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Interventional News, Latest Issue No. 16

Maynar in his office

Professor Manuel Maynar talks to Interventional News

Professor Manuel Maynar, Director of the Department of Endoluminal and Endovascular, Hospital Rambla of Tenerife and General Hospital of Catalunya, Sant Cugat del Valles, Barcelona, Spain, has been the first person to perform many interventional procedures in Spain and was the chairman of the hugely successful CIRSE 2004 meeting in Barcelona. Here he talks to Interventional News about his career and the state of the interventional radiology in Spain.

Professor Manuel Maynar started by explaining to Interventional News how he initially became involved in medicine. "My connections with the health care field are principally through my father who was a pediatrician and through my relative Don Santiago Ramon y Cajal, a Nobel Prize winner in Medicine," said Maynar. "From my father I learnt the love of medicine and the ultimate care for his patients, and from my relative's work I learnt to appreciate excellence in what we do and the need for research to improve outcomes in medicine." Maynar continued, "Another relative of mine was a Full Professor (catedratic) at the University in Tenerife, and was one of the leading proponents of Esperanto in Spain." He went on to point out that something that all of these relatives had in common was an adventurous spirit and an intense love for mankind.

In the early 1970s, Maynar was beginning his residency training in pediatrics at the Health Complex José© Antonio Prima de Rivera, Zaragoza, and at this time the Department Chairman of Radiology asked for a volunteer to get involved in the emerging field of vascular radiology. Maynar was attracted by this opportunity. "Because of my love of anatomy and procedures I volunteered," recalled Maynar, "and was sent to the Hospital Valle de Hebron of Barcelona to spend some time with Dr Jose Maria Rius Chornet with whom I spent two years. He was at that time the most prestigious interventional radiologist in Spain, who after training andInterventional News, Latest Issue No. 16Profile: Manuel MaynarMaynar in his officeProfessor Manuel Maynar talks to Interventional NewsProfessor Manuel Maynar, Director of the Department of Endoluminal and Endovascular, Hospital Rambla of Tenerife and General Hospital of Catalunya, Sant Cugat del Valles, Barcelona, Spain, has been the first person to perform many interventional procedures in Spain and was the chairman of the hugely successful CIRSE 2004 meeting in Barcelona. Here he talks to Interventional News about his career and the state of the interventional radiology in Spain.Professor Manuel Maynar started by explaining to Interventional News how he initially became involved in medicine. "My connections with the health care field are principally through my father who was a pediatrician and through my relative Don Santiago Ramon y Cajal, a Nobel Prize winner in Medicine," said Maynar. "From my father I learnt the love of medicine and the ultimate care for his patients, and from my relative's work I learnt to appreciate excellence in what we do and the need for research to improve outcomes in medicine."Maynar continued, "Another relative of mine was a Full Professor (catedratic) at the University in Tenerife, and was one of the leading proponents of Esperanto in Spain."

He went on to point out that something that all of these relatives had in common was an adventurous spirit and an intense love for mankind.In the early 1970s, Maynar was beginning his residency training in pediatrics at the Health Complex José Antonio Prima de Rivera, Zaragoza, and at this time the Department Chairman of Radiology asked for a volunteer to get involved in the emerging field of vascular radiology. Maynar was attracted by this opportunity. "Because of my love of anatomy and procedures I volunteered," recalled Maynar, "and was sent to the Hospital Valle de Hebron of Barcelona to spend some time with Dr Jose Maria Rius Chornet with whom I spent two years. He was at that time the most prestigious interventional radiologist in Spain, who after training and practicing the specialty abroad was starting the first cardiovascular radiology service in Spain." Maynar went on, "Dr Rius opened my eyes to the broad diagnostic and therapeutic opportunities offered by this field. Most of all I was impressed by the potential to develop alternative minimally invasive techniques to replace traditional surgical procedures, the ability to merge forward thinking with hand dexterity, never thinking that in such a short period of time technological advances would lead to the revolution on the way we manage patients that we have witnessed over the past two decades. Because of the potential I envisioned of these new techniques I abandoned the pediatric field and started my training in interventional radiology." Interventional radiology was Maynar's entry point into the specialty of radiology. "From the very beginning of my professional career I was never involved in the field of diagnostic radiology and have always practiced exclusively as an interventionalist," explained Maynar. "My goal as a professional has always been to help the patient, and to reach that objective I traveled widely in order to acquire and develop the best skills to put at the service of my patients. I consider myself more of a surgeon without a scalpel than a radiologist with interventional skills. Actually, I am at this point in my life developing laparoscopic skills in order to be able to merge these knowledge with that of the endovascular and interventional techniques."

