Current status and future prospects of interventional radiology in China

The phrase “interventional radiology” (IR) was first coined by Margulis in 1967,[1] defining an emerging discipline that leverages image-guided modalities for the diagnosis and management of space-occupying lesions (such as tumors) and vascular pathologies (such as thrombosis and atherosclerosis). Since its establishment in mainland China in the late 1970s, dedicated efforts by Chinese interventionalists have established the discipline as the “third pillar” of clinical medicine, along with internal medicine and surgery.[2] Interventional therapies are indispensable in clinical practice because of their minimally invasive characteristics, high reproducibility, precise targeting, favorable safety profiles, potentiation of therapeutic efficacy when combined with other treatment strategies, societal benefits at low cost, and the rapid return of patients to the activities of daily living, including work. With advances in medical technology, novel interventional methodologies, devices, and clinical paradigms continue to emerge. IR has demonstrated significant advances in both basic scientific and clinical applications. The present article provides a systematic overview of the current status and future prospects of IR in China, focusing on innovation and translation, discipline development and transformation, and training and standardization. 1. IR innovation and translation Technological innovations have underpinned China’s global prominence in the field of IR. Several interventional therapies have been pioneered in China, including the early application of radioembolization and recent breakthroughs, such as endovascular denervation for cancer- or type 2 diabetes-related pain. Emerging cutting-edge technologies have revolutionized conventional interventional therapies. For example, histotripsy, a high-intensity, focused ultrasound modality that mechanically liquefies tissue into subcellular debris using high-amplitude, focused ultrasound pulses under real-time sonographic monitoring, has demonstrated promise in diminishing heat-sink effects, generating sharply demarcated lesions with tissue-selective preservation, and inducing immunomodulation.[3] The evolution and translation of IR products are intrinsically linked to innovations in scientific theory, biomedical engineering, and materials science. For example, the concept of thermophysical immunotherapy for metastatic solid tumors has contributed to the development of a device for multimode ablation treatment.[4] Irradiation stenting, an innovative engineering method for loading iodine-125 seeds onto self-expanding stents, has profoundly transformed the treatment landscape for malignant luminal obstruction, especially esophageal cancer, malignant biliary obstruction, and malignant airway obstruction.[5,6] Breakthroughs in materials science have resulted in novel embolic agents, including the advent of surface-functionalized Pickering emulsions, demonstrating enhanced stability and stimuli-responsive behavior for targeted drug delivery,[7,8] liquid metal microspheres,[9] and microspheres loaded with radioactive isotopes, such as yttrium-90,[10] significantly enhancing treatment efficacy. The development of molecular and functional imaging has enabled real-time image-guided interventions,[11,12] significantly improving the accuracy and efficiency of nonvascular IR procedures, such as biopsy and ablation, while reducing radiation exposure and complications.[13–16] Multimodal imaging (a combination of ultrasound, digital subtraction angiography [DSA], computed tomography, and magnetic resonance imaging for specific tasks) provides excellent visualization of the therapeutic target, feeding vasculature, and adjacent normal anatomy, thus facilitating planning, treatment delivery, and therapeutic assessment.[17,18] For example, with the combination of photon-counting computed tomography in the interventional suite, diagnostic-quality imaging, perfusion, and dual-energy imaging capabilities can be offered with fast readout, low (or zero) electronic noise, high spatial resolution, and spectral imaging capability.[18] Domestically developed DSA systems, such as “uAngio” developed by United Imaging Healthcare (Shanghai, China) and “NeuAngio” developed by Neusoft Medical (Shenyang, China), represent a significant advance in medical imaging technology, providing high-resolution vascular imaging for interventional diagnostics and treatments, and supplying data for quantitative drug delivery and efficacy assessment during procedures.[19] Artificial intelligence (AI) integration optimizes IR workflows. AI-based methods have also been proposed for low-dose DSA imaging.[20] AI-based ablation software can map ablation zones and effectively assess complete tumor coverage.[21] Deep learning algorithms reduce radiation exposure during image acquisition.[22] Radiomic information obtained through AI can be integrated with other multi-omics information to accurately predict postintervention responses.[23] AI also synergizes with other emerging technologies such as augmented reality[24,25] and robotics,[26] collectively shaping next-generation IR paradigms. Interventional robots help shorten procedure duration, reduce radiation exposure, and improve precision in spatial positioning, stability, dexterous maneuverability, and operational endurance while enabling remote operation.[18,27] These systems function as teleoperated “arm extenders” or autonomous devices.[28] For example, neurointerventional robots are programmed to actively maintain microcatheter stability within intracranial aneurysms and aid in the precise deployment of stents in the brain. Convolutional neural network–programmed surgical robots can be developed to master the nonlinear skills of the Seldinger technique, actively advancing wires into distal locations and then advancing catheters and microcatheters over these wires.[29,30] In 2025, a randomized controlled trial in China will demonstrate the safety and efficacy of a novel domestic cerebral robot-assisted angiography (PANVIS-A).[31] Furthermore, the feasibility and safety of using a new domestic preloaded Robot-Assisted Thrombectomy Interventional (RATIONAL) system designed specifically for mechanical thrombectomy in acute ischemic stroke were first reported.