The ad hoc Working Group of the Section and Board of Vascular Surgery of the Union Europeenne des Medecins Specialistes (UEMS), under the direction of Fabrizio Benedetti-Valentini, in collaboration with the International Union of Angiology and with the contribution of many invited experts from all “Vascular Professions” has issued developmental guidelines for Vascular Centres in Europe. Vascular Centres are seen as a way of uniting the competing disciplines of vascular medicine, interventional radiology and vascular surgery, under one roof in which all the disciplines can be represented, for the betterment of the patient.
Professor Benedetti-Valentini told Vascular News, “In my mind the main concept is that best treatment for the vascular patient is provided not by a single professional, surgeon, physician or radiologist, but by a co-ordinated team including every kind of expertise. I think that all vascular professions should learn how to work together instead of fighting each other: it is better to talk close up, than yelling from a distance since the conflicting interests of different single specialists are not in the best interest of the vascular patient. It is also the only reasonable and viable way to overcome those nasty arguments.”
The latest guidelines from the UEMS valued the work previously done by some national societies. The first input came from a proposal for Vascular Centres, which was developed by a working committee from the German Vascular Society (DGG), under the leadership of Henning Eckstein, Munich. The second came from the excellent work done by the working group of the British Vascular Surgical Society (VSSGBI) coordinated by Peter Lamont, Bristol. Further contributions came from the Italian Society of Vascular Investigation (SIDV) and the European Federation for Ultrasound in Medicine (FESUMB).
Klaus Balzer, President of the Board of Vascular Surgery and President of the German Vascular Society, told Vascular News, “We invented vascular centres because of the issues surrounding the competing disciplines (of angiology, interventional radiology and vascular surgery). It’s a very good idea and at the moment we have all over Germany around 50 vascular centres. They are certified by our Scientific Society and they are working.”
The Working Group believes that research, including epidemiological data and practical observations, has justified a multi-disciplinary approach in the management of the vascular patients.
The UEMS believes “co-operation between members of the staff in a vascular centres and primary care physicians is desirable to diminish the workload of out-patient clinics and for more precise following of patients.” Indeed, since up to 30% of the patients present as emergencies the UEMS guidelines recommend, “a complete service of a Vascular Centre should be round the clock and round the year. In so doing the number of needed specialists should be defined and provided. In any case adequate surgical ‘protection’ should always be assured.”
The final edition of the “Guidelines for the organization of Vascular Centres in Europe” was completed in Rome, after two years of intensive multidisciplinary work, on September 9, 2005 and approved by the Section of Vascular Surgery of the UEMS on September 15, 2005 in Helsinki during the Congress of the European Society of Vascular Surgery. That session, chaired by Fabrizio Benedetti-Valentini, President of the Section, was also attended by Christos Liapis, then President of the ESVS, and Roger Greenhalgh, who in that occasion was nominated Honorary President of the Section of Vascular Surgery.
The guidelines state that “This is only Part I of a wider project designed to clarify all aspects of VCs. It states what is needed to establish a VC in terms of Specialisms involved, facilities, basic organisation, equipment and training. It is a first proposal to be forwarded to all institutions and health authorities involved as well as to the European Governmental organisations. Further steps will obviously be pr©cising specific competence, guideline for management and training etc.
Key components and features
The document from the UEMS also makes recommendations regarding the core competences to be present in a Vascular Centre and they should be there for elective cases and for emergencies. The guidelines state, “Diagnostic laboratory can be managed by any specialist with adequate competence and can vary from hospital to hospital, from country to country. Somewhere technicians are in charge of the practical part of the examination and the interpretation lies with the doctor, somewhere else the specialist him/herself takes care of the entire process. Anyhow, it is considered important that the investigations be supervised by a clinician (surgeon or physician) with solid experience. Overall, the workload should be appropriate to the size as it has been well recorded that high volume institutions and surgeons and specialised surgical training lead to better results.”
Specialist staff – service
Moreover, the guidelines recommend that expertise within the Centres should be present: members can vary according to the size of the hospital, number of referred patients etc. In order to take at least part of the service, particularly screening and follow up, closer to the patients it was felt that some clinics, closely connected to the Vascular Centres, can and should be located in the territory or in adjacent hospitals in strategic areas.
According to the principle of an appropriate caseload some numbers are indicated as considered reasonable and probably adequate by that group of experts. The guidelines state that these should be considered minimum numbers not suggested or advised numbers; in other words that is what can be sufficient to maintain the specialist staff in training. The guidelines state that the creation of so-called ‘Mega-centres’ would not be desirable. Centres should also be tailored to the territory it serves and its peculiarities – therefore in large dispersed areas it may be accepted just the minimum requested and the Centres can have a structural core and then become multi-modular.
Regarding the facilities and equipment available, the guidelines states that these “should be absolutely adequate, easily connected, possibly located in the same building and for some unit also in the same floor.” In addition, wards (one or more) should be divided by “organ disease” or by type or prevalent type of care (that is vertical or horizontal) surgical and/or medical, but it or they should be strictly dedicated. “At present time it is no longer acceptable nor useful, nor effective to keep vascular patients besides other sort of patients. We must not forget that also the nursing staff should become more or less specialised in taking care of persons with vascular diseases,” the report adds.
