- Email: [email protected]
There Is No Playing Field and Vascular Intervention Is Not a Game
Commentary
There Is No Playing Field and Vascular Intervention Is Not a ~arnel
I
Gary J. Becker, MD, FSCVIR, FACC, FACR
IN a recent editorial by Edward B. Diethrich (11, the author attempts to convince the readership of the Journal of Endovascular Surgery that training and/or experience in diagnostic angiography should be eliminated from the credentialing requirements for the performance of interventional vascular procedures by vascular surgeons. This communication is a pointby-point response to Dr. Diethrich's editorial. First, let us examine the name, Journal of Endovascular Surgery. It is interesting that a journal and an entire professional society, The International Society for Endovascular Surgery (ISES), have appeared in the absence of a medical specialty or subspecialty of "Endovascular Surgery." Endovascular procedures do indeed exist. Those outside of the heart and central nervous system are included in the subspecialty of Vascular and Interventional Radiology (VIR). VIR is recognized by the American Board of Medical Specialties (ABMS). Among the reasons it is recognized by the ABMS are the following: 1)There is a discrete body of knowledge and practice (clinical and procedural) comprising this discipline, that is not embodied in the training programs or routine practice of other clinical specialties or subspecialties. 2) All of the modern percutaneous transcatheter techniques are based on the Seldinger technique (2)
Index terms: Credentialing
Editorials
JVIR 1997; 8:286-288
' From the Miami Vascular Institute, Baptist Hospital of Miami, 8900 N Kendall Dr, Miami; FL 33176. Received January 6, 1997; accepted January 12. Address correspondence to G.J.B. O SCVIR, 1997
and diagnostic imaging, and have been developed within the field of diagnostic radiology. This has occurred in the same way that subspecialties of Surgery have evolved from General Surgery. 3) Approximately 80 fellowship training programs in VIR in North America have been accredited by the Accreditation Council for Graduate Medical Education (ACGME), and more have applications in process. Although not a guarantee, the issuance of a subspecialty certificate by a member board of the ABMS to an individual physician passing a certifying examination is one of the public's most reliable indicators that the physician practices within a generally accepted standard. Examinations are indeed administered in VIR and subspecialty certificates are issued. There are approximately 1,000 holders of these certificates in the United States today. No comparable certificate is offered by any other member board of the ABMS, including the American Board of Surgery. Therefore, no other discipline can offer the public comparable assurance. Returning now to the specifics of Dr. Diethrich's editorial, his first paragraph states that ". . . the vascular surgeon who is seeking training requisite for credentialing is confused and a t times outright obstructed in the quest to develop a practice in endovascular surgery." In response, I strongly suggest that the vascular surgeon ". . . who is seeking traini n g . . ." should do just that (ie, get whatever training it is that helshe is seeking). If helshe seeks a certificate in VIR, then helshe should complete the requisite training. Likewise, if a vascular and interventional radiologist wishes to perform Vascular Surgical procedures, helshe should complete the requisite training. I do not mean to suggest that compromise is unnecessary. On the contrary. I
believe that it will be very important. The future promises radical changes in the practice of Vascular Medicine, Vascular Surgery, and Vascular and Interventional Radiology. We must take a n active role in shaping these changes. Regarding shaping change, in 1994-1995, two meetings of a 12member SVSIISCVS-SCVIR task force were held. The meetings were aimed a t 1) resolving differences over training for endovascular procedures (surgeons' view) and 2) forging a new plan for a hybrid discipline for the future (radiologists' view). Despite initial optimism, the discussions stalled and no progress was made. The surgeons' conclusion was that the radiologists had refused to offer training. Although on the surface this was true, what the radiologists had really refused to do was to focus only on the current desire of practicing vascular surgeons to learn endovascular procedural methods. Instead, in those same meetings, the radiologists made several concrete proposals for