Training, competency, and credentialing standards for diagnostic cervicocerebral angiography, carotid stenting, and cerebrovascular intervention
A Joint Statement from the American Academy of Neurology, the American Association of Neurological Surgeons, the American Society of Interventional and Therapeutic Neuroradiology, the American Society of Neuroradiology, the Congress of Neurological Surgeons, the AANS/CNS Cerebrovascular Section, and the Society of Interventional Radiology*
John J. Connors, III, MD,
David Sacks, MD,
Anthony J. Furlan, MD,
Warren R. Selman, MD,
Eric J. Russell, MD,
Philip E. Stieg, PhD, MD and
Mark N. Hadley, MD for the NeuroVascular Coalition Writing Group
*These organizations represent all clinical medical specialties with formal accredited ACGME-approved training in the cervicocerebral vasculature and associated neurological pathophysiology. The executive committees and governing bodies of each organization have approved this document.
Address correspondence and reprint requests to Dr. John J. Connors III, Director of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Baptist Hospital Miami, 8900 N. Kendall Avenue, Miami, FL 33133; e-mail: budmancon{at}aol.com
Appropriate and adequate cognitive and technical training, proficiencyand experience are essential for the safe performance of proceduresthat confer significant risk to patient well-being. This principleis the foundation of all medical education and is especiallyimportant when considering the cerebral vasculature, for whichstroke is a defined risk for every endovascular procedure. Despiterecent advances in noninvasive diagnostic neuroimaging, diagnosticcervicocerebral angiography remains the cornerstone and "goldstandard" for the evaluation and treatment of patients withcerebrovascular disease.1 In addition to a high level of technicalexpertise, performance and interpretation of diagnostic cervicocerebralangiography requires in-depth cognitive knowledge of relatedneurological pathophysiology, neurovascular anatomy and pathology,and an understanding of the full range of neurodiagnostic possibilities.Expert diagnostic cervicocerebral angiography is the foundationfor safe and successful cervicocerebral endovascular intervention,including carotid artery angioplasty and stenting for atherosclerosis,interventional stroke therapy, intracranial angioplasty andstenting, and embolization of cerebral aneurysms, epistaxisand vascular malformations. All of these procedures are increasingin volume and complexity with recent technological advancesthat further mandate the need for adequate cognitive acumenand technical skills. To ensure proper outcomes, formal neurosciencetraining, adequate procedural training and sufficient experienceare all essential for competency in diagnostic cervicocerebralangiography and interventional procedures, including carotidstenting. These concepts have been delineated in training requirementsby the Accreditation Council for Graduate Medical Education(ACGME) and by previously published official society statements.The purpose of this document is to define the minimum trainingand experience necessary to provide adequate quality of patientcare for extracranial cerebrovascular interventions, particularlycarotid artery stenting. Hospital credentialing is the mechanismby which competence is ensured.
Risks of diagnostic cervicocerebral angiography.
Stroke is recognized as the most disabling and costly of allmedical conditions.2 Stroke is also the most feared of all iatrogenicmedical and procedural complications. The risk of procedure-inducedstroke may be a reason not to recommend the test for many physicians,and contributes to the reluctance of some patients to undergothe procedure.3–6 For medical and ethical reasons, anyprocedure that has "stroke" as a defined risk should be performedonly by medical professionals with appropriate training andexperience.
The risk of permanent neurological deficit as a result of diagnosticcerebral angiography is considerable and ranges from 0.3–5.7%.5,7–20Experienced neurovascular specialists may have complicationrates lower than 1%.20 There is additional risk of temporaryneurological deficit ranging from 0.3–6.8% with, on average,a 2–3 fold increased risk of temporary as compared topermanent neurological deficit.7–20 Patients with atheroscleroticcerebrovascular disease as manifested by neurological symptoms(ipsilateral transient ischemic attack [TIA] or stroke) havea 2–3 fold higher risk of stroke from diagnostic cerebralangiography (0.5–5.7% risk of permanent deficit) as comparedto asymptomatic lesions (0.1–1.2% risk).5–10,15–20In one study, 1000 consecutive patients undergoing diagnosticcerebral angiography were assessed for procedure-related neurologicaldeficits.5 The overall stroke rate was 1%. However, 9 of the10 patients experiencing neurological complications had a historyof prior stroke or transient ischemic attack and the tenth hadan "asymptomatic" bruit.5 Therefore the highest level of practitionertraining should be required for patients with prior symptoms,who are at highest risk for angiographic complications.
