Endovascular Specialist Competencies for Chronic Limb-Threatening Ischemia: What's in Your Toolbox?

SCAI/ACR/APMA/SCVS/SIR/SVM/SVS/VESS Position Statement on Competencies for Endovascular Specialists Providing CLTI CareJournal of the Society Cardiovascular Angiography & InterventionsVol. 1Issue 3100015PreviewChronic limb-threatening ischemia (CLTI) is advanced stage peripheral artery disease (PAD) characterized by rest pain or tissue loss. Up to 2 million individuals have this condition in United States, and prevalence anticipated grow owing aging population increase atherosclerotic risk factors such as diabetes renal disease.1 In addition threat limb dysfunction amputation, patients with are at a high cardio- cerebrovascular morbidity mortality, that exceeds most other cardiovascular patients. Full-Text PDF Open Access 2004, Interventions (SCAI), American College Cardiology, Physicians, Vascular Medicine Biology (SVMB, now “SVM”), Surgery (SVS) co-published first Clinical Competence Catheter-based Peripheral Interventions.1Creager M.A. Goldstone J. Hirshfeld Jr., J.W. et al.ACC/ACP/SCAI/SVMB/SVS clinical competence statement vascular medicine catheter-based interventions: report Cardiology/American Heart Association/American Physician task force (ACC/ACP/SCAI/SVMB/SVS Writing Committee develop disease).J Am Coll Cardiol. 2004; 44: 941-957Crossref PubMed Scopus (87) Google Scholar This consensus document outlined minimum education, training, experience, cognitive skills required competently evaluate treat arterial, venous, lymphatic disease. Procedural requirements were also proposed performance endovascular interventions. At time publication, intervention chronic was much less commonplace, specific competency operators performing these procedures not proposed. One year ago, under an Cardiology–led effort included SVM, Association, collaboration SCAI, SVS, Association Black Cardiologists, Nursing, updated publication Advanced Training Medicine.2Creager Hamburg N.M. Calligaro K.D. al.2021 ACC/AHA/SVM/ACP training (revision 2004 ACC/ACP/SCAI/SVMB/SVS interventions).Vasc Med. 2021; 26: 91-112Crossref (1) it, achieving (ie, Core Level III) medicine, beyond those expected during basic fellowship, outlined; importantly, apply noncardiologists who wish pursue medicine. issue JSCAI, Hawkins al3Hawkins B.M. Li Wilkins L.R. al.SCAI/ACR/APMA/SCVS/SIR/SVM/SVS/VESS position competencies specialists providing care.J Soc Cardiovasc Interv. 2022; 1100015Abstract Full Text publish provide care. The statement, led SCAI—the professional home interventional cardiology—and endorsed Radiology, Podiatric Medical Interventional Surgery, Surgical Society, addresses important gaps filled Medicine. writing group societies nominated its members be congratulated their outstanding work. Like organized around 6 Accreditation Council Graduate Education general domains. Its tables nicely summarize document's content, outlining differentiating between fundamental skills, respectively. provides much-needed road map specialist, acknowledging unique multidisciplinary multispecialty aspects care addressing entire spectrum, from diagnosis medical therapy revascularization. Although comprehensive scope, there additional might warrant inclusion future updates, many which appeared referenced previously. Noteworthy examples include understanding biology atherosclerosis thrombosis; familiarizing oneself indications, contraindications, benefits, risks, pharmacology medications used disease; using strategies reduce disparities health; barriers adherence, including social determinants maintaining continuity care; accessing novel therapies available through trials; coordinating multisystem discussing sensitive topics end-of-life emotional support families. Future updates reconsider skillsets versus fundamental. Unlike technical require exposure complex anatomic scenarios, nonprocedural should Prescription optimal major adverse coronary events after interventions, example, part management all CLTI. Initiation evidence-based salutary effects loss life, low-dose rivaroxaban plus aspirin PCSK9 inhibitors, “complex” incorporated into plan qualify. it laudable considers team-based when evaluating treating CLTI,4Kolte D. Parikh S.A. Piazza G. al.Vascular teams disease.J 2019; 73: 2477-2486Crossref (14) missing recommendation provider interactions bidirectional design respectful contributions made each team member. To end, seems irrelevant (if counterproductive) note surgeons only can