future hybrid VIR-Vascular Surgery training that included substantial compromise, with a shortened duration of Radiology training. The suggestions, though not approved by or even presented to the American Board of Radiology (ABR) in advance, did represent the views of certain members of the ABR's committee on Hybrid Pathways. For reasons evidently beyond their control, the Vascular Surgery members of the task force were not in a position to propose a similar compromise on the part of the American Board of Surgery (ABS) or to accept for consideration the ones we had proposed. Although the task force failed to produce a concrete plan acceptable to either the surgeons or the radiologists, it remained clear to all that some solutions would be required in the near term. For several reasons, the timing seemed ideal for vascular
Becker
287
Volume 8 Number 2
perform brain surgery. Obviously, I surgeons and vascular and intervendo not have the training, certification, tional radioloeists to combine forces. " The reasons for this opinion and experience, or judgment to even comment on the topic. While the several concrete suggestions have analogy exaggerates the point, the been published (3). Most prominent message is clear. among the reasons were a common Dr. Diethrich's next major point is interest in vascular ~ a t i e n t sand their diseases, a common interest in emerg- that there is a current movement afoot, shifting practice away from ing vascular therapeutic technologies diagnostic angiography and toward (most notably endografts), compleless invasive diagnostic methods. In mentary skills, and competitive his opinion, this movement supports market forces creating the impetus his position, and that of ISES, that for vertical integration. angiographic skills are not required to Allow me to address Dr. Diethperform interventional vascular procerich's notion that vascular surgeons dures. I agree that noninvasive diagare " . . . confused and a t times outnostic methods are in fact being used right obstructed in their quest to with increasing frequency in periphdevelop a practice in endovascular eral arterial occlusive disease surgery." In the first place, if they (PAOD). Still, Dr. Diethrich's single feel confused and obstructed. it is case example of a patient who underprobably because they have forgotten went stent placement for iliac disease what they were trained to do, and using only duplex ultrasonography instead have focused their attention and intravascular ultrasonography elsewhere. It is inappropriate and without contrast angiography is interunethical for a physician to launch a esting, but not particularly relevant. "quest" to develop a practice in a field The scenario most likely to unfold in of medicine for which helshe has not the next few years is that noninvasive been fully and properly trained. For tests such as magnetic resonance example, it would be completely angiography (MRA) and ultrasonograoutside of ethical bounds if I were to phy will become better, and angiostart a quest to incorporate Vascular graphic examinations will become Surgery into my practice. More to the more focused. The result will be a point concerning the topic a t hand, reduction in the use of contrast matebecause there is no field of "Endovasrial, but a preservation of the pacular Surgery," proper training for tient's transcatheter interventional the ~erformanceof vascular intervenalternatives to surgery. Already in tional procedures includes completion our practice, a normal angiogram is of an ACGME-accredited VIR fellowextremely rare. When a patient comes ship training program or its equivato angiography for PAOD, we already lent. know the symptoms and physical In his second paragraph, Dr. Difindings, the pulse volume recording ethrich goes on to state that "The results, the Doppler waveforms, and International Society for Endovascuthe thigh:brachial and ank1e:brachial lar Surgery (ISES) has taken the indices. In many instances, color position that there is absolutely no Doppler flow imaging has been used relationship between the performance as a supplement. The point is that of a diagnostic angiogram and the when the patient reaches the angioability to perform interventional graphic table, there is almost never a vascular procedures." ISES is an question about whether there is organization not recognized by any disease or where it might be. The licensing, accrediting, examining, question is whether there are reasoncredentialing or certifying entities in able transcatheter treatment options Vascular Surgery