Operator experience as measured by decreased complications anddecreased fluoroscopy time necessary for the exam improves ina linear fashion up to 100 cases.10 Analysis of the traineelearning curve suggests that 200 exams are necessary for a physicianto become a competent and secure examiner of the carotid andintracranial vasculature.10 Operator risk factors for angiographicallyproduced ischemic complications (temporary and/or permanentstroke) are well known and include increased procedure and fluoroscopytime, increased number of catheters used, and performance ofarch aortography.6–8 Performance of arch aortography maylead to greater numbers of emboli thus leading to higher procedurecomplication rates than selective carotid angiography and isnot infrequently performed by less well-trained practitioners.8,21All of the above-mentioned factors, including procedural timeand multiple catheter use, are not independent and are typicallyrelated to inexperience and lack of specialized training inthe cervicocerebral circulation.8,12 The effect of trainingand experience, and/or lack thereof, was clearly shown in a5000-angiogram analysis that demonstrated that fellowship-trainedspecialists have fewer neurological complications (0.5%) thaneven experienced angiographers (0.6%), and both have far fewercomplications than trainees under supervision (2.8%).7,18,19In the Asymptomatic Carotid Atherosclerosis Study (ACAS), therate of stroke as a complication of diagnostic cerebral angiographywas approximately 1.2%.17 This may be greater than the actualrisk of stroke caused by the stenosis itself for many patientswith asymptomatic stenosis.17 Indeed, this fact has led somevascular surgeons to suggest that diagnostic cervicocerebralangiography even when performed by well-trained neurovascularspecialists may be too dangerous for the indication of asymptomaticcarotid artery stenosis.22 However, more recent data has confirmedthat the rate of stroke during routine diagnostic cerebral angiographywhen performed by appropriately trained and experienced neurovascularspecialists is less than half the rate reported in ACAS.20
Clinically obvious stroke may be the tip of the iceberg regardingcomplications of cervicocerebral angiography. "Silent" neuropathologicalsequelae of cerebral embolism are even more common than overt,clinically demonstrable neurological complications.20,21,23–25The fact that thromboembolic occurrences may be "silent", yetstill represent serious pathologic brain damage has recentlybeen described in two magnetic resonance imaging (MRI) studieswhere diffusion weighted pulse sequences ideal for detectingsmall infarcts were obtained after angiography.23,24 In onestudy, small new areas of brain infarction without overt clinicalcorrelates were identified in 25% of 66 patients after diagnosticcerebral angiography.23 Detection of apparent embolic insultsby MRI was more common in cases with longer fluoroscopic/proceduraltimes (p < 0.01) and was associated with the use of multiplecatheters (p = 0.02).23 Both of these parameters have been shownto be associated with sub-optimal training and experience.24"Subclinical" infarcts have been shown to result in cognitivedeficits on neuropsychological testing after endarterectomyas well as carotid artery stenting.25 Similar procedural injuryto the heart has been extensively documented secondary to coronaryinterventions by measurements of elevations in troponin levels(so-called troponin "leak") and constitutes justification forthe current stringent training standards for coronary intervention.26,27
In addition to the technical risks of cerebrovascular procedures,there is also a risk of misdiagnosis if images are not interpretedcorrectly. This fact justifies formal and adequate cognitivetraining related to neurological and neurovascular anatomy,neurodiagnostic imaging, and neuro-pathophysiology. Physiciansmust be able to accurately identify stroke and TIA etiologiesand evaluate traumatic and/or atherosclerotic neurovascularlesions and inflammatory conditions of the central nervous system.Evidence from numerous studies of coronary angiography performedby trained cardiologists demonstrates errors between observers’assessments ranging from 15% to 45% for evaluating essentiallyonly one variable, ischemic vascular disease.28 The ramificationsof inter-observer variation are considerable. If readings areerroneous, some patients will undergo interventional proceduresunnecessarily, others might be denied an essential treatment,while still other patients may have pathological findings thatare totally unrecognized.28 The implications of this degreeof variability for patients with cerebrovascular conditionsare significant when considering that physicians may be performingand interpreting cervicocerebral angiography outside of theirprimary specialty training and may then be performing interventionsthat have stroke as a defined potential risk. Even if a cervicocerebralarteriogram is performed solely for assessment of extracranialcarotid occlusive disease, unexpected findings (vasculitis;congenital vascular malformations; tumors; mass effects; emboliccomplications; acute, subacute, or chronic dissection as opposedto atherosclerotic disease; aneurysms; arteriovenous fistulae,etc.) require extensive neurodiagnostic and neuroangiographicknowledge and interpretive skills which can only be obtainedwith appropriate formal training.
