Advancing patient care with interventional MRI

Episode Transcript

Behind every case, there’s a story. Behind every story, there’s a lesson. And behind every lesson learned, there’s a trusted mentor. This is Prepped & Draped with Dr. John Kaufman, where candid conversations, actual cases, and bold new professionals shape medicine.

So hi, everybody. It’s John Kaufman on Prepped & Draped. And this episode is going to be with a good friend, Dr. and Prof. Afshin Gangi. I’m really excited to have him on the session with us, because you will find he is just a fascinating individual who’s doing some really great work. Afshin is a professor and chair of radiology, of nuclear medicine, at the University Hospital in Strasbourg. He’s also head of a Department of Interventional Radiology at the University of Strasbourg. He’s a past president of the Cardiovascular and Interventional Radiology Society of Europe and a gold medalist of that society. So there’s a whole lot more about you, Afshin, but if you could just tell us a little bit about your background. And I will say Afshin is fluent in four languages—English, French, German, and Persian—and I’ve selected English for this podcast.

Thank you so much, and it’s a pleasure to see you as usual. You are a legend, and talking to you is always a pleasure and an honor. I’m Afshin Gangi. I’m intervention radiologist. I’ve begun radiology in 1989, and I become immediate interventional radiologist. I didn’t wanted to do radiology. I wanted to become a more surgeon, but at the moment I discovered interventional radiology, I fall in love with this specialty. I cannot do anything else than this. And I’m so lucky I have done it. And every day I’m enjoying doing this job. It’s one of the most exciting thing which happened in my life. And I cannot imagine my life without this passionated job. We are so lucky to doing it. That’s the resume of my life.

It’s great when we love what we work. And I think that’s a theme for a lot of proceduralists, that they actually really, really love what they do. And the fact that they get paid for it is even better, right? But we really love that ability to do procedures, interact with patients. You’ve mentioned in the past that one of your mentors and the people that’s been important to you has been Peter Mueller—

Yes.

—who’s from Mass General Hospital, who’s also someone that I connected with when I worked there. Very important to me, even though we were actually in different sections within the department. But this— he’s 3,000 miles away. He was in Boston and you were in France. So can you talk a little bit about how that worked out and this— how mentoring is— can happen like that from that far away?

Many people like Peter Mueller and the other, Robert Francis Dondlinger, these people are people who have influenced all my life. And I always wanted to become like you, John, again, you too, to follow your pathway, because you opened the door for us. And I try to do the same thing to open the door to all these young people to coming. And the most important interventional radiology is every day we are doing novelties. Every day we are discovering novelty. We have changed medicine for reality. And finally, I see that people are coming inside the specialty, and they discover it and they love it. Young people coming. This morning, I have a young lady to come to see if she wants to do interventional radiology. When she left this afternoon, she told me, “I’m sure that’s what I want to do.” What is better than this? What is better than this? I think nothing.

Well, I think all proceduralists are going to feel that way. That’s great, because it’s just so exciting to be engaged in something that’s new and changing and evolving. And we see that across a lot of the specialties. You’ve been a big proponent of interventional MRI. I mean, it’s clearly something that’s of interest to Cook, and we’ve kind of focused on that. But I’m just curious, clinically, why you’ve been so interested in this, why you think it’s important.

As a story, I begun my master in science— because in France to become a professor, you need to have a master and a PhD. I begun my master. I proposed to produce— it was 1992, 1933. I was really finishing my residency, to do my master, developing a non-ferromagnetic needle for MR. That was a joke for many of my professors, telling me, “Why this?” Because, seriously, thinking about MR at this moment for me, it was clear that we need to use all modality to interventional radiology, and MR was opening the door to many things. And since then, I’m continuing to do this. And finally, after so many years, in 2007— and I obtained in Strasbourg, with a budget of research, a proper dedicated interventional MR in Strasbourg. At the beginning, everybody was very skeptic, saying, “We aren’t sure. It’s long, it’s expensive, it’s painful, it’s so difficult.” All these are just legend, because when you begin something new, you think it’s impossible.

And there is expression; we say, “I didn’t knew it was impossible. That’s why I have done it.” That’s important to tell. That’s the French expression we use always. And at the moment I got this, I tell you something, sure, at the beginning you need to open the doors to many difficult points. But imagine when you think MR. I’m not telling fluoroscopy is not good, ultrasound is not good, CT is not good. They are all very good. However, just imagine MR. You have a real-time imaging with MR, means real-time. You have a multiplanar imaging with MR. Imagine any plane you want to obtain; you have it. You have no large bore. You have no radiation. You have the best contrast you can imagine. You see the tissue better than any other modality. And you have a thermal imaging. If you’ll put all this together, you are in an environment which is safe if you don’t use any metallic stuff.

