The Institute Guest Speaker Jens Froelich – interview by Christine ...

The Institute
Guest Speaker Jens Froelich – interview by
Christine Vanderley Reichner
What made you come to Australia?
This was a strange incident! My original plan was to visit Austria for
a skiing event in Lederhosen. However, I somehow stuffed it up at
Frankfurt airport, and ended up on the wrong plane and surprisingly
was brought to Australia. Being Downunder and not accepting
the sphecric theory of planetay configuration, I was initially a bit
worried about falling off the earth. However, it turned out that the
Australian dialect was not as hard to understand as the Austrian
accent, so perhaps it was fate. And, originally being a ski instructor,
I was quite flabbergasted with respect to apparent deficits in local
wintersport facilities. However, intermittently I got adapted to my new
environment, learnt to love it and I am not planning to leave anymore,
even though I quite miss my parents and friends overseas. My wife
and the kids are here now as well. I have met quite a number of good
blokes and sheilas and I also found mates to hang out with. Meanwhile
I have completed my studies for the Level 1 travel tutorial course How
to get lost with style with an A grade and I got quite used to retrieving
my international mail from Tanzania, as the German post still seems
to have no bloody idea what TAS means.
When did you decide that interventional radiology was to become
your speciality?
This was another incident and I guess I have had quite a bit of an
odyssey. I started my training in cardiothoracic and vascular surgery
with a particular focus on vascular disease. I found the early results of
interventional radiology in comparison with open surgical procedures
quite promising and realised the future potential of endovascular
procedures, which at that time were still stuck in its infancy. That
was during the time when an Italian named Dr Guido Guglielmi
developed electolytically detachable coils for treatment of intracerebral
aneurysms. Subsequently, I decided to switch my surgical training to
8 Spectrum November 2012
radiology. Shortly after termination of my surgical residency I took a
little break and went on vacation to the Carribean. While away I sent
a handwritten application on official letterhead from the Guanahani
Hotel on St Bartholomy, French West Indies via Fax to the Philipps
University in Marburg. Two days later and somewhat to my surprise, I
got a reply to start my registrar position. This somwhat ruined a great
vacation. I left this lovely Carribean island early and started my new
training position just on time, quickly figuring out that nobody else
was interested in doing interventional radiology. However, my new
boss, Prof KJ Klose forced me into a very intense three month long,
day and night crash course in interventional radiology and tought me
everything he knew – which was a lot.
In addition, I got support from an interesting girl working in the Red
Light District (that’s how I used to call the radiographic film development
room). This particular girl turned out to be the radiographer in charge
of angiography and she tought me additional skills. During this
interventional crash course, I had to organise research grants. Prof Klose
then put me into an airplane and sent me to Washington, DC, where I
was supposed to commence a six-month long research fellowship at
Georgetown University, Armed Forces Institute of Pathology and at
the National Institutes of Health with Prof Klem Barth who tought me
additional tricks and treats. When I came back to Germany from the US,
I was left more or less in charge of interventional radiology.
Subsequently the interesting female chief angio lab radiographer
became so very interesting that we finally got married. Apart from
many common interventional procedures we now have two children
aged 14 and 17 and trust me, these kids are a fantastic joy to the both
of us. Today I would say that I still have the best job in medicine:
everybody else seems to be pracicing medicine by the book while I
have the opportunity to write the book while I am going along.
What special skills does an interventional radiologist need ?
Interventionalists must be able to see and control devices remotely as
they work within their patients. They have to have extensive knowledge
of all imaging modalities and they need to have 3D comprehension
of anatomy and be able to work in real time with theoretical and
actual anatomical data. In addition, interventional radiologists need
to understand the essential parts of clinical medicine for the vast
majority of clinical disciplines. These stringent requirements place
great demands on the technological community. Medical physicists,
imaging system engineers, materials scientists, pharmacologists
and experts in many other discipines are needed to support the
interventionalist. The whole team must fully understand the clinical
requirements before proceeding to work with each other toward the
common goal of improved patient care.
