Response to the ACC/ACP/SCAI/SVMB/SVS Clinical Competence Statement on Catheter-based Peripheral Vascular Interventions

Abstract

THE August 16, 2004, issue of the Journal of the American College of Cardiology contains an article titled “Clinical Competence Statement on Vascular Medicine and Catheter-Based Peripheral Vascular Interventions (1).” It is an official multisociety statement from the American College of Cardiology (ACC), the American College of Physicians, the Society of Cardiac Angiography and Interventions, the Society for Vascular Medicine and Biology, and the Society for Vascular Surgery. The statement had its origins in an ACC/American Heart Association (AHA)/American College of Physicians task force and originally included authors from interventional radiology as well. The Society of Interventional Radiology (SIR) had fundamental disagreements with significant portions of the document that prevented endorsement from the Society and resulted in the removal of the names of the interventional radiology authors from the document. When the statement was submitted to a vote by all of the AHA scientific council leaders after open discussion, a narrow majority voted several times to remove the AHA’s name and endorsement from the document. Instead, it was published through the ACC with endorsement from the other listed societies. The document contains two separate parts. The first part is a training curriculum for those who wish to be called vascular medicine specialists. This involves a description of the optimal training to produce a specialist competent to care for patients with any vascular problem of any complexity. The SIR does not disagree with the value of the suggested curriculum, although recognition of medical specialties and creation of training curricula come from the American Board of Medical Specialties and the Residency Review Committee rather than from statements from those within the field. The second part of the document is a revision of the original 1992 AHA minimum training necessary for competence to perform catheter-based peripheral vascular interventions (2). The original AHA training requirements (also adopted by the ACC [3]) were authored by members from interventional radiology, interventional cardiology, and vascular surgery. The requirements were 100 diagnostic peripheral arteriograms, 50 peripheral angioplasty procedures, and 10 cases of percutaneous catheter-directed thrombolysis, of which 50% must be performed as primary operator. The new requirements as stated in the current ACC document have two major changes. There are separate requirements for extracranial cerebral interventions (section 2d in the Table) and there are now categories of competence restricted to individual arterial vascular beds (aortoiliac/brachiocephalic, infrainguinal, and renal; section 3 in the Table). The SIR has fundamental disagreements with these revisions. For competence to perform extracranial cerebral interventions (predominantly carotid artery stent placement), the ACC statement has two training pathways. If the physician is fellowship-trained in peripheral vascular interventions, there are no specific requirements for performance of diagnostic cerebral arteriography or extracranial cerebral interventions. For established physicians without such previous fellowship training in peripheral vascular interventions, the statement requires the operator to have performed 30 diagnostic cerebral arteriography procedures and 25 extracranial cerebral interventions, with at least half of the procedures as primary operator. The diagnostic arteriography procedures and interventions are likely to be performed on the same patient in the same sitting. Therefore, the requirements are only 15 diagnostic arteriograms (as primary operator) and 13 interventions (as primary operator). These cases contribute to the overall requirement of 100 diagnostic peripheral arteriograms and 50 interventions in any vascular bed that the physician must still meet. The document acknowledges that the cerebral vasculature is a unique category beFrom the Department of Radiology, The Reading Hospital and Medical Center, Department of Radiology, Sixth and Spruce Streets, Reading, Pennsylvania 19603; Standards Division Councilor, Society of Interventional Radiology, Fairfax, Virginia. Address correspondence to D.S.; E-mail: davidsacks@pol.net