Regarding “standards of practice: Carotid angioplasty and stenting”

Abstract

We appreciate Ouriel et al's commentary (J Vasc Surg 2004;39:916-7) highlighting the quality improvement guidelines for the performance of cervical carotid angioplasty and stent placement.1Barr J.D. Connors III, J.J. Sacks D. Wojak J.C. Becker G.J. Cardella J.F et al.Quality improvement guidelines for the performance of cervical carotid angioplasty and stent placement Developed by a collaborative panel of the American Society of Interventional and Therapeutic Neuroradiology, the American Society of Neuroradiology, and the Society of Interventional Radiology.J Vasc Interv Radiol. 2003; 14: 1079-1093Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar We wish to clarify that the radiology guidelinesprovide a training pathway for physicians with experience sufficient to meet the American Heart Association requirements for peripheral vascular interventions, this being prior experience of 100 diagnostic cervicocerebral angiograms with documented acceptable indications and outcomes.1Barr J.D. Connors III, J.J. Sacks D. Wojak J.C. Becker G.J. Cardella J.F et al.Quality improvement guidelines for the performance of cervical carotid angioplasty and stent placement Developed by a collaborative panel of the American Society of Interventional and Therapeutic Neuroradiology, the American Society of Neuroradiology, and the Society of Interventional Radiology.J Vasc Interv Radiol. 2003; 14: 1079-1093Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 2Levin D.C. Becker G.J. Dorros G. Goldstone J. King 3rd, S.B. Seeger J.M. et al.Training standards for physicians performing peripheral angioplasty and other percutaneous peripheral vascular interventions A statement for health professionals from the Special Group of Councils on Cardiovascular Radiology, Cardio-Thoracic and Vascular Surgery, and Clinical Cardiology, American Heart Association.Circulation. 1992; 86: 1348-1350Crossref PubMed Scopus (84) Google Scholar In agreement with previous recommendations by the American Heart Association, regardless of the number of angiograms in another vascular bed, each vascular bed is distinct and 100 angiograms are necessary.2Levin D.C. Becker G.J. Dorros G. Goldstone J. King 3rd, S.B. Seeger J.M. et al.Training standards for physicians performing peripheral angioplasty and other percutaneous peripheral vascular interventions A statement for health professionals from the Special Group of Councils on Cardiovascular Radiology, Cardio-Thoracic and Vascular Surgery, and Clinical Cardiology, American Heart Association.Circulation. 1992; 86: 1348-1350Crossref PubMed Scopus (84) Google Scholar We agree with the authors that carotid stenting is a dynamic area. As stated in our guidelines, the document was developed on the basis of evidence-based literature. As additional peer-reviewed studies are published, we look forward to working with all interested specialties to refine these guidelines in order to ensure excellence in patient care. We have long recognized the valuable impact that multidisciplinary documents have in the improvement of patient safety and patient care outcomes. We agree that clinical trial data are important for evaluating new technology. However, as noted in the commentary of Ouriel et al., some procedures prematurely become widely accepted before convincing evidence is available. In these circumstances, a consensus statement summarizing the available evidence-based recommendations for treatment is valuable. For example, experience has demonstrated that while benefit seemed “intuitively clear” for extracranial-intracranial bypass surgery for carotid and intracranial atherosclerosis, true clinical trial data led to the demise of this procedure.3The EC/IC Bypass Study Group: failure of extra-intracranial arterial bypass to reduce the risk of ischemic stroke: results of an international randomized trialN Engl J Med. 1985; 313: 1191-1200Crossref PubMed Scopus (1557) Google Scholar Additionally, for 4 decades warfarin was “thought to be” the “maximum medical therapy” for cerebrovascular disease, but it was then proven that aspirin was as good as or better than warfarin.4Mohr J.P. Thompson J.L.P. Lazar R.M. Levin B. Sacco R.L. Furie K.L et al.Warfarin–Aspirin Recurrent Stroke Study GroupA comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke.N Engl J Med. 2001; 345: 1444-1451Crossref PubMed Scopus (1018) Google Scholar, 5Chimowitz M, for the WASID investigators. Warfarin versus aspirin for symptomatic intracranial disease. San Diego: American Society of Anesthesiology; 2004.Google Scholar The Society of Interventional Radiology and the American Society of Interventional and Therapeutic Neuroradiology are committed to working with industry and government to ensure that appropriately selected patients have access to this beneficial new technology. In addition to guideline development, we will work with other specialties to ensure future coverage by Centers for Medicare and Medicaid Services.We look forward to working with all those involved in carotid stenting to further develop and evaluate this important new technology.