or VIR. Yet its or whether the patient must submit leadership has simply and arrogantly to surgery. Knowledge, experience, decided that there is no relationship judgment, training, and skill all come between angiography and the ability into play, a s this central issue gets to perform interventional vascular resolved while the patient is on the procedures. This is as ludicrous as if I angiographic table. For this issue to were to start my own organization of be resolved to the patient's best adinterventionalists who might decide vantage, the alternatives must be that there is no relationship between discussed thoroughly in advance, and doing craniotomies and the ability to the angiographic procedure must be u
performed by someone with the knowledge and skill required to make appropriate choices and institute therapy. Otherwise, the patient will fall victim to the limited repertoire of a less capable practitioner, and the preponderance of alternatives offered will be open surgical ones. Dr. Diethrich correctly points out that there is not even agreement between the various specialty societies as to what constitutes appropriate traininglexperience for the performance of interventional vascular procedures (4-7). That is precisely why the multidisciplinary document adopted by the American Heart Association (AHA) is so important (8). This document, prepared under the auspices of the AHA with input from the Councils on Clinical Cardiology, Cardiothoracic and Vascular Surgery, and Cardiovascular Radiology, has been widely adopted by hospitals across the United States as a credentialing standard for interventional vascular procedures in PAOD. Dr. Diethrich warns his readership that without ". . . proper endovascular surgery representation on such policy-generating bodies, doctrine may be established that: 1)is contrary to our beliefs, practice, needs, and opinions; and 2) impedes (intentionally or not) the entry of vascular surgeons into this burgeoning arena." How about considering what is best for the patient? I think he has missed the point! Also, what is "proper endovascular surgery representation?" Because there is no field of endovascular surgery, this is difficult to answer. However, i t would seem that the composition of the AHA group, which mirrored the proportions of interventional vascular procedures being performed by each type of specialist in the United States a t the time, represents the best attempt a t both fair representation and protection of patients' interests. Finally, Dr. Diethrich falls back on the all-too-familiar worn out statement that ". . . the vascular surgeon also has the capability to immediately address any complication that may occur as a result of an endovascular procedure." This may or may not be true, but complications of transluminal procedures can most often be handled by additional catheter methods, given an operator with the requisite knowledge, skill, and experi-
288
.
Journal of Vascular and Interventional Radiology
March-April 1997
ence. My fear is that in the hands of less skilled operators, patients may be left with only surgical solutions to their complications. Moreover, they may be subjected to higher endovascular procedural complication and failure rates, and a lower threshold in general for conversion of catheter procedures to open surgical ones. In his concluding paragraph, Dr. Diethrich calls on the SVS to join with ISES in the development of "surgical criteria" for the performance of endovascular surgery. In doing so he has asked the SVS to assist in the development of a credentialing standard for the performance of endovascular procedures. But, as he suggests in his editorial, these guidelines to be developed for vascular surgeons will reflect his opinion that there is absolutely no relationship between the performance of diagnostic angiography and the ability to perform interventional vascular procedures. In other words, the guidelines will aim to provide a vehicle for surgeons (even those without catheter skills or knowledge of angiography) to gain hospital credentialing for the performance of interventional vascular procedures. On the surface, the credentialing document(s) may have an appearance like that of any other; however, it will have been written to conform with the background and experience of the surgeons who wish to implement it, rather than to protect the interests of patients. What would a credentialing standard in this field written by general surgeons for general surgeons look like? And one written by general internists? Others?
