Endovascular Credentialing

Letters

Endovascular Credentialing From: The Endovascular Surgery Credentialing and Training Subcommittee Rodney A. White, MD Harbor-UCLA Medical Center 1000 W. Carson St Torrance, CA 90509 Editor: The following is a response to an editorial in JVIR by Drs van Breda and Becker (1).The comments in the JVIR editorial primarily address a document entitled "Endovascular Surgery Credentialing for Vascular Surgeons," which was prepared by an Ad Hoc Committee of the Society for Vascular SurgeryIInternational Society for Cardiovascular Surgery (SVSIISCVS) and published in the Journal of Vascular Surgery (2). Although this discussion responds to the editorial by van Breda and Becker, the comments are also applicable to the editorial by Spies (3) in the same issue of JVIR. This letter is written with the intention of maintaining a congenial atmosphere and working relationship between vascular surgeons and interventional radiologists. , for whom we have the highest regard. We are concerned that the objectives of the document prepared by the SVSI ISCVS Ad Hoc Committee are misunderstood, and we would like to clarify several issues that were raised in the JVIR editorial. The JVIR editorial states that the title of the SVSI ISCVS endovascular document "suggests the authors' unwillingness to make objective, fair recommendations that include comparable experience for all physicians performing the procedures." The intent of the SVSIISCVS Ad Hoc Committee's report is clearly stated in the title and in the first paragraph of the article. The guidelines were developed to address issues for vascular surgeons with no intention to suggest guidelines for other subspecialties. The exclusion of other subspecialties was not meant to be objectionable, but rather is based on the premise that the training programs for each group have different components and that credentialing and training guidelines should recognize the individual variations. In contrast to what was suggested in the JVIR editorial, the SVSIISCVS Committee had no intention of taking a "giant step backward" by inhibiting the "dialogue and mutual respect between the disciplines of vascular surgery and vascular and interventional radiology." The committee was particularly careful to restrict the considerations to vascular surgeons, since other efforts had focused on developing guidelines using the components and requirements of other training programs and had not considered in depth the influence that surgical training had on the application of endovascular methods. There are several comments in the JVIR editorial re-

garding the efficacy of balloon angioplasty, the approach that surgeons' have toward the application of interventional methods based on a knowledge of the anatomy and natural history of atherosclerosis, and surgical expertise with percutaneous access. The position of the SVSIISCVS Committee regarding these issues is clearly stated in our report and we remain confident regarding these discussions as originally stated. The JVIR editorial suggests that the SVSIISCVS guidelines "essentially equate operative angiography with diagnostic arteriography." The editorial further comments on "the Ad Hoc Committee's lack of appreciation for the skills required of contemporary ang-&rahers." Neither statement is an accurate re~resentation. k s indicated in the SVSIISCVS endovascular document, vascular surgeons currently do not train to perform diagnostic angiography, although they are trained in the interpretation and application of angiographic studies. Operative angiography was discussed in the SVSIISCVS paper as a unique component of the surgeons experience that should be considered when assessing training qualifications for endovascular procedures. The JVIR editorial also addresses judgment regarding choices of interventional methods for the treatment of atherosclerotic vascular disease. They appropriately question that "10-15 cases can provide sufficient experience to invoke sound judgment." The SVSIISCVS document does not suggest that limited case experience evokes appropriate judgment, but rather relies on the training required in general and vascular surgery programs as the discriminator in developing judgment regarding the appropriate choice of interventional method. We believe that all interventional subspecialties should consider the opinions of trained vascular surgeons regarding the choice of treatment for specific lesions. This is the standard in most institutions and forms the basis for our statements regarding the influence of surgical training on the choice of therapeutic options. The 10-15 procedures discussed in the SVS/ISCVS document refer to the number of hands-on interventions required for surgeons to become proficient a t any particular modality with which the surgeon may not be familiar. The article does not mean to suggest that 10-15 endovascular procedures are all that is required to demonstrate endovascular expertise. Although this number has been criticized, it is similar to the hands-on experience required in other interventional documents that have been published for demonstrating endovascular competence. Other interventional guidelines usually suggest that 25 hands-on procedures constitute adequate training to use a particular method, for example, balloon angioplasty. The JVIR editorial quotes Dr John Porter's discussion of the training required to become a highly skilled arteriographer. Dr Porter's comments outline the requirements that have been established for a radiology residency and subsequent arteriographic fellowship. We must emphasize that there is no attempt to have vascular surgeons develop the skills of a diagnostic interven-