And the only problem is the noise, and we have noise-canceling now. This is the modality which is really perfect to do many things. Not everything. But today, I cannot imagine our department without the interventional MR. Even the people who were not trusting this—say guy is not sure—at the moment they come in the room two, three times, they cannot change their opinion. They want to continue to do this. All biopsy, a biopsy of the kidney, upper pole, liver segment eight. You choose the pathway, you see your needle going up to the segment eight. In the plane you have chose— many plane: sagittal, axial, coronal. You see your needle in real time. Your hands then inside, no radiation. You get to the target, which is visible because of the beautiful contrast, and it’s done. At the moment you are mastering this, you cannot come back.

And it’s like everything. At the moment you have it, you use it, you cannot tell, “I don’t need it anymore.” That’s why we need to push today. All our radiologists who are, in my opinion, not ambitious enough—because telling is difficult, is expensive—it’s ridiculous for me, because I don’t know any surgeon telling that robotic is expensive. Do you know many of them who tell you, “Hey, robot is too expensive for me. I don’t want to have it.” No, doesn’t exist. That’s more expensive than interventional MR. About twice the price of interventional MR today. And we can use it for the brain, for the soft tissue. You see the temperature when you do ablation? Thermal ablation, you see the temperature, 45, 55. In color, even in color, you can see the iceball in every organ. You see the iceball in the fat, you can see the iceball in the bone, which is impossible with CT scan.

And again, as I said, we want to attract more ladies in our specialty. No radiation. And now we have seen, we have done it in Cook lab with my colleague, Emanuele Boatta, the full angio of the kidney, balloon insertion in the renal artery, all done in MR. You can imagine? This is something 10 years ago, even I was not believing on it. And it was feasible, and we have done it. Means now I’m doing a lot of cryo on MR because it’s more compatible and I see the iceball so nicely. All renal tumors are done MR, because the tumor without contrast is visible. When I do hydrodissection, the water is seen in hypersignal in white. No contrast. So I see it exactly. I put the— my cryoprobes in. If I have the balloon inside, that’s done. Means I’m transferring an activity which was done in angio, CT, with fluoroscopy, with x-rays to environment which I see better, without radiation.

That’s it. I think I said everything. In a few words: You need to have it. And today I’m so happy that finally companies like Siemens are producing new MR with larger bore, larger than some CT scans, with shorter bore, with 0.5 Tesla—means less magnetic field, plus less problem with the needles, less artifact, cheaper, lighter, with one liter helium. And at the same time we have labs like Cook, which are finally really convinced, and they are putting all their energy developing new instrument for us. Means the marriage between a producer of imaging and a producer— and a company who is producing all catheters, guidewires, needles for us, that’s a perfect wedding. You have the combination of two companies which finally will help us to go inside the field. The problem was before there are one or two companies producing the needles before. It means when you need a biopsy needle, the price was quite high.

Now, if we can do a democratic needle production, catheter production, the price will come down, and everybody, all big centers, can have their own MR. I’m not telling to using it 24/7, but interventional MR, like the CT scan, can be used in the morning with general anesthesia, biopsy, everything in the morning. In the beginning of the afternoon, you transform into your office. All patients you are seeing in consultation in your office have their MR on this MR scan and you see them. So the MR is never stopping. That’s the key. Means economically talking, we can as a radiologist, an interventional radiologist, make use of this system the whole day. We thought letting it in a corner like a robotic surgery, which in the evening is closed or in the afternoon is closed because anesthesiologists are gone. This is economically completely efficient, in my opinion.

Well, I get the feeling you’re not excited about this at all. [laughter]. No, I mean, you have been a pioneer in so many different oncologic interventions and interventions in general. And this is— just so everyone understands, it’s just one of the areas that you’re pioneering in. So just a tremendous amount of experience. And I think one of the— we’re talking about the low-field-strength magnet, just so everyone is level set, the 0.55 T magnet with a large bore. But I think a lot of people are looking at this and trying to figure out, “Well, how am I going to fit this in? I need CT scanners; I need angio rooms.” You’re well along the pathway. You have a structure that’s allowed you to do this. How would you suggest people start if they’re interested in doing this? What are the stakeholders? I mean, the proceduralists are the obvious stakeholders, but who are the other stakeholders that need to be involved? And what kind of applications do you see as the early wins to really prove the value?

I think the first, the best ally for us, are the oncologists. Means they can send you a hundred of patients. Surgeons are the same, because the surgeons know the value of a scan. Means a neurosurgeon will tell you, “I want it tomorrow morning.” But they will use it once a week, once every two weeks. This is not enough. And I’m proposing this to all my clinicians. I said, “Look, interventional radiology department is a five-star hotel, all-inclusive. You don’t need to buy your CT scan, your MR. You need it, you tell me. You come in, I provide my knowledge, all the technicians, we do together what you need to do.” And here they are very happy to do it. That’s why in Strasbourg, nobody’s asking to have this own CT scan, their own MR scan, because they know when they have an indication for skull base they come to us.

