Invited commentary

Abstract

We know that high clinician volume of carotid artery stenting (CAS) is associated with low rates of complications of this procedure. Similarly, one would think that high clinician volume of other endovascular procedures might translate into low rates of complications of CAS. However, why should a low CAS complication rate be associated with high clinician volume of aortic endografting but not with high clinician volume of coronary stenting, as reported in this article? After all, don't both CAS and coronary stenting require high levels of expertise and skill? The authors surmise that in addition to the technical skills necessary to perform CAS, a “cognitive component” of the procedure is essential to achieving optimal outcomes. The authors quote the multispecialty consensus statement on training and credentialing for CAS qualifications: “physicians who wish to perform carotid stenting should be required to have the cognitive, technical, and clinical skills necessary to care for patients with carotid artery disease.” Cardiologists might interpret the authors' comments as suggesting that they have lower IQs than vascular surgeons. However, the authors are actually proposing that insufficient experience in managing cerebrovascular disease on the part of cardiologists could have implications for patient selection and intraoperative decision-making for CAS. On the one hand, instead of disparaging this article, cardiologists might consider these findings as being important for their training programs. If other studies support this one and show that high volume of interventional cardiology procedures does not translate into low complication rates of CAS, then cardiology program directors should consider increasing their trainee's exposure to management of cerebrovascular disease if they wish to produce CAS specialists. On the other hand, the authors of this article suggest that a high clinician volume of aortic endografting (which is primarily performed by vascular surgeons) may be a substitute for CAS stenting experience before achieving low complication rates of this procedure, whereas a high clinician volume of coronary stenting (primarily performed by cardiologists) is not an adequate substitute for CAS stenting experience. Cardiologists may interpret this point of view as being self-serving because numerous reports have shown that cardiologists can perform CAS with very low complication rates. In the future, if an article written by cardiologists shows that vascular surgeons who perform a high volume of endovascular procedures for lower-extremity occlusive disease have higher rates of CAS complications than those who perform low-volume endovascular procedures for lower-extremity occlusive disease, would vascular surgeons believe it? Low rates of complications for carotid artery stenting are associated with a high clinician volume of carotid artery stenting and aortic endografting but not with a high volume of percutaneous coronary interventionsJournal of Vascular SurgeryVol. 60Issue 1PreviewPrior studies have demonstrated improved clinical outcomes for surgeons with a high-volume experience with certain open vascular operations. A high-volume experience with carotid artery stenting (CAS) improves clinical outcomes. Moreover, it is not known whether experience with other endovascular procedures, including percutaneous coronary interventions (PCIs), is an adequate substitute for experience with CAS. The goal of this study was to quantify the effect of increasing clinician volume of CAS, endovascular aneurysm repair (EVAR), and thoracic endovascular aortic aneurysm repair (TEVAR), and PCI on the outcomes for CAS. Full-Text PDF Open Archive