Risks of cervicocerebral interventional procedures.
Endovascular interventions carry a higher risk than diagnosticangiography in all vascular beds. The American College of Cardiology(ACC) has recognized this by requiring physicians to completediagnostic coronary angiography training prior to beginninginterventional coronary training.29 The risk of elective carotidstenting is greater than the risk associated with elective coronaryintervention, which is typically less than 2% for emergencycoronary artery bypass surgery and less than 2% for death.30,31Randomized controlled trial data indicate stroke and death ratesfor carotid stenting ranging from 4.4% to over 12% at 30 days,with a one-year stroke and death rate of up to 12%.32–41MRI examinations demonstrate detectable ischemic lesions in22% to 29% of brains after carotid stenting.42,43 Additionally,a significant learning curve for carotid stenting has been clearlydocumented.44
Potential benefit from "embolism protection" devices might rendercarotid stenting safer than is currently documented, but proceduralstroke and death rates still range from at least 2.8% in oneregistry to over 6% at 30 days in other unpublished registriesfor both asymptomatic and symptomatic patients.34,36,37,40 Indeed,in two randomized controlled trials comparing stent procedureswith "protection" and with "no-protection", there was conflictingevidence concerning protection, with one trial indicating nodifference and the other actually demonstrating worse outcomes"with protection."45–47 Possible efficacy of "protection"devices has been demonstrated in at least one registry, in thecarotid stenting arm of an endarterectomy versus stenting trial,and in a review article.40,48,49 Therefore, for carotid stenting,the conflicting proof of efficacy for protection devices, provenfailure to eliminate all complications including stroke or death,and demonstrated patient risk greater than elective coronaryintervention, for example, reaffirms that carotid stenting beperformed only by individuals with sufficient cognitive neuroscienceknowledge coupled with sufficient training and experience andsubsequent excellent procedural technique, as described herein.
Cervicocerebral intervention not only includes carotid arteryand extracranial angioplasty and stenting but also intracranialangioplasty and stenting as well as other therapies. The risksof neurological complications from intracranial angioplastyand stenting and cerebral aneurysm coiling are substantial.The reported neurological complication rate for intracranialangioplasty and stenting ranges from 5% in 30 days to 36%.50–59A significant learning curve has been demonstrated for coilingof cerebral aneurysms and the reported neurological complicationrate ranges from 5% to 14%.60–64 Similar to the findingsin carotid stenting, diffusion-weighted MRI reveals a higherrate of distal embolization associated with this procedure (upto 61%) than overt symptoms; many of the emboli are "silent."21,23,24,65
Introduction.
Official standards of training for all specialties have existedfor over a quarter century, are the hallmark of medical licensure,board examinations and residency programs, individual physicianprivileges and hospital credentialing, and are recognized asvital by the Accreditation Council for Graduate Medical Education(ACGME), the Federation of State Medical Boards of the UnitedStates, Inc., the American Board of Medical Specialties (ABMS),and the National Board of Medical Examiners® (NBME®).66–68Furthermore, continuing assessment of competence is mandatedby the Centers for Medicaid and Medicare Services as well asstate medical licensing boards in the form of Continuing MedicalEducation (CME) credits.69–71 The Joint Commission onApproval for Healthcare Organizations (JCAHO) is working withtwo other accrediting organizations, the National Committeefor Quality Assurance and URAC (formerly known as the UtilizationReview Accreditation Commission), on coordinating and aligningpatient safety standards.72–74 JCAHO has established guidelinesfor primary stroke centers based on Brain Attack Coalition recommendationsthat include quality of service standards for diagnostic cervicocerebralangiography.75 The Brain Attack Coalition has also establishedguidelines for Comprehensive Stroke Centers that mandate cognitiveand technical neurovascular training and expertise in orderto perform carotid stenting (Alberts MJ, Latchaw RE, SelmanWR, et al. Recommendations for Comprehensive Stroke Centers:A Consensus Statement from the Brain Attack Coalition. Submittedfor publication.).