[32] In the future, interventionalists may rely on high-precision robots to perform more complex and high-risk procedures, enhance the quality and standardization of existing operations, and enable remote interventional diagnoses and treatments in specific scenarios. 2. IR discipline development and transformation Innovative advances in IR technologies and medical devices have profoundly catalyzed the evolution of this discipline. In 1967, Margulis[1] suggested that a subspecialty of diagnostic radiology be named “interventional diagnostic radiology”. As interventions became a larger part of practice, the subspecialty envisioned by Margulis required competency in nonprocedural care, in addition to imaging and interventional competency, to provide the best outcomes for patients. Since the American Board of Medical Specialties approved the IR primary certificate on September 11, 2012, creating the 37th primary American Board of Medical Specialties specialty and the fourth primary certificate within the American Board of Radiology, the clinical evaluation and longitudinal care of patients by IR physicians, essential for determining a patient’s suitability for treatment and providing management of the patient’s underlying disease, have become an integral element of contemporary IR practices.[33,34] With the scope of IR continuing to expand to include minimally invasive image-guided therapy for vascular (including aortic), oncological, gastrointestinal, hepatobiliary, genitourinary, pulmonary, musculoskeletal, gynecological, and neurological conditions in adult and pediatric patients, the relationship between IR and other clinical disciplines is transitioning from competition toward collaborative integration, underscoring its growing significance. Nevertheless, given the expansive scope of interventional therapies, practitioners must continually improve their clinical competencies, including technical proficiency, radiological imaging expertise, disease, and equipment-related theoretical knowledge and advances. Such multifaceted developments will broaden clinical perspectives, improve patient outcomes, and, ultimately, propel the specialty forward. IR practices worldwide vary according to local factors. In some countries, IR remains under the aegis of diagnostic radiology without subspecialty distinction, whereas in other countries, such as Japan, Canada, and the United Kingdom, IR has achieved subspecialty status within radiology,[35] and in the United States, IR has been formally recognized as a distinct medical specialty.[33,34] In China, rather than operating as a subsidiary of diagnostic radiology, the interventional specialty in most hospitals has established independent departments or centers designated as “IR department,” “interventional radiology department,” “interventional and vascular surgery department,” etc. Future priorities should include establishing comprehensive interventional specialty units and large-scale integrated interventional centers that unify clinical care, research, and training. Interventional practitioners in China have diverse clinical backgrounds, including radiology, vascular surgery, neurosurgery, and oncology. The multidisciplinary composition of practitioners has fostered the development of specialized interventional subspecialties, such as interventional oncology, general IR, vascular intervention, and neurointervention. Interdisciplinary competition has driven interventional radiologists and departments toward clinical maturation, establishing dedicated interventional wards and independent departments. Although the absence of an exclusive discipline code confines the IR department to technical aspects of medical administration, it is recognized as a priority discipline in numerous provincial and municipal institutions. Most health care institutions that provide interventional diagnostic and therapeutic services have established dedicated IR departments, outpatient clinics, and specialized inpatient units. A national survey of 539 tertiary referral hospitals published in 2017 indicated that 43.7% of the hospitals had IR departments. Within these departments, 68.8% operated independent inpatient wards, and the average number of licensed beds and DSA instruments were 37 and 2.4, respectively.[36] From 2007 to 2017, the proportion of hospitals with independent IR departments in Jiangsu Province, China, demonstrated a substantial increase, from 24% to 57%, as the total number of inpatient beds increased, from 328 to 1410, during this period[37] (Figure 1). The quantity and quality of specialized imaging-guided equipment have significantly improved. Although international manufacturers continue to dominate the market, the share of domestic equipment is steadily increasing.Figure 1: The expansion of the interventional radiology (IR) department in Jiangsu Province, China, from 2007 to 2017.3. IR specialist training and practice standardization The expansion and maturation of the IR discipline necessitate cultivating a larger specialized workforce, an imperative that has driven an intensified focus on foundational and advanced training programs in recent years. IR specialist training in China remains nascent and continues to encounter significant challenges. Although IR was formally incorporated into residency training programs in 2019, it has not yet been implemented. Training systems in other countries may offer valuable insights. For example, the United States initiated IR fellowship training in the late 20th century and, in 2012, became the first nation to recognize IR as a primary specialty within residency programs following approval by the American Board of Medical Specialties.[38] The Society of Interventional Radiology has a well-established training framework and standardized curriculum, whereas the Cardiovascular and Interventional Radiological Society of Europe has its own training system and primary certificate task force (European Board of Interventional Radiology [EBIR]). Dedicated, standardized, and regulated IR training programs must include clinical practice training in addition to formal training and assessments in image-guided, minimally invasive therapies, diagnostic imaging, radiation physics, and safety. Such training is mandatory for all health care systems. Completion of standardized clinical IR training programs must be followed by formal examination of the trainees, which should be comprehensive in terms of the clinical management of patients and scope of IR treatment. Smaller countries may benefit from an internationally organized examination, such as the EBIR, organized by the Cardiovascular and Interventional Radiological Society of Europe . The first EBIR examination was held in 2010, and its use continues to increase around the world.