That’s first. Means clinician should be convinced you are not working for yourself, you are working for the patient, and that’s an open door. You know what? They understand very quickly when they come in that they cannot manage it alone. You know what I mean? This is it. They say, “I cannot go to a robotic surgeon.” I said, “Hey guys, let me do it.” It’s not like this. So they understand it very well. Second, you need to convince your CEO of your hospital and your university. First of all, it’s not something luxurious. And my plan was like this. At the beginning, I said, “That’s clinical research, but this machine will be used on real patients, and it will be used always.” Means I’m not closing the door at the moment I don’t have a patient. I transformed this MR to a clinical MR of my own patients.

Immediately after I have finished my intervention, I can go in this room and transform it to ambulatory patient. Sure, the environment is sterile, means the patient should get changed, come in. But all of them are accepting. When you tell the patients, “You need to put a gown to come in,” they said, “Okay, no problem.” You know what I mean? They need to come up with that rest. They change. They are adapting to your habits, and the machine can be used all day. At the moment you do this reasoning: say, “Okay, during the day, I can accelerate my biopsy. I can do it better. I can do it without radiation.” Don’t forget something like this, because in the CEO of a hospital, today we are the only specialty with cardiologist and vascular surgeon to accept radiation. Go to the industry, tell an engineer, “You need to accept this dose.”

They will say, “Are you crazy? No way. My job is to get zero doses. If I get a dose, it’s an incident.” That means you tell them, “Look, we are young people. The new generation should not be accepting the same risk we have done. And MR is a safe environment. Means patient is safe, I’m safe, so we need to have it.” That’s another reasoning. All this reasoning together, when you put it together, and you make it economical— pathway to say, “Look, you will not lose money. We will even win money. We will shorten the biopsy pathway.” Clinician will follow you, but you need to prove what you promised is true. And I tell you, if I have done it in the small city of Strasbourg, everybody can do it. And look, now we have two interventional MR. It’s not because we are stars or something like this.

It means we have proven to the university that we publish, we do cases, and everybody has an advantages, all clinicians and all patients. And we have a better view. It’s not just luxurious imaging, it’s everyday. The only difficulty, John, I have with MR is for us, you and me, the environment of CT and MR is the same. You do the same job. You push a needle, you push a catheter. You see. It means for you and me is not different. For who is different is the technicians. The radiographers and the technicians should be the top-level people, because they are the one who manage the visualization of the needle, the pathway arrangement, and the sequences. You need to see better. And I’m always telling them, “I’m the pilot, but the airway control are the technicians outside.”

They tell me, “You are too high. Come down. You are changing the line. You need to come right. There is a turbulence in front of you. Be careful.” So without them, I’m in the fog. So without you I cannot. That’s why good technicians are the key of successful MR. You and me in any environment, angio, we are used to use it. Okay? CT is the same. MR is just the image is different, but you know where you want to go, you see the pathway, you do it. For you and me, we learned this in a few days, but for technicians to make them completely specialized in MR, you need to have a dedicated MR team for interventions. That’s the difference.

Yeah, yeah, that’s a really important point. You’ve said so many things that I’d love to sort of dig into, your point about doing all these things for improving the patient experience and the patient outcomes, right? That really— what drives a lot of this, the growing awareness of radiation, and maybe if there are ways to do things without radiation, we always seek to do minimal, but I think you and I both see there’s a lot of cavalier attitudes about radiation among people who use it a lot. You don’t feel it, you don’t see it, so you stop worrying about it. And that last part about the team. And it does remind me a little bit of, I guess, the old days of intervention before you and I. The equipment was really— every little parameter of the equipment had to be tuned and adjusted. It wasn’t just an automatic push-a-few-buttons like we do now on most of our angio equipment.

We’re kind of back to that a little bit with MR, because that sequence and that partnership with technologists is just so critical to get the outcomes. I’m curious, you say you do a lot of biopsies. You’re now very fluent in this. This is, I guess— your sixth language is interventional MRI, or fifth. How long does it take you to do just a standard liver biopsy? And why would you— instead of using ultrasound, why would you do it in MR? Is there a time savings? I’m just curious how that— you think about that.

You are absolutely right. What I can see easily with the ultrasound— we have a fourth room for ultrasound. We do them all on an ultrasound. I will not transform accessible tumor to ultrasound to MR. It’s a nonsense. I will not do this. However, when I have a segment eight, the lesion is high, the patient is quite large. I have difficulty. I know I will not see it. I have done the ultrasound; it’s difficult. At this moment, I will not hesitate one second between CT scan and MR. I will choose always MR. Because at the moment I begin— it’s like CT. I do my MR scan, contrast, I choose the best contrast. I can see the tumor. I meet my target. I say, “I want to finish here, and I want to begin here.” And immediately they construct the pathway and the slices exactly in this pathway.