Training guidelines for diagnostic arteriography and endovascularintervention are necessary for optimal and safe patient careand have been formulated and officially stated by numerous medicalsocieties, including the American Heart Association (AHA), theACC, the Society for Vascular Surgery (SVS), the Society ofInterventional Radiology (SIR), the American Society of Neuroradiology(ASNR), and the American Society of Interventional and TherapeuticNeuroradiology (ASITN).76–98 These AHA, ACC, SVS, SIR,ASNR, and ASITN guidelines mandate at least 100 diagnostic angiogramsregardless of the vascular bed. The fact that there are varyingdegrees of difficulty for certain procedures and that theseprocedures thus impart associated degrees of risk to the patienthas also been specifically recognized and summarized by theACC.79 For example, in recognition of the critical nature ofcertain catheter based procedures, the ACC has published theRevised Recommendations for Training in Adult CardiovascularMedicine Core Cardiology Training II statement (COCATS 2).29In addition to the required minimum 24 clinical months of trainingby COCATS 2, diagnostic coronary catheterization mandates aminimum of 8 dedicated months in a cardiac catheterization laboratoryduring training in the pathophysiology and treatment of heartdisease with specific requirements for approved supervised trainingon at least 300 diagnostic coronary angiograms before a practitioneris judged competent for credentialing purposes.29 This sameconcept is at least as important when dealing with the cerebralvasculature and the performance of cervicocerebral angiography.
The ACC has determined that cognitive training about the pathophysiologyof the heart in addition to credentialing in diagnostic coronaryangiography is a prerequisite for training in coronary intervention.80,84,86,87Furthermore, in addition to the core 24 month training periodand 300 diagnostic coronary angiograms, the ACC recommends afull 20 months of supervised cardiac catheterization lab trainingwith at least 250 supervised coronary stent procedures as theminimum acceptable requirements before a practitioner is judgedcompetent to perform coronary interventions.88–92 TheABMS has not only affirmed that high degrees of training arenecessary for appropriate and safe cardiac patient care butacknowledged this high level of achievement in the form of aCertificate of Added Qualification (CAQ) for InterventionalCardiology.99 These same principles are necessarily as crucialfor the performance of interventional procedures relating tothe cervicocerebral vasculature, including carotid stenting.
Existing standards.Cognitive training in cerebrovascular disease.
The American Board of Radiology examinations for DiagnosticRadiology include written and oral subspecialty evaluation ofneurodiagnostic imaging, and neurological and neurovascularanatomy and pathophysiology.100 This cognitive knowledge baseincludes stroke syndromes and TIA etiologies, evaluation oftraumatic and/or atherosclerotic neurovascular lesions, andinflammatory conditions of the central nervous system.
The range and complexity of neuroradiology, neurodiagnosticimaging and cervicocerebral angiographic procedures is suchthat this has been recognized by the ABMS in the form of a CAQin Diagnostic Neuroradiology.101 This training mandates a minimumof an entire additional year of formal ACGME-approved trainingbeyond the radiology residency and this knowledge is formallytested with an oral examination.101 This depth of knowledgeand experience is unachievable in a casual or informal setting.
Due to the extensive body of knowledge in the medical disciplinerelated to cervicocerebral pathophysiology and its clinicalmanifestations, an entire year beyond residency in Neurologyis required to achieve competence in Vascular Neurology. Thecomplexity of this field of study of patients with cerebrovasculardisease is further affirmed by the creation of the new ACGME-approvedsubspecialty of Vascular Neurology.102 Only after completingone year of Vascular Neurology training with additional trainingin neuroradiology can the neurology applicant enter into trainingin Endovascular Surgical Neuroradiology (ESN).103 The body ofknowledge and skill obtained during the minimum of these twofull years of additional dedicated formal postgraduate trainingafter completion of a complete neurology residency are not achievablein a casual or informal setting.
Diagnostic cervicocerebral angiographic training.
