets and clinical audits, etc

Internal Assessment: Theory 100 Marks and Practical Examination of 50 marks

Theory paper will consist of 10 long essay questions

University Examination (Pattern-Theory and Practical)

The final Examination: Theory 200 Marks (100 marks two papers) and Practical Examination of 100 marks. Each theory paper will consist of 10 long essays

Paper – I - Basics of interventions – 40 marks Instrumentations – 30 marks Physics – 30 marks	100 Marks
Paper – II – Advanced interventional procedures-1	100 Marks
Total	200 Marks

Duration of Theory Papers: 3 hours

Practical Examination: -

OSCE (Objective Structured Clinical Examination) 3 Stations with one observation station	30 Marks
Practical Skills Demonstration (Simulation lab , Skills demonstration in cath lab, USG,MDCT) Simulated case	30 Marks
Viva Voce: Discuss case scenarios, complex concepts, clarity of subject, case-based discussions, etc.	30 Marks
Portfolio	10 Marks
Total	100 Marks

Eligibility to appear for University Examination

Minimum 80% attendance
At least one presentation/poster in international/national/state conferences.
Minimum 40% marks in Internal Assessment examination
Logbook submission

Criteria for pass

Minimum 50% marks in Theory
Minimum 50% marks in Practical

Declaration of Results

Declared by the Yenepoya (Deemed to be University)/ Yenepoya Medical College

Logbook/Portfolio (if applicable)

Portfolio should record the learning experiences with reflections and which must be countersigned by the course director

Recommended books

Abrams textbook of angiography and interventional radiology
Diagnostic Neuro angiography by Anne Osborne
Vascular and Interventional Radiology: The Requisites – Kaufmann & Lee
Radiation Protection in Medical Radiography: Mary Alice Statkiewicz Sherer (5th ed)
Handbook of Interventional Radiologic Procedures: Krishna Kandarpa (4th ed)
Angiography & Interventional Radiology: Stanley Baum (2nd ed)
Textbook of Gastrointestinal Radiology - George & Levine (3rd ed, Vol I)
Textbook of Gastrointestinal Radiology - George & Levine (3rd ed, Vol II)
Surgical Neuroangiography Vol I, II and III: P. Lasjaunias, A. Berenstein, K.G. Ter Brugge
Practical Neuroangiography: Pearse Morris
Tutorials in Endovascular Neurosurgery and Interventional Neuroradiology: James Vincent Byrne (Springer)
Textbook of Interventional Neurology: Adnan I. Qureshi
Interventional Neuroradiology: Robert W. Hurst and Robert H. Rosenwasser (Informa Healthcare)
Cerebral Angiography (Normal Anatomy and Vascular Pathology): Gianni Boris Bradac (Springer)
Diagnostic Cerebral Angiography: Anne G. Osborn (Lippincott Williams & Wilkins)
Indian Council of Medical Research. National Ethical Guidelines for Biomedical and Health Research involving Human Participants. New Delhi; 2017. Available from:https://icmr.nic.in/guidelines/ICMR_Ethical_Guidelines_2017.pdf

Physics:

MRI The Basics: Ray H Hashemi, William G. Bradley
MRI in Practice: Catherine Westbroook and Carolyn Kaut
Susceptibility Weighted Imaging in MRI - Basic Concepts and Clinical Applications: Haacke, Mark E. / Reichenbach, Jürgen
Radiology and Imaging Physics
PACS and IT in imaging

Journals

Seminars in Interventional Radiology
Journal of Vascular and Interventional Radiology (JVIR)
Cardiovascular and Interventional Radiology
Journal of Neuro-interventional Surgery (JNIS) for Neuro intervention
RSNA Journals – Dedicated articles/sections for interventions
AJNR (American Journal of Neuroradiology)

Any other information

During the training program, patient safety is of paramount importance, therefore,skills are to be learnt initially on the models in the simulation laboratory and on large animals, later to be performed under supervision followed by performing independently.

ANNEXURE

Blueprint for Theory and Practical Examination
Question paper layout for theory examinations
Logbook template (if applicable)
Any other Checklists/Formats for assessment

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FELLOWSHIP IN INTERVENTIONAL RADIOLOGY