So I begin with— And we mark the skin before an MR will be begun. It was no marking of the skin, means I need to put my big finger to find the entry point. You know what I mean? Everyone was joking: “With your big finger for entry point? Come on.” So now it’s not like this. It’s exactly like CT scan. Laser light, the entry point is here, you begin. You put your needle in, and then you watch the screen, axial on one slice, then the other one. With one yank, I just inclinate, “Okay, I’m in the good pathway to reach the lesion,” and then I correct the angulation. It’s— any kid can do it. And a segment eight with this has nothing to do with ultrasound, because you know what I mean? Foggy images, difficult images that you need years of training to become good, to do a good ultrasound-guided biopsy.

Difficult one, not the easy one. A difficult one. You need years of seeing this. And sometimes you are really in trouble. The lung is coming down. Then the patient is bleeding. You don’t see the pathway anymore. You need to rely on your experience. Here—you know what I mean?—you see the lesion, you see the needles. I’m in, I’m not in. You know what I mean? That’s a lot easier to learn. The learning curve of MR is a lot shorter than ultrasound. A lot shorter. I tell you, my resident here, they are usually six months with me. After three months, they can do every— I tell you, this is perhaps disappointing, because you needed years to do something, these young guys are coming in after three months to repeat exactly what you are doing after years. This is a success finally.

It is success, actually. We got to get used to that, right? And that’s part of the process. I think as medicine advances, the more difficult things become easier. And it’s interesting you described taking the hardest lesions and putting them in the MR and making them the easiest to do. When you say “any kid,” I’m thinking, Wow! We can start taking elementary school fellows, right? Their eye-hand is so good, and they’re so used to working with screens and stuff. We can maybe help increase the workforce. Afshin, this is— we could go on for hours, but we’re not going to. It’s late for you. You got to get home and have your dinner, and we want to give you a little bit of rest before your day starts tomorrow.

I always like to close this— If you— We’ve been talking about a lot of things, mostly about MRI, but some other things as well. Just give you an opportunity. If there’s one message you want to communicate to those that are listening, all the— And again, it’s going to be proceduralists of all kinds that will be listening. Just give you that last word as we close out.

Thank you so much, John. First of all, thank you for giving me this opportunity to do this. Because I’m so convinced that I’m not telling only MR, not at all. I tell you multimodality. And who is the one who should use multimodality are radiologists. Because we know the machines, you know what I mean? We can fly with them. We are— The pilot license of us has done to fly with all this instrument, not the others. So we are the best one to do it. What I want to convince radiologists, interventional radiologists, go and come or come to us, do one of our workshops, hands-on workshop with MR. I have done one a few weeks ago with the ESIR course at CIRSE. Everybody who left the MR room after one hour with me, they were smiling, a big smile in their face that— “My God, it’s not so difficult. I can do it.”

Means try it, try it, and be ambitious, please. Be ambitious. It’s not because you’re radiologist, you should be shy. This machine is for patient. It’s not your machine. And don’t tell it’s expensive. Don’t tell me it’s difficult. It’s not more difficult than fluoroscopy, it’s not more difficult than ultrasound, it’s not more difficult than CT scan. We just need to have it. And please, I’m not advertising for any company, but you need to have it and to make it democratic for the patient. At the moment you have put your hands on and you see the environment, you cannot come back. It’s not so expensive as you think it is, because you will use this machine for other things too. It’s not just interventional. And the low-field MR can be used for brain, can be used for bone, can be used for radiotherapy, for planning, can be used plenty.

And it’s not because it’s low field, it’s not good resolution enough. And all patient you are treating have already an MR with 3 Tesla, 1.5 Tesla, CT, and everything. It means when I’m trying to have decided to operate on these patients, I have already a big imaging before. So I don’t need to have a high resolution 3 Tesla to do my intervention anymore. I need to see well. I need to be in a large bore. I need to see real time. I need to have the screen in face of me. And I need to have noise-canceling. That’s all. It’s feasible to everyone. It is not— you don’t need to be a Michael Schumacher, a driver, to make it. Believe me. Believe me, it’s very easy.

Afshin, I think everyone’s smiling after they spend an hour with you, because you just make everyone feel good. You’re so much fun to talk to.

Thank you.

Thank you so much for doing this and being on this episode of Prepped & Draped, and I look forward to the next time we get to see each other.

Great. Pleasure. Anytime for you, John. It’s always a pleasure. Thank you so much.