Influences

Interventional News then asked Maynar about his formative influences. Maynar replied: "As I mentioned earlier my first mentor was Dr Jose Maria Rius Chornet, who trained in Sweden and France and returned to Spain in 1975 to start the first interventional service at the Hospital Valle de Hebron de Barcelona. From him I learnt to travel across the patient's natural conduits with catheters and wires under fluoroscopic control. Later on I had the privilege of visiting Dr Andreas GrÃ1?4ntzig and from him I learnt the technique of transluminal angioplasty. On my return to Spain I performed the first angioplasty on a Spanish patient. Some of these patient's arteries are still open 24 years after. Later on I visited leading interventional radiologists including Drs Amplatz, Castaneda, Zeitler, Rösch, Gianturco and Wallace. From each one of them I harvested a new seed of knowledge which I have put to the service of my patients."

Milestones

Professor Maynar then looked back on the highlights of his career thus far. "I would like to say that the largest milestone of my life was back in 1978 landing my first job with a group of very progressive, open minded vascular surgeons in Asturias, Spain," said Maynar. "Together we developed a multidisciplinary approach to the management of peripheral vascular disease. The first angioplasties in Spain were performed there, we rounded together and residents on vascular surgery rotated through my service for six months." "Another significant milestone was observing how Drs GrÃ1?4ntzig and Schneider opened obstructed arteries; this opened for me the field of endovascular therapy," continued Maynar. "I have been blessed with the opportunity to bring many of these new therapeutic alternatives to Spain, including: angioplasty in 1980, as already mentioned, TIPS in 1991, AAAin 1994, as well the introduction of many other devices such as stents, atherectomy, stent grafts, etc. "Thanks to all of this activity, and my publications and presentations in international journals and at scientific meetings, I was able to transcend Spain and I have been invited to lecture and to perform live demonstrations all over the world. I was the one of the first four European interventionalists invited by the American Society of Interventional Radiology (SIR) to lecture at their annual meeting in the mid-1980s." One of the most rewarding experiences, according to Maynar, was the organization, beginning in 1988, of the first European meetings including live demonstrations. In addition to the hundreds of attendees, these courses were transmitted live via satellite throughout Latin American, the USA and Europe where they were watched by thousands of professionals. Maynar then went on to describe his situation at the moment. "My clinical practice is currently divided between the Hospital General de Cataluna (HGC) in Barcelona and my two centers in Tenerife at Hospiten," said Maynar. "I have 10 full time MDs working for me, some of them as attending and others as fellows in training. Our service works in close relationship with the vascular surgery, cardiac and cardiology services, we jointly discuss the patients and decisions are reached as a group on what is the best therapy for the patient's management." "Non-invasive tests such as Doppler Ultrasound, CTA, and MRA are performed under our control in order to assess and follow-up patients after endovascular surgery. In respect to new technologies we as a group decide on what new technologies must be brought to the center, i.e., laser, ozone therapy, etc. Our purpose is to offer the patients the best available therapeutic procedures independently of who is the operator. "Our group performs all of the endovascular and non-vascular procedures at these institutions. The total number of procedures performed annually exceeds 1,000 endovascular cases, in addition to the non -vascular interventional procedures and the cardiac interventions. We also have our own outpatient clinic where we see new and follow-up patients. Our endovascular group also admits its own patients." "In addition, I have a direct link with the Minimally Invasive Surgery Center in Caceres, Spain, where I am the Director of Endoluminal Surgery. This center is under the direction of Dr Jesus Uson Gargallo. All the staff there is made up of veterinarians and their functions include teaching and research. Yearly we organize a hands-on symposium for people interested in the latest endovascular techniques. The faculty of this course is international and at the highest level of experience. "Another important teaching activity organized by my group is the ACAVA course held three times a year for physicians interested in cardiovascular pathology. This course is an intense tutorial for five physicians with live cases, conferences and patient interactions. The faculty includes cardiac surgeons, vascular surgeons, interventional cardiologists and endovascular specialists." Professor Maynar's group is currently developing techniques for the percutaneous creation of an extraluminal femoropopliteal bypass, percutaneous arteriovenous fistulas for hemodialysis, and a combined laparoscopic/endovascular approach for the management of AAA They are also studying the complex problem of aortic dissections.

CIRSE 2004 meeting

Describing what he saw as highlights of the CIRSE 2004 meeting in Barcelona of which he was the chairman, Professor Maynar said, "More than the specific topics that caught my fancy, I would like to stress the high level achieved by the scientific program, the introduction of the patient as a topic of discussion and the addition to the end of each scientific session of take home points. Most remarkable was the record breaking attendance for CIRSE with a 100% increase over the meeting two years ago. However, whether this was due to the attractions Barcelona or to the quality of the scientific program is open for discussion."