It has been proposed on various occasions, by radiologists as well as surgeons, to build and equip a radiological and surgical unit, a ‘radio-surgical suite’, in order to concentrate there all endovascular and open surgical activities. It should be used by all endovascular specialists, jointly or separately, and is supposed to attain the best of both technical lines. However, that Working Group believes that, although radio-surgical suites are very desirable and very likely to come in the future, a separate endovascular radiological suite and one (or more) dedicated vascular surgical theatre should be provided in a Vascular Centre. As so many large pieces of equipment are needed in a vascular surgical theatre, many of them not easily manoeuvrable, and so high is the priority for sterility and electric insulation etc, that in Vascular Centre the surgical theatre for vascular surgery cannot be shared with any other surgical speciality, “though it can be used by radiologists and angiologists”.
Non-invasive ultrasound investigations and radiological studies are the two main streamlines of workout in the vascular patient. Colour coded duplex scanning is definitely the core instrument of a vascular laboratory: many forms of treatment, endovascular and open surgical, are carried out today with the only support of its findings. Transcranial doppler is becoming more and more necessary now that carotid surgery and stenting are reaching large numbers of cases. The guidelines acknowledge that a “dedicated radiology” is not strictly needed, however those investigational means should all be present and readily available also for emergencies, that is 24 hours a day.
The Working Group also recommended a list of specialists that should be present in a Vascular Centre. The report states, “a good, real, effective Vascular Centre can only be organised in a big hospital where all those specialities and services are usually present”.
Some numbers were agreed upon by that group of experts as the minimum requested to keep in good professional shape a minimal staff – if a surgeon or an endovascular specialist does not operate on a certain number of cases per year, at least for the main pathologies, his/her skill cannot be maintained at the adequate level.
Database and programme for audit
The guidelines also address the importance of keeping records and doing it in a way that the data of patients and investigations and trials and personnel can be elaborated and assessed. Therefore, the report states that adequate programme enabling medical staff and administrators to realise what is going on is “definitely crucial”.
The guidelines close setting some points that the Working Group considered important.
First it is recommended that vascular investigations, that is laboratory non-invasive techniques, should be clinically driven, that is managed and controlled by the vascular physician or the vascular surgeon or both of them. This point is emphasised since in some countries ultrasound examinations and the likes are basically done by technicians and in some other conditions are done by medical specialists not very clinically involved.
It has been said repeatedly “it doesn’t matter who delivers endovascular treatment, provided he/she has the necessary expertise”. The Working Group did not agree completely and stated, “as far as Vascular Centres are concerned vascular surgeons, angiologists and interventional radiologists, jointly or separately, are entitled to perform endovascular treatments provided they had appropriate training and certification and comply with guidelines. Such procedures will be done either in the vascular surgical theatre or in the endovascular facility according to needs, type of procedure, combination of procedures or local agreements; but for certain procedures surgical standby should be assured and readily available.”
The guidelines acknowledge that the discussion and agreements about who is in charge of the patient and, therefore, makes the final decision on treatment could last forever. However, the Working Group recommends, “The correct, honest, way out of this pitfall is establishing clear clinical pathways and internal guide lines of the Vascular Centre and updating them according to evidence, audit of outcomes, technological developments and so forth.”
Finally, the guidelines state that Vascular Centres are proposed as the best locations for training centres in the ‘vascular professions’. Many agree that there are common grounds and distinctive features for each of them. Therefore, Vascular Centre training pathways should be worked out and prepared for practical application.
“The guidelines are, on one side, suggestions and advice on how a Centre devoted to vascular care should be built, and on the other hand they are stated parameters to judge for the certification of a Vascular Centre at European level,” said Benedetti-Valentini. “Our Guidelines have been submitted to the President and to the Secretary General of the UEMS in order to obtain formal approval from the Management Council. Further step may be to take the document straight to the European Government and have it translated into a Directive.”
However, the establishment of Vascular Centres may not be without opposition. In Germany, where Centres are considered a success there was some initial resistance. Balzer said, “The strongest opposition comes from the cardiologists. They also need to work with angiology, but angiology in Germany is a known speciality. We had problems at first with the angiologists – who published a similar paper – but now we have agreed that the certifying process (for the centres) can be done by either angiologists or vascular surgeons. It’s the same process and it’s recognised by both societies. However, there are still some reservations against the surgical concept.”
Balzer added, “I think the future may be to live in a Vascular Centre together with the other disciplines or to change vascular surgery to a discipline that covers the entirety of vascular medicine. You might do both, it’s not prescribed what you have to do, but I think a Vascular Centre has to represent the entirety of vascular medicine.”
“So I am real happy about the European Guidelines for Vascular Centres. The forthcoming publication of the guidelines for Vascular Centres in Europe now means the most important part of the job can start: getting the health and governmental authorities in every single country and at European level to accept the proposals and help building those multidisciplinary Centres for vascular patients. Special thanks to Christos Liapis, John Wolfe, Marc Cairols and Fabrizio Benedetti-Valentini and – last but not least – to Roger Greenhalgh.”
Vascular News would also like to congratulate the German Vascular Surgery, which became an independent speciality on 1st January 2006. As a result, the last word should go to Klaus Balzer, “The future is bright. We have the model that we are working on together with other surgeons, and I hope that all European countries will have an independent speciality eventually.”