288

Journal of Vascular and Interventional Radiology

March-April 1995

tional radiologist. The SVSIISCVS Committee also does not believe that the requirements for training interventional radiologists should have any influence on the criteria that the American Board of Surgery accepts for training of general and vascular surgeons. The JVIR editorial suggests that the SVSIISCVS article supports a "breech of physician responsibility" by recognizing that some physicians gain skills in new surgical interventional methods by participating in protocols approved by Institutional Review Boards (IRBs), or by participating in investigational programs sponsored by the Food and Drug Administration (FDA). This statement in the SVSIISCVS document does not suggest that individuals participating in IRB or FDA-sponsored studies do not have skills appropriate for a study, but rather that new skills or techniques are developed, moderated, and approved by these mechanisms. We agree that it is irresponsible for any physician to participate in a human trial of new technology or device if any of the other investigators do not have the skills required to safely perform the procedures. To suggest that surgeons irresponsibly use either IRB or FDA-sponsored protocols in the manner suggested in the JVIR editorial is unsubstantiated. The JVIR editorial also states the SVSIISCVS paper reports "vascular fellowship training programs have incorporated endovascular technologies." The SVSiISCVS document does say "as the endovascular technologies have improved, vascular fellowship training programs have incorporated them into the programs." We do not claim that all programs have adopted these methods. To the contrary, the SVSIISCVS guidelines were established in part to look a t these issues within the vascular societies and to use this information as a guide to training physicians. Our final comment relates to the summary statement in the JVIR editorial that suggests that the surgical community should not adopt the SVSiISCVS Ad Hoc Committee's recommendations, but rather support the American Heart Association (AHA) training standards. This document, which was reproduced in JVIR and was originally published in Circulation (4) includes two comments that are unacceptable to vascular surgeons. The first is the statement that endovascular training should include 100 diagnostic arteriograms, with a diagnostic arteriogram being defined as "imaging the entire vascular distribution in question using conventional serial film changers or large field digital imaging systems. For example, peripheral angiography of the lower extremity vessels must image the vessels of both lower extremities from the distal aorta to a t least the ankle." This definition eliminates subspecialties other than interventional radiologists from doing peripheral endovascular interventions. The second unacceptable comment is in the final section of the report: "Maintenance of Privileges." It stipulates that any physician who does not meet the full requirements outlined in the Circulation document within 3 years would no longer be eligible for recertification.

This requirement would essentially eliminate all vascular surgeons performing endovascular interventions within 3 years unless they obtained training comparable to that offered in fonnal interventional radiology programs. Even though two surgeons are listed as authors on the AHA article, the SVSIISCVS Endovascular Subcommittee believes that the document is biased against surgeons and that it essentially describes an interventional radiology training program. The SVSIISCVS Ad Hoc Committee is comprised of experienced practicing vascular and endovascular surgeons who are qualified in all respects to assess the ability of surgeons to perform endovascular interventions. We do not intend to define interventional radiology criterion and object to having the outlined requirements imposed on vascular surgery training programs when the intended goals are dissimilar. References 1. van Breda A, Becker GJ. Endovascular credentialing (editorial). JVIR 1994; 5:90-92. 2. White RA, Fogarty TJ, Baker WH, Ahn SS, String ST. Endovascular surgery credentialing and training for vascular surgeons. J Vasc Surg 1993; 17:1095-1102. 3. Spies JB. Accepting a multispecialty credentials standard for peripheral angioplasty (editorial). JVIR 1994; 5:86. 4. Levin DC, Becker GJ, Dorros G, e t al. Training standards for physicians performing peripheral angioplasty and other percutaneous peripheral interventions. Circulation 1992; 86:1348-1350.

Drs van Breda and Becker respond: We thank Dr White for his comments and we are certain that they were intended as collegial. However, despite his contention that the objectives of the SVS were misunderstood we maintain our original position. We concur that each specialty involved with vascular disease has unique training programs with "different components." Our mutual recognition of the differences in specialists' background should foster the understanding that certain basic skills may be required to perform a given procedure safely and competently. A hypothetical role reversal may serve to clarify the interventionalist's reaction to the SVS document. "Vascular Surgical Credentialing for Interventional Radiologists" might contain such statements and recommendations as the following: "Surgical access/techniques are used during general interventional training for performance of cutdowns, for nonvascular tract dilation, and for abscess drainage. Because of this experience, interventional radiologists are fully qualified to perform surgical procedures if they are supplemented with basic training with surgical experience in the vascular system. If an interventionalist has no experience, development of this skill should be enhanced by performing 10-15 surgical procedures in collaboration with a physician trained in this technique." The document might further indicate that "these skills are easily acquired by the interventional radiologist because tactile agility is a prerequisite