The entire concept is flawed. There is no playing field and vascular intervention is not a game. One cannot simply re-write the rules to accommodate one's level of knowledge and skill. To protect patients by assuring an acceptable level of competence, a proper credentialing standard or guideline must describe the minimum training andfor experience required and the proper environment and support personnel with which to perform a procedure. Finally, when a widely accepted credentialing standard (such as the AHA document [8]) already exists, is it ever appropriate or ethical to implement a new lower standard? The answer is obvious. One can only hope that the SVS will not heed Diethrich's call. In his editorial, Dr. Diethrich has made it clear that he wants vascular surgeons to have a future in endovascular interventions. We all want to have a role in the future of this field, and I do not know a single interventionalist who wants to see Vascular Surgery excluded from it. Working together with the surgeons at the Miami Vascular Institute on endograft cases has made it clear to me that vascular and interventional radiologists and vascular surgeons have complementary skills, as well as interest in and knowledge of the same disorders. Each should have a stake in the future. Personally, I would like to see a rekindling of interest in the task force discussions of 2 years ago. I would like to see active involvement on the parts of the ABR and either the ABS or the newly incorporated American Board of Vascular Surgery,
including serious consideration of hybrid training programs that offer tangible decreases in the duration of both radiology and surgery training. I firmly believe that this sort of an effort would bear the durable fruits of labor that cannot be derived from yet another credentialing battle. References 1. Diethrich EB. Let's level the playing field once and for all! J Endovasc Surg 1996; 3:259-261. 2. Seldinger SI. Catheter replacement of needle in percutaneous arteriography: new technique. Acta Radio1 (Stockh) 1953; 39:368. 3. Becker GJ, Katzen BT. The vascular center: a model for multidisciplinary delivery of vascular care for the future. J Vasc Surg 1996; 23:907-912. 4. Society of Cardiovascular and Interventional Radiology. Credentials criteria for peripheral, renal and visceral percutaneous transluminal angioplasty. Radiology 1988; 167:452. 5. Wexler L, Dorros G, Levin DC, et al. Guidelines for performance of peripheral percutaneous transluminal angioplasty. Cathet Cardiovasc Diagn 1990; 2:128-129. 6. Spittel JA, Creager MA, Dorros G, et al. Recommendations for peripheral transluminal angioplasty: training and facilities. J Am Coll Cardiol 1993; 21: 546-548. 7. White RA, Fogarty TJ, Baker WH, et al. Endovascular surgery credentialing and training for vascular surgeons. J Vasc Surg 1993; 17:1095-1102. 8. Levin DC, Becker GJ, Dorros G, et al. Training standards for physicians performing peripheral angioplasty and other percutaneous peripheral vascular interventions. Circulation 1992; 86: 1348-1350.
There Is No Playing Field and Vascular Intervention Is Not a ~arnel
I
Gary J. Becker, MD, FSCVIR, FACC, FACR
IN a recent editorial by Edward B. Diethrich (11, the author attempts to convince the readership of the Journal of Endovascular Surgery that training and/or experience in diagnostic angiography should be eliminated from the credentialing requirements for the performance of interventional vascular procedures by vascular surgeons. This communication is a pointby-point response to Dr. Diethrich's editorial. First, let us examine the name, Journal of Endovascular Surgery. It is interesting that a journal and an entire professional society, The International Society for Endovascular Surgery (ISES), have appeared in the absence of a medical specialty or subspecialty of "Endovascular Surgery." Endovascular procedures do indeed exist. Those outside of the heart and central nervous system are included in the subspecialty of Vascular and Interventional Radiology (VIR). VIR is recognized by the American Board of Medical Specialties (ABMS). Among the reasons it is recognized by the ABMS are the following: 1)There is a discrete body of knowledge and practice (clinical and procedural) comprising this discipline, that is not embodied in the training programs or routine practice of other clinical specialties or subspecialties. 2) All of the modern percutaneous transcatheter techniques are based on the Seldinger technique (2)
Index terms: Credentialing
Editorials
JVIR 1997; 8:286-288
' From the Miami Vascular Institute, Baptist Hospital of Miami, 8900 N Kendall Dr, Miami; FL 33176. Received January 6, 1997; accepted January 12. Address correspondence to G.J.B. O SCVIR, 1997
