Turf wars intensify over endovascular training

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The number of peripheral interventional procedures performed by interventional cardiologists has increased remorselessly over the last ten years. Recently interventional cardiologists have been mandated to learn carotid stenting as part of the core curriculum. In the meantime cardiothoracic surgeons are keen to learn endovascular skills and documents point to a need to perform only 5 thoracic endovascular procedures to be trained to carry out thoracic endografting.

At the 2005 TransCatheter Therapeutics (TCT) meeting Barry Katzen pointed that interventional cardiologists have carried out an increasingly large proportion of peripheral interventional procedures in the United States against a background of an almost doubling of the number of procedures from 340,000 in 1996 to 750,000 in 2005 (see table one). This is because the volume of coronary interventions is relatively flat and the number of interventional cardiologists getting trained is increasing per year and exceeds the number of vascular surgeons and interventional radiology fellows by 5-6:1. “The perception: is that peripheral vascular is a growth market and cardiology is a stable one”, said Dr Katzen.

Dr Katzen called for immediate solutions such as considering vascular centers for neutral ground where multiple disciplines can function. He also emphasized the need to establish high levels of QA and credentialing and to remember destructive nature of turf battles. He highlighted the reality: that most centers dominated by single specialty expertise Dr Katzen also called for a final common pathway to train the vascular interventional specialist of the future. “We need to revamp training programs and align them and hold a high level summit of leadership of ACC/SVS/SIR to consider new specialty with different platform of training and final common pathway for the vascular interventional specialist.”

These developments are against a background of increasing public demand for accountability and competence. News headlines have shown concern over the ethical issues surrounding deaths in gene therapy and the reporting of them and claims are that 44,000 – 98,000 deaths per year due to medical errors.

Dr Katzen assess the interested parties in the management of peripheral vascular disease. Interventional Radiology has been historically involved and has done majority of diagnostic procedures and peripheral interventions. Historically interventional radiologists have had no clinical training and have had mixed success advancing intervention due to surgical influence. Interventional cardiology numbers are greater than vascular surgery and interventional radiology by 5 to 1. Historically interventional cardiologists have no training in PVD or vascular procedures but high skill levels in catheter/wires/complex devices. They also control patients with cardiovascular disease. Vascular surgery has been the historic gatekeeper of vascular care. Vascular surgeons have been resistance to less invasive (interventional) therapies. After endografts (1999) vascular surgeons embraced endovascular therapy with no real training pathways and no way to integrate training.

Dr Katzen quoted the ACC/AHA Task Force published in 1988 which highlighted that those physicians with appropriate training and demonstrated competence should be credentialed to perform peripheral interventional procedures:

“…the physicians with appropriate training and demonstrated competence in the performance of angioplasty are those who should receive proper credentialing to perform angioplasty in hospitals. It is recognized that hospitals are currently under intense pressure to grant privileges to cardiologists who have not had adequate training so as to protect the hospital’s referral base. This practice should not be condoned; rather, the responsible leadership…should insist on the documentation of accredited training and the maintenance of skill of its approved operators…”

Dr Katzen highlighted that qualification can be by training, experience or apprenticeship where the trainee carries out 100 diagnostic angiograms, 50 peripheral/renal PTA procedures with 50% as primary operator and participation in 10 thrombolytic cases. “Current qualification numbers are based on minimum numbers and depend heavily on a strong quality process. Credentialing principles include a base of knowledge necessary to perform procedures, specific training requirements: numbers, types, etc., demonstrated quality and results, activity levels to maintain proficiency and ongoing QA results, performance outcomes”, said Dr Katzen.

Dr Katzen drew attention to a number of problems facing specialists involved in the management of peripheral vascular disease including turf battles and lack of informational integration. There is also a lack of incentives to work together where free market pressures work against centers of excellence models. Finally there is a lack of common quality process and enforcement. Dr Katzen challenged whether the minimum credentialing numbers were sufficient. “What defines excellence vs competence? Is limited competency limited incompetency?” He quoted the Journal of Vasuclar Surgery to highlight the difference between training and certification and competence: “Although proper training and certification are a means of defining a surgeon’s qualifications, they do not assure competence in a particular specialty.”

Against this background accommodating others who seek certification in vascular intervention is difficult. The only current Certificate of Added Qualifications for Peripheral Intervention is in VIR Boards. “The ideal would be a training program structured like the one for endovascular surgical neuroradiology/nuclear medicine. Trainees would be able to enter from radiology, vascular surgery, or cardiology”, said Katzen. According to Katzen elements of an ideal training program in vascular intervention would include a solid foundation in all vascular imaging and diagnosis as well as procedural focus (indications, contraindications, angiographic interventions, vascular cutdown and pre- and post-procedural care). “The Program Director could belong to any of the 3 disciplines and the name of the new discipline is up in the air but could be ‘vascular endosurgery’, ‘endovascular therapist’ or ‘endovascular surgery’, said Katzen.

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