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Peripheral Vascular Disease Treatment

Cardiologist Q&A:

Who should perform peripheral vascular intervention: Cardiologist, Radiologist or Vascular Surgeon and why?


Dr Nicholas Chalmers
Consultant Vascular Radiologist
Department of Radiology
Central Manchester University Hospitals NHS Foundation Trust

It is much easier to address this question in the NHS environment than in countries where the operator’s livelihood is dependent on cornering as much of the market as possible.  In this country, we can put the interests of the patients and service first.

Individuals from any clinical background can learn the relevant manual skills and technical knowledge. Some individuals are naturally gifted, most are trainable and very few need to be tactfully pointed towards a different career path. However, this aptitude is independent of specialty.

Who can provide the best service to patients? It seems obvious to me that the specialist should have a major interest in peripheral vascular disease. This includes the conservative, non-interventional management of vascular disease, such as medical therapy, exercise programmes and ulcer care. The holistic care of the vascular patient requires more than treating the stenosis.

This logic leads to the conclusion that peripheral intervention should be provided by vascular surgeons and this is almost certainly the direction of travel in the UK. Radiologists have been involved in peripheral intervention since its inception and have provided a high quality service for years. However, the expansion and development of endovascular interventions have brought them from the margins to the mainstream. Thus it is important that the new generation of vascular surgeons ensure that they are properly trained in endovascular techniques and that consultant surgical posts have angio room sessions in the job plan. I anticipate that the future of radiological involvement in
peripheral intervention will mirror what happened in coronary intervention 20 years ago: the radiologists will progressively lose their role in this service provision.

This prognosis has a significant downside. Vascular radiologists currently provide a broad range of services to many hospital departments for bleeding, tumour embolisation, vascular access, caval filter placement and so on. These are valuable services, but it will not be possible to sustain a comprehensive vascular radiology service without the workload that comes from vascular surgery referrals. The danger is that, if vascular surgeons take on all the peripheral intervention, vascular interventional radiology will atrophy.

The optimal solution is therefore a harmonious collaboration between radiologists and surgeons, with each specialty providing an overlapping and complementary range of skills. This is the reality in many UK centres at present, but I fear it is not sustainable in the long term.

 

Dr David Smith
Consultant Cardiologist,
Morriston Hospital

All of the above, provided they are interested and are prepared to work collaboratively and share their relevant clinical skills and experience!

I think we need to learn from the lessons gained from transcatheter aortic valve implantation (TAVI), where we have found that the multi-disciplinary “TAVI team” has been instrumental in the successful introduction of TAVI into mainstream treatment of aortic valve disease. Equally we need to avoid the “turf war” scenario that we have previously seen with interventional and surgical treatment for coronary disease.

In my opinion, no individual clinician has the complete range of clinical skills and experience to provide a comprehensive peripheral vascular interventional programme. I would advocate the development of multi-disciplinary “endovascular teams” to provide the current and likely future range of minimally invasive/ endovascular treatments for cardiovascular disease. This would be in keeping with the “heart team” approach recently advocated by our European colleagues for the revascularisation of coronary artery disease. Such teams would need to take advantage of local skills, interests and resources with
clinicians working collaboratively.

 

A/Prof Michael Denton
Director of Vascular Surgery
St Vincents Hospital
University of Melbourne
Melbourne, Victoria
Australia

The sensible answer in the medical world of 2011 is a medical practitioner who has a suitable clinical background and knowledge level, but is also demonstrably competent in the interventional technical skill sets. Of course a cardiologist, vascular surgeon or interventional radiologist can acquire this technical expertise in a broad array of interventional procedures, the same way as a limited procedural skill set can be acquired by neurologist (carotid stenting) or nephrologist (fistuloplasty). If their skills are competent and their knowledge base is sound, or if they work in a team setting with suitably trained clinicians (as we have seen for years with many interventional radiologists and vascular surgeons) then they should be recognised as such and accredited by the appropriate institution.

We have resolved this issue in Australia and NZ by establishing a committee to recognise such peripheral endovascular training regardless of the specialty. This committee has been sanctioned by the three Colleges involved namely: RACS , RACP and RANZCR . It has drawn criteria for recognition of training in 3 areas:

  • General peripheral endovascular intervention
  • Carotid stenting
  • Fenestrated and branched endografting

Supervisor’s reports +/- references are also required to confirm competence.

This approach has been based on the model used by gastroenterology groups to deal with similar issues relating to diverse specialties performing endoscopy.

We have completed the grandfathering component successfully, and have already discovered the utility of this model in resolving difficulties with the hospital accreditation of specialists in ‘scope of practice’, and also in resolving turf wars, which were a perennial problem.

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