The ACC and AHA recognize that adequate cognitive knowledgeof the heart is a mandatory foundation for performance of coronaryangiography and intervention and mandate 24 months as minimumcognitive training period.29 The clinical neuroscience societiesherein, in agreement with the principles espoused by the ACCand AHA, believe that adequate cognitive knowledge of the brainis a mandatory foundation for performance of diagnostic cervicocerebralangiography and intervention. The cervicocerebral vasculatureis technically demanding and clinically unforgiving and mandatescompetence in the performance of any procedures involving thisvasculature. In recognition of this fact, the American Academyof Neurology has published guidelines for cervicocerebral angiographythat recommend 100 appropriately supervised cervicocerebralangiograms as a minimum for required training and credentialingfor this invasive procedure.95,96 Training and quality improvementguidelines for adult diagnostic cervicocerebral angiographyhave been officially formulated and published by the AmericanCollege of Radiology, the ASITN, the ASNR and the SIR.77,82Radiology and its subspecialty neuroradiology were formerlythe only medical specialties that incorporated cervicocerebralangiography into ACGME-approved residency training programs.101,104Cervicocerebral angiography and intervention is now includedin the new ACGME-approved Endovascular Surgical Neuroradiologytraining program that includes physicians from neurosurgery,neurology, and neuroradiology.103
Interventional cervicocerebral training.
The ACC, the AHA, and the SIR have published guidelines requiring100 diagnostic angiograms for credentialing in peripheral vascularangioplasty.76,78–81 These AHA, ACC, and SIR standardsmandate competence regardless of subspecialty background and/orendovascular experience in any other vascular bed, includingthe heart.
In recognition of the complexity and critical nature of interventionalcervicocerebral procedures, the American Association of NeurologicalSurgery (AANS), the Congress of Neurological Surgeons (CNS),the AANS/CNS Cerebrovascular Section, the American Society ofInterventional and Therapeutic Neuroradiology, and the AmericanSociety of Neuroradiology published a unanimously endorsed statementspecifying training requirements for the safe endovascular treatmentof conditions that affect the brain, including the procedureof carotid stenting.97 These Program Requirements for Residency/FellowshipEducation in Neuroendovascular Surgery/Interventional Neuroradiology:A Special Report on Graduate Medical Education mandate 100 diagnosticcervicocerebral angiograms prior to training in this neurointerventionalspecialty, similar to the mandated requirements of COCATS 2.29This requirement is not altered by prior angiographic experiencein any other vascular territories.
The ACGME has given its highest form of recognition for theneed for advanced training for endovascular interventions involvingthe cervicocerebral and intracranial vasculature by officiallyrecognizing the new discipline of Endovascular Surgical Neuroradiology.103The complexity of this medical/surgical discipline requiresa minimum total of 7 to 8 years of dedicated formal postgraduatecognitive and procedural training with qualified supervision:far longer than most specialties. Appropriately prepared neurologists,neurosurgeons, and neuroradiologists are eligible to enter thisACGME training program. This ACGME-approved ESN training programexplicitly incorporates additional training in clinical neurointensivecare, as well as thorough training in advanced endovascularneuroradiological procedural techniques.103 The ACGME-definedprogram of ESN specifically elucidates training in the indications,contraindications and technical aspects of carotid stentingfor atherosclerosis.103
Knowledge necessary for cerebrovascular intervention.
Our collaborative neuroscience societies, in agreement withthe principles espoused in the ACC COCATS 2, recognize the necessityof three components of adequate training for competency to performcervicocerebral diagnostic and interventional procedures: 1)formal training which imparts an adequate depth of cognitiveknowledge of the brain and its associated pathophysiologicalvascular processes, including management of complications ofendovascular procedures, 2) adequate procedural skill achievedby repetitive supervised training in an approved clinical settingby a qualified instructor, and 3) diagnostic and therapeuticacumen, including the ability to recognize and manage proceduralcomplications, achieved by studying, performing and correctlyinterpreting a large number of diagnostic procedures with propertutelage. Just as with diagnostic coronary angiography and coronaryintervention, extensive knowledge of the brain and the abilityto correctly interpret a cervicocerebral angiogram is the prerequisiteand foundation for the technical performance of cervicocerebralangiography. The ability to adequately assess the array of diagnosticimaging studies of the brain with adequate knowledge of thenumerous pathophysiological possibilities is a necessary attributeof any practitioner who would perform cervicocerebral procedures,irrespective of the primary specialty of the practitioner.
