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Societies release consensus statement on training, credentialing for carotid stenting
The Society for Cardiovascular Angiography and Interventions and the Society for Vascular Medicine issued an expert consensus statement on physician training and credentialing to help incorporate carotid artery stenting into clinical practice.
“[Carotid artery stenting] with embolic protection requires capable operators, well-prepared facilities and appropriately selected, well-informed patients,” Herbert D. Aronow, MD, MPH, FSCAI, FSVM, from the Cardiovascular Institute of Rhode Island and Alpert Medical School of Brown University, Providence, Rhode Island, and colleagues wrote. “The recommendations herein are intended to assist in the safe, effective and appropriate application of this established revascularization modality. Continued careful evaluation of relevant process and outcome metrics, both locally and nationally, will ensure maintenance of operator and facility competency and adherence to national quality benchmarks.”
Physician training and credentialing for carotid artery stenting is challenging because the procedure has declined in frequency in recent years due to concerns about reimbursement and an emphasis on managing patients with carotid artery stenosis medically, Aronow and colleagues wrote.
Knowledge base
The document lists the knowledge, technical skills and clinical competency required before physicians begin training for carotid artery stenting. These include knowledge of arterial diseases, vascular access site selection and techniques, radiation exposure and vascular imaging; proficiency in catheter-based skills for invasive diagnostic angiography; and “extensive prior experience” with coronary and/or peripheral endovascular intervention.
Cognitive requirements include normal cerebrovascular anatomy, physiology and hemodynamics; pathophysiology of cerebrovascular disease; clinical manifestation of stroke and cerebral ischemia; pharmacology of relevant anticoagulant drugs, antiplatelet drugs and contrast agents; and radiation safety.
The statement recommends that clinical requirements should include performance of a thorough neurological history and physical exam; ordering and interpreting cerebrovascular imaging studies; selecting appropriate cases; providing informed consent; educating cath lab trainees and nonphysician staff; recognizing and managing clinical and angiographic complications; and coordinating long-term follow-up.
Technical requirements recommended include documented proficiency in vascular access and noncarotid vascular angiography and intervention; experience performing and interpreting diagnostic cervicocerebral angiography; ability to select proper catheters for patients with challenging anatomies; having supervised experience as the primary operator in carotid stent procedures; experience in using proximal and distal embolic protection devices; and familiarity with using guide catheters and sheaths in carotid stenting.
Risk discussion
“An important clinical skill involves providing the patient with a balanced and easily understandable discussion of the risks, benefits and alternatives of medical therapy, [carotid endarterectomy] and [carotid artery stenting],” Aronow and colleagues wrote.
All institutions with a carotid artery stenting program must have a quality assurance program to measure outcomes, the authors wrote.
Because of the low number of carotid stenting procedures, it is difficult to quantify operator volume requirements, according to the authors. “In the current era of low [carotid artery stenting] volumes, 25 lifetime transradial/transfemoral [carotid artery stenting] procedures is a reasonable threshold for achieving, and 10 to 15 annual transradial/transfemoral [carotid artery stenting] procedures for maintaining competency, so long as outcome benchmarks (30-day stroke and death rate of 3% for asymptomatic and 6% for symptomatic patients) are met or exceeded,” they wrote. – by Erik Swain
Disclosure: Aronow reports no relevant financial disclosures. See the full statement for a list of relevant financial disclosures of the other authors and reviewers.