Clearly, interventional procedures require dedicated training apart
from natural cognitive and manual skills. Part of the training of a
qualified interventionalist is to develop the abstract conceptualisation
necessary to have a perfect as possible eye-hand coordination while
viewing several monitors from a remote site and simultaneously
keeping focused on the patient’s wellbeing. These skills are considerably
different from the traditional surgical training in which eye-hand
coordination is based on direct visual contact with the target organ.
This difference is absolutely critical in the training of physicians, as
was demonstrated in notably high morbidiy and mortality rates
associated with the development of laparoscopic procedures without
appropriate training and guidelines.

What procedure that you do, gives you the most pleasure?
Generally the procedure that I don’t have to do because it is unneccessary
and particularly on a Friday afternoon! Apart from that, it feels quite good
to save lives, restore functionality and help people getting back on track. I
personally love and prefer neurointerventional work. Mortality in patients
with ruptured intracerebral aneurysms ranges between 50 and 70 per cent
with a very high and devastating morbidity rate among the few survivors.
I am well aware that it is not possible to save everybody’s life, it fulfills
me with joy if I have been able to save a live without having to open the
skull and expose the brain. Similar pleasure is obtained by saving a patient
from developing a devastating stroke. However, every other successful
procedure also gives me great satisfaction.
How do you cope with the fact that not all your procedures will have
a good outcome?
Honestly? Pretty badly! Not uncommonly we are confronted with
desperate clinical circumstances, where the alternatives are either “nothing
more can be done” or only extreme therapeutic options are available. These
include death from exsanguination after arterial ruptures, continued
neurological deterioration in cases of intracranial disorders, amputations
in case of peripheral vascular disorders and progressive hepatic failure in
hepatobiliary diseases. After considering these alternatives we frequently
have to accept high risks and we try to find a compromise to suceed. This
implies that there will be negative outcomes which then causes significant
frustration and grief not only to the interventionalist but in particular to
the patients and their families. Whenever there is a real risk for adverse
outcomes, we try to communicate and liase with the patient’s family before
getting into action or as soon as possible thereafter. Fortunately, I am in
the lucky situation, that my family is always supporting me whenever I
am desperate or very unhappy about an unsuccessful or complicated
procedure.
What procedures you do now, did you never think would become
possible?
When I had to watch my beloved Grandpa suffer and finally die
from a large stroke at the age of 72, I was a young medical student.
This was a terrible incident for me. All I could do was be with him
and watch him pass away, without any possibility of helping. At that
time I had no idea, that 15 years later I would personally have the
knowledge and technology for saving his life. And this relates to most
currently applied interventional and neurointerventional procedures.
Technical developments and innovations have had an extremely
rapid evolution: we can now replace aortic valves, place arterial
bypasses, repair the complete aorta, treat prostate hyperplasia, uterine
fibroids, hepatic tumors, lung and bone tumors, repair vertebral body
fractures, treat acute stroke, fix intracerebral aneurysms, myocardial
infaction, generate transhepatic portosystemic bypasses and occlude
vessel injuries throughout the body rapidly without open surgery
and frequently just under local anesthesia. If somebody would have
told me about these possibilities 25 years ago, I would probably have
thought that he or she has lost their marbles. I am pretty sure we will
be even more impressed with our achievements after another 25 years.
If you had a crystal ball, what do you think will be the next big
breakthrough for an interventional radiologist?
That would be the upcoming App release for the latest i-Phone called
i-Fix. It will work similar to the i-Pod. The initial release will come
with three registers: cardiovascular disease, oncology and neurodegenerative
disorders. i-Fix consequently covers those diseases with
the highest morbitity and mortality rates in our environment. All you
have to do is open the i-Fix App, put the i-Phone on the diseased body
part and press the Start button: Finished, problem fixed and solved!
Wouldn’t it be nice to have that App?! Of course: currently such a
vision seems to be impossile. But then back in 1985 did you think, you
would be able to watch TV, receive e-mails and do interactive video
conferences on your own tiny mobile telecommunication device kept
somewhere in your pocket or handbag? Today I can already access the
Radiology PACS system with my old i-Phone and I can indeed plug in
an ultrasound transducer into this device to do an ultrasound exam.