Although interpretative skills of imaging are essential, clinicalcognitive skills related to the epidemiology, diagnosis, andmanagement of patients with cervicocerebral vascular disordersare the sine qua non of quality patient care, safety, and treatmentselection. All major industry and National Institutes of Health(NIH) sponsored trials related to carotid stenting and cervicocerebralinterventions, including asymptomatic, symptomatic and highsurgical-risk patients, have required an independent assessmentby a board-certified neurologist. This assessment includes documentedcompetency in performing a complete neurological evaluationincluding the NIH Stroke Scale. Consequently, we not only endorsethis principle in general practice, but also mandate adequatetraining for all neuroendovascular practitioners that encompassesknowledge of stroke syndromes and includes formal training andcompetency in the NIH Stroke Scale.
Competence in recognizing any procedural complication and beingable to offer the most appropriate treatment is one of the basicgoals of adequate formal training, particularly concerning cervicocerebralangiography and/or intervention. This would include the abilityto recognize clinical intra- or post-procedural neurologicalsymptoms as well as pertinent angiographic findings and theproper cognitive and technical skills to offer the most appropriatetherapy. While this therapy might entail intracranial endovascularrescue, it might also entail optimal hemodynamic managementnecessitating sufficient clinical neurointensive skills.
Our collaborative neuroscience societies recognize that practitionersfrom a variety of backgrounds may currently have or wish todevelop endovascular skills. Our consensus is that a minimumamount of formal cognitive training specifically related tostroke and cerebrovascular disease is essential for any physicianto perform diagnostic cervicocerebral angiography and interventionalprocedures. Therefore, in addition to procedural technical experiencerequirements, a minimum of 6 months of formal cognitive neurosciencetraining in an ACGME-approved training program in radiology,neuroradiology, neurosurgery, neurology, and/or vascular neurologyis required. This minimum formal training applies to all practitionerswho wish to be credentialed to perform diagnostic cervicocerebralangiography and/or cervical carotid interventions, includingpractitioners from specialties with or without dedicated trainingin clinical neuroscience as part of their ACGME-approved residencyprograms.
Augmentation of training.
Simulator training has been shown to be of benefit in limitedmedical applications.105–112 At the present time, appropriateformal training and experience in clinical cervicocerebral angiographyand intervention in an approved clinical training program hasno adequate substitute in contemporary medical practice, butfuture trainees may benefit from added training on medical simulators.At the present time, simulator equipment is neither perfectednor validated for training purposes concerning the cervicocerebralvasculature, but it is anticipated that eventually these technologiesmay offer up to, but not greater than, 20% of the required trainingexperience in procedural technique. Our collaborative societies,consistent with ACGME training standards and the ACC trainingstandards (COCATS 2), emphasize that industry-sponsored seminars,continuing medical education (CME) coursework, and self-taughtlearning are insufficient for credentialing related to diagnosticcervicocerebral angiography, extracranial interventions, intracranialinterventions, or carotid stenting.
Maintenance and assurance of continuing quality of care.
Procedures that have stroke as a defined potential risk requirethe highest level of competency. Proficiency is maintained bylifelong continuing medical education as well as continuingperformance of cases with adequate success and outcomes withminimal complications. Quality Assurance and continuing improvementare necessary for high quality healthcare regardless of whichdiscipline might be involved in treating patients. The qualityimprovement process is a patient oriented process, designedto ensure a baseline level of quality and predictable outcomes,and represents in many ways a safety net for the credentialingprocess. A post-hoc quality assurance process is no substitutefor adequate and appropriate physician training leading to acceptablyskilled practitioners suitable for credentialing. A qualityassurance process should confirm that procedures are performedfor appropriate indications with rates of success and complicationsthat meet acceptable standards. Such Quality Improvement standardshave been published for diagnostic cerebral angiography as wellas extracranial carotid stenting.77,82,95,113 Such standardsare necessary for quality assurance for procedures of such considerableconsequence. The outcomes required by these standards shouldbe achieved both during the training cases and following grantingof credentials in order to ensure maintenance of competence.At this time there is insufficient information to know if maintenanceof competency requires annual performance of specific numbersof cases, but data from other vascular interventional proceduressuch as coronary stenting, coronary artery bypass grafting,and carotid endarterectomy indicate that, in general, greaterexperience confers better outcomes.114–116
Consensus of the collaborating neuroscience societies
All collaborating neuroscience societies are of the unanimousopinion that the safety of the patient is paramount.