[39] Ideally, the successful completion of a certification examination is followed by a system of continued maintenance of certification and/or education. Formal acknowledgment by board-certifying organizations (or their equivalents) of IR, as a distinct subspecialty of radiology or a primary specialty, should be aspired to and pursued. Recently, several academic organizations have emerged in China, including the Chinese Society of Radiology, Chinese Society of Interventional Radiology, and Chinese College of Interventionalists. Furthermore, Chinese experts cofounded the International Society of Multidisciplinary Interventional Oncology, which facilitated academic exchanges, specialty training, and sustained partnerships with global organizations. Additionally, influential national research collaboration platforms have been established, such as the Chinese Liver Cancer Clinical Study Alliance, whose high-quality research outcomes have significantly supported and revised clinical practice guidelines,[40] and the Executive Master of Interventional Radiology, which is aiming to pioneer a new chapter in interventional medical education. Using these platforms, continuing education, research projects, and publications in the field of IR have exhibited sustained growth. Chinese interventionalists’ annual publications surged from 4 to 987 from 2006 to 2016,[36] and the number of national continuing medical education programs increased from 24 to 115 from 2008 to 2023 (Figure 2). Some original Chinese publications have provided high-level clinical evidence, such as the application of a transjugular intrahepatic portosystemic shunt (TIPS) for portal hypertension, particularly for salvage or preventive treatment of variceal bleeding.[41,42] Recently, Chinese interventional radiologists have conducted numerous high-quality clinical trials to transform the treatment landscape into various IR subspecialties. The ATTENTION,[43] BAOCHE,[44] and ANGEL-ASPECT[45] trials established evidence for endovascular thrombectomy in acute basilar artery occlusion and large anterior circulation infarcts within an extended time window (up to 24 hours), prompting guidelines for stroke management. The Chinese Liver Cancer Clinical Study Alliance 001 study[46,47] was the first to identify the superiority of transarterial chemoembolization (TACE) combined with immunotherapy-based systemic therapies for advanced hepatocellular carcinoma in real-world settings, thereby establishing a foundation for targeted immunotherapy integration in hepatocellular carcinoma management.Figure 2: The medical education programs of interventional radiology (IR) in China from 2008 to 2023.Chinese interventionalists demonstrate a comprehensive capability to perform virtually all IR procedures, achieving international leadership in both procedural volume and quality, including TACE, ablation, endovascular treatments, neurointerventional treatments, TIPS, and vertebroplasty. Although the standardization of interventional procedures commenced relatively late, it is fundamental for the advancement of IR. In recent years, dozens of guidelines and expert consensus have been formulated under the auspices of various interventional societies, including the Chinese clinical practice guidelines on TACE from the Chinese College of Interventionalists[40] and the international expert consensus on TACE from the International Society of Multidisciplinary Interventional Oncology,[48] which play pivotal roles in technological standardization. 4. Summary In the development of modern IR, conducting high-level clinical research and exploring underlying mechanisms and theories are essential for innovation and breakthroughs in interventional theories, devices, and efficacy validation. These efforts will significantly expand the depth and breadth of the discipline and ensure healthy and rapid development. Despite promising advances, IR in China continues to encounter systemic challenges. First, most high-end devices (e.g., DSA systems) still rely on imports from corporate entities (Philips/Siemens/GE Healthcare dominance) increasing health care costs and treatment expenses. Second, high-quality IR research remains limited, hindering the recognition of IR therapies as safe and effective alternatives to more invasive therapies. Third, the absence of a designated specialty code and a dedicated training system leads to the shortage of IR-specialized medical staff, which may impact procedural safety. In addition, Diagnosis-Related Group–based health care payments in China inadequately cover complex IR procedures restricting the clinical adoption and innovation of interventional therapies. Therefore, more policy support and financial investment are needed for China’s IR infrastructure to bridge these gaps, prioritizing high-quality clinical practice and groundbreaking innovation. In the future, comprehensive and in-depth discipline construction, scientific and systematic training systems for interventionalists and students, and deep integration with emerging diagnostic and therapeutic technologies and products will provide unprecedented opportunities for the development of IR in China. Key directions include drug-device combination products, advanced embolic materials and radiopharmaceuticals, image-guided cell and gene therapies, tumor neuromodulation, and organoid-based and “organ-on-a-chip” therapeutic platforms. Chinese interventionalists should seize these opportunities to embrace an era of AI and technological advances. Multiple, highly advanced, endovascular interventional robotic systems, such as ETcath and RATIONAL, have achieved preliminary clinical validation and are on the cusp of entering clinical practice. Through multidisciplinary collaboration, IR in China will be elevated to new heights, leading to the global frontier of the field.

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