and diagnostic imaging, and have been developed within the field of diagnostic radiology. This has occurred in the same way that subspecialties of Surgery have evolved from General Surgery. 3) Approximately 80 fellowship training programs in VIR in North America have been accredited by the Accreditation Council for Graduate Medical Education (ACGME), and more have applications in process. Although not a guarantee, the issuance of a subspecialty certificate by a member board of the ABMS to an individual physician passing a certifying examination is one of the public's most reliable indicators that the physician practices within a generally accepted standard. Examinations are indeed administered in VIR and subspecialty certificates are issued. There are approximately 1,000 holders of these certificates in the United States today. No comparable certificate is offered by any other member board of the ABMS, including the American Board of Surgery. Therefore, no other discipline can offer the public comparable assurance. Returning now to the specifics of Dr. Diethrich's editorial, his first paragraph states that ". . . the vascular surgeon who is seeking training requisite for credentialing is confused and a t times outright obstructed in the quest to develop a practice in endovascular surgery." In response, I strongly suggest that the vascular surgeon ". . . who is seeking traini n g . . ." should do just that (ie, get whatever training it is that helshe is seeking). If helshe seeks a certificate in VIR, then helshe should complete the requisite training. Likewise, if a vascular and interventional radiologist wishes to perform Vascular Surgical procedures, helshe should complete the requisite training. I do not mean to suggest that compromise is unnecessary. On the contrary. I
believe that it will be very important. The future promises radical changes in the practice of Vascular Medicine, Vascular Surgery, and Vascular and Interventional Radiology. We must take a n active role in shaping these changes. Regarding shaping change, in 1994-1995, two meetings of a 12member SVSIISCVS-SCVIR task force were held. The meetings were aimed a t 1) resolving differences over training for endovascular procedures (surgeons' view) and 2) forging a new plan for a hybrid discipline for the future (radiologists' view). Despite initial optimism, the discussions stalled and no progress was made. The surgeons' conclusion was that the radiologists had refused to offer training. Although on the surface this was true, what the radiologists had really refused to do was to focus only on the current desire of practicing vascular surgeons to learn endovascular procedural methods. Instead, in those same meetings, the radiologists made several concrete proposals for future hybrid VIR-Vascular Surgery training that included substantial compromise, with a shortened duration of Radiology training. The suggestions, though not approved by or even presented to the American Board of Radiology (ABR) in advance, did represent the views of certain members of the ABR's committee on Hybrid Pathways. For reasons evidently beyond their control, the Vascular Surgery members of the task force were not in a position to propose a similar compromise on the part of the American Board of Surgery (ABS) or to accept for consideration the ones we had proposed. Although the task force failed to produce a concrete plan acceptable to either the surgeons or the radiologists, it remained clear to all that some solutions would be required in the near term. For several reasons, the timing seemed ideal for vascular
Becker
287
Volume 8 Number 2
perform brain surgery. Obviously, I surgeons and vascular and intervendo not have the training, certification, tional radioloeists to combine forces. " The reasons for this opinion and experience, or judgment to even comment on the topic. While the several concrete suggestions have analogy exaggerates the point, the been published (3). Most prominent message is clear. among the reasons were a common Dr. Diethrich's next major point is interest in vascular ~ a t i e n t sand their diseases, a common interest in emerg- that there is a current movement afoot, shifting practice away from ing vascular therapeutic technologies diagnostic angiography and toward (most notably endografts), compleless invasive diagnostic methods. In mentary skills, and competitive his opinion, this movement supports market forces creating the impetus his position, and that of ISES, that for vertical integration. angiographic skills are not required to Allow me to address Dr. Diethperform interventional vascular procerich's notion that vascular surgeons dures. I agree that noninvasive diagare " . . . confused and a t times outnostic methods are in fact being used right obstructed in their quest to with increasing frequency in periphdevelop a practice in endovascular eral arterial occlusive disease surgery." In the first place, if they (PAOD). Still, Dr. Diethrich's single feel confused and obstructed. it is case example of a patient who underprobably because they have forgotten went stent placement for iliac disease what they were trained to do, and using only duplex ultrasonography instead have focused their attention and intravascular ultrasonography