Credentialing Criteria for Carotid Stenting: Vascular Surgery Perspective
Awarding of privileges for carotid artery stenting is ultimately a local process, designed to offer quality care to patients. The Society of Vascular Surgery (SVS) has stated, “because carotid stenting is a new procedure to the majority of vascular surgeons, interventional cardiologists, and interventional radiologists, training and credentialing present unique challenges. Each of the vested specialties has a different skill set and knowledge base.” The SVS has called on Societies representing the specialties to establish their own sets of responsible guidelines for credentialing requirements with the understanding that final decisions will be made locally.
Accordingly, the board and membership of the Alabama Vascular Society, which is the state organization in Vascular Surgery, reviewed the carotid artery stent procedure at its spring meeting in May 2004. This review included a comprehensive presentation and discussion of the elements of credentialing, the decision process, current publications, and model guidelines for its members to use in developing competence in this procedure. Also at this same meeting, two scientific presentations occurred on carotid stenting. Dr. William D. Jordan, Jr., vascular surgeon, presented long-term ultrasound results of carotid stenting. Dr. Robert Hobson, vascular surgeon and principal investigator of the CREST multicenter randomized trial of carotid stenting, presented information on technical considerations in performance of the procedure, including management of complicated and difficult cases.
The skills required for carotid artery stenting include expertise in diagnosis of carotid disease, treatment choices, indications for intervention, familiarity of the anatomy and behavior of the cerebral vessels, skills in catheter and stent procedures, and neurological and critical care monitoring during and after the procedure. Case numbers are less relevant than demonstrated competence. An arbitrary minimum of diagnostic cerebral angiograms should not be the prerequisite credentialing requirement for carotid stenting, because increasingly there remain relatively few indications for diagnostic angiograms performed as sole procedures, due to the availability now of improved ultrasound, magnetic resonance, and CT angiography. As stated by the SVS, “to create any threshold to training on this basis creates an unacceptable risk to the patients, as there is a definite incidence of stroke from the diagnostic procedure alone irrespective of an intervention. Further, such diagnostic procedures do not provide experience in the more complex techniques such as guide/sheath cannulation of the common carotid artery, use of embolic protection devices, and stent deployment.”
Based on our discussion and the extensive information reviewed, members of the Alabama Vascular Society can use the following guidelines to work toward acquiring competency in carotid artery stenting (CAS).
1. Surgeons who perform carotid endarterectomy (CEA) have extensive knowledge and experience with cerebrovascular anatomy, patient evaluation, indications for treatment, management of complications in the carotid artery, and critical care experience required for monitoring and managing these patient after the CAS procedure. Privileges to perform CEA, or past performance of 25 CEA operations would satisfy this guideline.
2. If these same specialists also have adequate experience or training in catheter and guidewire manipulation, stent deployment, and the additional details of guiding the catheter to the thoracic aortic arch branches, they have all the prerequisites for safe CAS deployment, with the exception of the additional procedural steps for each particular stent. Past experience in non-carotid stenting is a more useful determinant of the needed interventional skills than past performance of diagnostic carotid arteriography. 25 previous coronary, renal, or femoropopliteal stenting cases has been mentioned and could be used as a guideline for advanced catheter and stent skills. Selective cannulation of the thoracic arch branches, especially the innominate artery, is a required technical skill. A guideline for performing carotid stenting would be privileges and past experience in aortic arch branch cannulation. A specific number of these cannulations is not as important as is the ability to perform it correctly.
3. Knowledge and ability to perform the additional procedural steps unique to each particular stent and embolic protection device is another required skill. The FDA approves each carotid stenting device independently from the other competing devices. Accordingly, as with aortic stent grafts, the steps for each device are customarily taught in industry-developed courses for each device. It is expected that for each device, the FDA will require the manufacturer to train the physician, and this may include didactic lectures, observation of cases, and hands-on experience with actual patients or models/simulators. For a certified, practicing vascular surgeon (as opposed to a resident in training) who is experienced in carotid artery surgery, catheter manipulation, stent deployment, thoracic aortic arch branch cannulation, and critical care abilities, our guidelines do not include performing a specific number of carotid artery stent procedures on patients in a training institution, but rather successful completion of a carotid stenting course for each stent to be used.
The Alabama Vascular Society offers these guidelines to its vascular surgery members for achieving the ability to perform carotid artery stenting. The information has been reviewed by members, and approved by the Board of Directors. Other guidelines might be appropriate for practitioners in other specialties. The Society accepts no responsibility for the determination of local credentialing standards, which are solely the rules of hospitals and provider groups.