Challenges in Spain

According to Maynar, the challenges facing interventional radiologists in Spain are the same as in the rest of the world, that is the interest of other specialists, i.e. vascular surgeons, cardiologists, nephrologists, angiologists, etc, in getting involved in these minimally invasive techniques. "The roots of this problem goes all the way back to the origins of vascular radiology as a subspecialty of diagnostic radiology. Organized radiology never accepted the fact that these individuals were a different breed, one with more clinical involvement than the traditional general radiologist and consequently hampered their development as a new discipline. This opened the doors to other specialists that saw the lack of clinical skills of the radiology based vascular radiologists as a handicap, a handicap that they did not have. The problem for all of these clinical branches of medicine interested in endovascular techniques was the lack of formal training in them. This they have 'solved' by attending weekend or week long training courses, which allowed them to return to their practices and claim to be capable of performing endovascular techniques. The problem here is for the patient who ends up in the hands of poorly trained individuals and ends up paying the price. The solution is the creation of official joint training programs where specialists interested in training can train for one to two years in the field of endovascular therapy. Built in recertification requirements will mandate training in new technical developments and knowledge every few years in order to ensure the maintenance of knowledge and skills, for the benefit of the patient. The only challenge is to understand the evolution of the specialty and to accept that only properly trained specialists should be performing these techniques." Interventional News then asked Maynar what he thinks the future holds for interventional radiology. "I would like to say that there will be turmoil until everybody involved or interested understands and accepts the need for the creation of specifically designed and unified training programs. Acceptance by the governing boards of the different specialties and the governmental agencies is a must before this can happen. As important as the development of uniform training guidelines will be the integration of new developments in laparoscopic and robotics into the training on endovascular techniques, since it seems obvious that a properly trained endovascular specialist should be able to handle the laparoscopic techniques as an adjuvant to the endoluminal route."

Beyond IR

"Beyond my work I have many interests," said Maynar, "first of all are my children, closely followed by the enjoyment of family and friends. I love to travel, to read good books and to collect paintings." Maynar has also developed his own brand of cigar, around his taste and wishes. "They are hand made by artisans in the Canary Islands," said Maynar, "and they are mostly for my enjoyment and obviously for those of my friends that have heard of them. In reality a good cigar is like a salad, the difference is that you eat the salad on a plate and the cigar you smoke it, it is like smoking your salad." Fact file: Manuel Maynar Moliner

Born

June 16 1948, Zaragoza, Spain

Residency

1974-1977 - Department of Radiodiagnostic, Health Complex José© Antonio Primo de Rivera, Zaragoza, Spain

PhD 1985 - PhD in Medicine and Surgery, University of Zaragoza, Spain

Current posts

Full Professor of the University of Las Palmas de Gran Canaria (ULPGC) l Full Professor of the Louisiana State University, New Orleans (L.S.U.) l Director of the Department of Endoluminal in the Minimal Invasive Surgery Centre, Animal Lab, Cáceres, Spain l Director of the Minimally Invasive Diagnostic and Therapeutic Institute, Hospital Rambla, Santa Cruz de Tenerife, Spain l Director of the Department of Endoluminal / Endovascular, Hospital General of Catalunya, Sant Cugat del Valles, Barcelona, Spain

Selected awards

l Special Mention for the video "Transjugular Percutaneous Intrahepatic Porto-Systemic Shunt (TIPS)", 4th World Congress International Gastro- Surgical Club, Madrid, Spain, October 1993 l Award for a Paliative Medicine paper: "Tratamiento Paliativo de las Lesiones Estenóticas Malignas de Esófago mediante Prótesis Metálicas Autoexpandibles", Zaragoza, Spain, December 1994 l First place of Communication Video: "Radiología Intervencionista y Obstrucción de la vía lacrimal: Tratamiento mediante endoprÃ3tesis de poliuretano", V Congreso Nacional de Vídeo Cirugía, Alicante, Spain, October 1997 l Award to the oral communication "Tratamiento endovascular de lesiones ilíacas mediante prótesis metálicas tipo NHS", V Reunión Bienal de Sociedad Andaluza de Angiología y Cirugía Vascular, Huelva, Spain, December 1998 l Award "Ciudad de Olivenza" in the XII edition of Videomed (Videomed 2000), Badajoz, Spain l Award 2nd place, Resident Research day 2004, Louisiana State University Health Science Center New Orleans (USA), February 2004 l Poster Award, honors, 29th Annual Scientific Meeting of the Society of Interventional Radiology (SIR 2004), Phoenix, Arizona, (USA), March 2004 l Award 2nd place in the XIV edition of Videomed (Videomed 2004), Badajoz, Spain