elsewhere. It is inappropriate and without contrast angiography is interunethical for a physician to launch a esting, but not particularly relevant. "quest" to develop a practice in a field The scenario most likely to unfold in of medicine for which helshe has not the next few years is that noninvasive been fully and properly trained. For tests such as magnetic resonance example, it would be completely angiography (MRA) and ultrasonograoutside of ethical bounds if I were to phy will become better, and angiostart a quest to incorporate Vascular graphic examinations will become Surgery into my practice. More to the more focused. The result will be a point concerning the topic a t hand, reduction in the use of contrast matebecause there is no field of "Endovasrial, but a preservation of the pacular Surgery," proper training for tient's transcatheter interventional the ~erformanceof vascular intervenalternatives to surgery. Already in tional procedures includes completion our practice, a normal angiogram is of an ACGME-accredited VIR fellowextremely rare. When a patient comes ship training program or its equivato angiography for PAOD, we already lent. know the symptoms and physical In his second paragraph, Dr. Difindings, the pulse volume recording ethrich goes on to state that "The results, the Doppler waveforms, and International Society for Endovascuthe thigh:brachial and ank1e:brachial lar Surgery (ISES) has taken the indices. In many instances, color position that there is absolutely no Doppler flow imaging has been used relationship between the performance as a supplement. The point is that of a diagnostic angiogram and the when the patient reaches the angioability to perform interventional graphic table, there is almost never a vascular procedures." ISES is an question about whether there is organization not recognized by any disease or where it might be. The licensing, accrediting, examining, question is whether there are reasoncredentialing or certifying entities in able transcatheter treatment options Vascular Surgery or VIR. Yet its or whether the patient must submit leadership has simply and arrogantly to surgery. Knowledge, experience, decided that there is no relationship judgment, training, and skill all come between angiography and the ability into play, a s this central issue gets to perform interventional vascular resolved while the patient is on the procedures. This is as ludicrous as if I angiographic table. For this issue to were to start my own organization of be resolved to the patient's best adinterventionalists who might decide vantage, the alternatives must be that there is no relationship between discussed thoroughly in advance, and doing craniotomies and the ability to the angiographic procedure must be u
performed by someone with the knowledge and skill required to make appropriate choices and institute therapy. Otherwise, the patient will fall victim to the limited repertoire of a less capable practitioner, and the preponderance of alternatives offered will be open surgical ones. Dr. Diethrich correctly points out that there is not even agreement between the various specialty societies as to what constitutes appropriate traininglexperience for the performance of interventional vascular procedures (4-7). That is precisely why the multidisciplinary document adopted by the American Heart Association (AHA) is so important (8). This document, prepared under the auspices of the AHA with input from the Councils on Clinical Cardiology, Cardiothoracic and Vascular Surgery, and Cardiovascular Radiology, has been widely adopted by hospitals across the United States as a credentialing standard for interventional vascular procedures in PAOD. Dr. Diethrich warns his readership that without ". . . proper endovascular surgery representation on such policy-generating bodies, doctrine may be established that: 1)is contrary to our beliefs, practice, needs, and opinions; and 2) impedes (intentionally or not) the entry of vascular surgeons into this burgeoning arena." How about considering what is best for the patient? I think he has missed the point! Also, what is "proper endovascular surgery representation?" Because there is no field of endovascular surgery, this is difficult to answer. However, i t would seem that the composition of the AHA group, which mirrored the proportions of interventional vascular procedures being performed by each type of specialist in the United States a t the time, represents the best attempt a t both fair representation and protection of patients' interests. Finally, Dr. Diethrich falls back on the all-too-familiar worn out statement that ". . . the vascular surgeon also has the capability to immediately address any complication that may occur as a result of an endovascular procedure." This may or may not be true, but complications of transluminal procedures can most often be handled by additional catheter methods, given an operator with the requisite knowledge, skill, and experi-
288
.