both open surgical Operators even within any single specialty possess varied skillsets. fact perform bypass does excuse mandate collaborate, learn from, rely colleagues disciplines. intervention, developed radiology cardiology worlds subsequently adopted surgeons, dominant approach More, less, cross-specialty fertilization knowledge what enables progress better outcomes. Indeed, no possesses capacity manage Collaboration across lines—and same specialized knowledge—is essential consideration includes skilled surgeon individual familiar options independent specialist advance judgment lesion subsets. situations where surgery given patient, recognizing may equipoise,5Menard M.T. Farber A. Assmann S.F. al.Design rationale best critical (BEST-CLI) trial.J Assoc. 2016; 5: e003219Crossref (135) angiograms reviewed multiple specialties, possible, conference6Shishehbor M.H. Hammad T.A. Rhone T.J. al.Impact interdisciplinary system-wide salvage advisory council lower extremity amputation.Circ 15: e011306Crossref (0) so avail patient full range options. politically challenging institutions, step toward establishment formal team, akin heart making treatment decisions structural Another consideration, sometimes overlooked due political issues, turf battles, economic motivations, importance having highly operator revascularization procedure. With surgery, success often dependent capabilities surgeon; thus, appropriate direct competent distal procedures. Similarly, directed capable obligation particularly compelling CLTI, procedural paramount successful treatment. guidance documents could underscore requirements: demonstrated expertise access site management, degree skill experience guidewire selection manipulation, proper use devices (eg, wire, balloon, stent, atherectomy, crossing, re-entry), facility complications. Achieving outcome ultimate goal. Protection turf, ego, pride must get way Treatment evolving rapidly. As such, statements regarding outcomes therapy—specifically outdated Bypass Versus Angioplasty Severe Ischaemia Leg (BASIL) trial (in comparator plain-old balloon angioplasty)—must taken grain salt.7Adam D.J. Beard J.D. Cleveland T. al.Bypass angioplasty severe ischaemia leg (BASIL): multicentre, randomised controlled trial.Lancet. 2005; 366: 1925-1934Abstract (1550) relative “suitability” over multilevel supported level I evidence comparative effectiveness studies date. forthcoming Best Therapy Patients Critical Limb Ischemia trial5Menard address some current techniques accountability important. We would advocate favor registry participation institutions trend process metrics time, benchmark against others, local quality improvement initiatives. Now norm case well. Multiple exist, SVS Quality Initiative, Radiology VIRTEX, Outpatient registries. Competency inform hospital privileging efforts centers States. For still volume thresholds document. That territories, well subsets carotid/vertebral, aortoiliac/brachiocephalic, abdominal visceral/renal, infrainguinal arteries. present offered procedures, below knee, ostensibly lack recommendations; however, base supporting territories more robust. next do suggest minimal thresholds, if arbitrary, facilitate consistency operators; modified emergence new data raising lowering bar. Finally, effectively operationalize multisocietal requires development standardized curricula, measurable competencies, tools enable assessment. Board Examination, Inteleos, one excellent tool cardiologists ascertainment, we encourage sit examination. Evaluation applications smartphone) integrate seamlessly provided bedside areas.8Belvroy V.M. Murali B. Sheahan M.G. O'Malley M.K. Bismuth fundamentals model motion reliably differentiate competency.J Vasc Surg. 2020; 72: 2161-2165Abstract (3) ensuring delivery right performed fashion will our toolboxes. Care standardizing rapidly space. H.D.A. consultant Philips Silk Road Medical; co-chair SCAI Disease Council, president Medicine, member Patient Safety Organization. K.R. consultant/scientific board Althea Medical, Angiodynamics, Boston Scientific, Contego, InspireMD, Magneto, Mayo Clinic, Neptune Philips, Summa Therapeutics, Surmodics, Thrombolex, Terumo, Truvic; reports institutional grants National Institutes Health Scientific ; equity Accolade, Vascular, Aerami, Cruzar Systems, Embolitech, Endospan, JanaCare, Orchestra, PQ Bypass, Prosomnus, Shockwave, Truvic, Valcare; PERT Consortium, not-for-profit 501(c) organization dedicated advancing improving pulmonary embolism.