Doesn’t this look as if we’re going somewhere?
The future of interventional radiology is extremely bright. As more
innovative physicians, engineers and other interested parties become
involved with our field, it is apparent that our imagination is the only
limitation. The expansion of ideas continues and undoubtedly in this
millenium techniques that are currently inconceivable, will soon be
practised on a daily routine basis.
We will hopefully soon see what happens to inhibit the
problematic neointimal proliferation and thrombotic complications
that can develop after percutaneous revascularisation and remodeling
procedures. Initial current studies with drug-eluting balloons and
stent have recently shown very promising results. Radioactive and
bioabsorbable stents are also under investigation. Flow diverting
devices have recently shown stunning results within cerebrovascular
Yamba voted No. 1
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Opportunity for new radiologist
business in area without this service
• For lease with option to purchase property.
Presently fully set up for medical practice.
• 160m 2 of quality fitout (excludes medical
equipment)
• Building only completed four years and
constructed to meet radiology needs.
• Fully secured patient parking. Disabled friendly.
Area population 17,000. Great lifestyle area.
Two hours from Gold Coast.
Larger floor area may be available if required
Inquiries invited to
Col McIlveen mob. 0410 467 226
Email cmgrumbles@bigpond.com
Spectrum November 2012 9

The Institute
applications and will soon offer fascinating treatment opportunities
also in peripheral applications.
Most certainly, nanotechnology will equip interventional
radiology with completely new possibilities to manage malignancies
endovascularly. A Nanotechnology treatment kit would likely include
an inhibitor to specifically shut down growth and mitosis of cancer
cells. The use of short interfering RNAs, seems to be particularly
suitable to be attached to nanoparticle delivery platforms. MRIguided
external magnetic localisation will likely be used to direct
iron-based nanoparticles towards tumours in order to provide local
thermotherapy. Recently radiofrequency ablation has been combined
with doxorubicin nanoparticles to increase thermal ablation zones,
and this technique is already in last phase clinical trials. Nanoparticles
can also be used to carry certain new drugs, inhibiting the growth
of tiny blood vessels that supply atherosclerotic plaques. Again, using
endovascular techniques, these loaded nanoparticles can be directed
to the site of new blood vessels within the base of atherosclerotic
plaques. Activity can be maintained when components fastening the
nanoparticles to cells found in newly developing blood vessels are used
(= fellow nanoparticle passengers). Fixed in position, the nanoparticle
can drop its drug load to concentrate within the atherosclerotic
plaque to generate plaque absorption. Alone or in combination
with nanoparticles, gene-therapy will also almost certainly change
and improve current treatment approaches for the majority of
arteriosclerotic, neoplastic and neurodegenerative disorders. Gene
therapy is transferring recombinant genetic material (DNA or RNA)
to the host cell in order to change tumour related gene expressions.
10 Spectrum November 2012
Interventional techniques will offer a fantastic targeted application
method for these gene and Nanoparticle vectors in order to assure
high focal efficacy and low systemic side effects.
Your greatest wish as an interventional radiologist?
One thing that will certainly change is the discipline of our field. It
is very unlikely that ‘interventional medicine’ will be so narrow to
be considered interventional radiology much longer. The use of
multiple imaging modalities, shared by a variety of disciplines, such as
surgery, cardiology and radiology will make the field of interventional
medicine considerably broader than it is today. Additionally, other
imaging modalities which have traditionally not been included within
a radiology environment may become increasingly utilised, such as
endoscopic and other video-based techniques.
I share the opinion of most interventional fellows, that we still
stand at the threshold of the development of our discipline, despite its
previous dynamic history of more than 20 years. The characterisation
of the interventionalist must continue being driven by improvement
of the status quo, and continuously strive to find lesser invasive and
more cost effective therapies.
Just recently, the large European and North American radiologic
and interventional societies have taken the first step in this process and
acknowledged Interventional Radiology as its own speciality, which in
my opinion was more than overdue. I hope that Australia will soon
follow this example and will realise the tremendous potential of this
discipline with regards to dedicated funding, research cooperation
and with its own clinical patient management. s