Journal of Vascular and Interventional Radiology
March-April 1997
ence. My fear is that in the hands of less skilled operators, patients may be left with only surgical solutions to their complications. Moreover, they may be subjected to higher endovascular procedural complication and failure rates, and a lower threshold in general for conversion of catheter procedures to open surgical ones. In his concluding paragraph, Dr. Diethrich calls on the SVS to join with ISES in the development of "surgical criteria" for the performance of endovascular surgery. In doing so he has asked the SVS to assist in the development of a credentialing standard for the performance of endovascular procedures. But, as he suggests in his editorial, these guidelines to be developed for vascular surgeons will reflect his opinion that there is absolutely no relationship between the performance of diagnostic angiography and the ability to perform interventional vascular procedures. In other words, the guidelines will aim to provide a vehicle for surgeons (even those without catheter skills or knowledge of angiography) to gain hospital credentialing for the performance of interventional vascular procedures. On the surface, the credentialing document(s) may have an appearance like that of any other; however, it will have been written to conform with the background and experience of the surgeons who wish to implement it, rather than to protect the interests of patients. What would a credentialing standard in this field written by general surgeons for general surgeons look like? And one written by general internists? Others?
The entire concept is flawed. There is no playing field and vascular intervention is not a game. One cannot simply re-write the rules to accommodate one's level of knowledge and skill. To protect patients by assuring an acceptable level of competence, a proper credentialing standard or guideline must describe the minimum training andfor experience required and the proper environment and support personnel with which to perform a procedure. Finally, when a widely accepted credentialing standard (such as the AHA document [8]) already exists, is it ever appropriate or ethical to implement a new lower standard? The answer is obvious. One can only hope that the SVS will not heed Diethrich's call. In his editorial, Dr. Diethrich has made it clear that he wants vascular surgeons to have a future in endovascular interventions. We all want to have a role in the future of this field, and I do not know a single interventionalist who wants to see Vascular Surgery excluded from it. Working together with the surgeons at the Miami Vascular Institute on endograft cases has made it clear to me that vascular and interventional radiologists and vascular surgeons have complementary skills, as well as interest in and knowledge of the same disorders. Each should have a stake in the future. Personally, I would like to see a rekindling of interest in the task force discussions of 2 years ago. I would like to see active involvement on the parts of the ABR and either the ABS or the newly incorporated American Board of Vascular Surgery,
including serious consideration of hybrid training programs that offer tangible decreases in the duration of both radiology and surgery training. I firmly believe that this sort of an effort would bear the durable fruits of labor that cannot be derived from yet another credentialing battle. References 1. Diethrich EB. Let's level the playing field once and for all! J Endovasc Surg 1996; 3:259-261. 2. Seldinger SI. Catheter replacement of needle in percutaneous arteriography: new technique. Acta Radio1 (Stockh) 1953; 39:368. 3. Becker GJ, Katzen BT. The vascular center: a model for multidisciplinary delivery of vascular care for the future. J Vasc Surg 1996; 23:907-912. 4. Society of Cardiovascular and Interventional Radiology. Credentials criteria for peripheral, renal and visceral percutaneous transluminal angioplasty. Radiology 1988; 167:452. 5. Wexler L, Dorros G, Levin DC, et al. Guidelines for performance of peripheral percutaneous transluminal angioplasty. Cathet Cardiovasc Diagn 1990; 2:128-129. 6. Spittel JA, Creager MA, Dorros G, et al. Recommendations for peripheral transluminal angioplasty: training and facilities. J Am Coll Cardiol 1993; 21: 546-548. 7. White RA, Fogarty TJ, Baker WH, et al. Endovascular surgery credentialing and training for vascular surgeons. J Vasc Surg 1993; 17:1095-1102. 8. Levin DC, Becker GJ, Dorros G, et al. Training standards for physicians performing peripheral angioplasty and other percutaneous peripheral vascular interventions. Circulation 1992; 86: 1348-1350.