Definedformal training and experience in both the cognitiveand technicalaspects of the neurosciences are essential forthe performanceand interpretation of diagnostic and therapeuticcervical andcerebrovascular procedures. Therefore, in additionto proceduraltechnical experience requirements, a minimum of6 months offormal cognitive neuroscience training is requiredin an approvedprogram in radiology, neuroradiology, neurosurgery,neurology,and/or vascular neurology for any practitioner performingcervicalcarotid interventional therapy, including carotid stenting.This minimum neuroscience training recommendation applies toall practitioners, whether from specialties with or withoutdedicated training in the clinical neurosciences as part oftheir ACGME-approved residency programs.
All collaboratingneuroscience societies endorse the principlesof the severalpublished standards from our various societiesfor trainingand quality concerning cervicocerebral angiographyand intervention.77,82,95–97,113We affirm the necessityfor adequate and appropriate cognitiveknowledge as well asadequate specialized procedural trainingand experience as describedherein for credentialing in cervicocerebralangiography. Credentialingto perform (and in some cases interpret)cervicocerebral angiogramsfor one single purpose (e.g., evaluationof carotid occlusivedisease) theoretically approves performanceand interpretationfor all purposes or neurovascular conditionswithout distinction,some of which (e.g., cerebrovascular trauma,vasculitis, congenitalvascular malformations, tumors, masseffects, identificationof embolic complications, differentiationof acute/subacute/chronicdissection from atherosclerotic disease,diagnosis of arteritides,identification of intracerebral aneurysms,etc.) clearly demandinterpretive skills not conferred by casualtraining and experience.Therefore, limited credentialing forlimited procedures withlimited training is unacceptable.
Allcollaborating neuroscience societies recommend appropriatelysupervised cervicocerebral angiography training and resultantcredentialing with an accumulated total of 100 diagnostic cervicocerebralangiograms before post-graduate training in cervicocerebralinterventional procedures, including carotid stenting, as describedherein.29,97
All collaborating neuroscience societies endorsethe principlesof training and quality assurance espoused inthe multisocietyQuality Improvement Guidelines for the Performanceof CarotidAngioplasty and Stent Placement,113 which includea definedtraining pathway for any qualified practitioner forcarotidstent training.
All collaborating neuroscience societiesspecifically endorsethe principles of the ACGME and the trainingprograms in EndovascularSurgical Neuroradiology,103 VascularNeurology102 and Neuroradiology.101
All medical societies directly or indirectly involved with cervicocerebralangiography concur in the necessity of quality and safety ofpatient care. Credentials committees at each hospital and institutionmust promote adequate standards of training and experience forinitial accreditation in diagnostic cervicocerebral angiographythat are uniform across all specialties, guarantee patient safety,and assure continuous high quality of performance. Furthermore,credentials committees should certify and enforce prospectivequality improvement programs that are consistent with mandatedand accepted training standards as defined by the ACGME, theAmerican Medical Association, the ABMS, and individual statemedical licensing boards. Credentials committees are expectedto guarantee that individual physicians diagnosing and treatingcerebrovascular disease with endovascular procedures have sufficientformal neuroscience training and experience as well as adequatetraining in the performance and interpretation of diagnosticcervicocerebral angiography and the implications of the variedpotential findings so as to optimize the proper expected medicaloutcomes and assure patient safety. Due to the grave consequencesof inadequate or deficient training, stringent credentialingcriteria with formal neuroscience training as specified by publishedstandards and as elucidated herein should be mandated for thoseperforming carotid, vertebral, and intracranial cerebrovascularinterventions, just as is the case with coronary interventions.83–94,97,113
The following individuals served as authors/reviewers of theNeuroVascular Coalition Writing Group: John J. Connors, III,MD (ASITN), Miami Cardiac & Vascular Institute, BaptistHospital of Miami, Miami, FL; David Sacks, MD (SIR), The ReadingHospital and Medical Center, West Reading, PA; Anthony J. Furlan,MD (AAN), Cerebrovascular Center, The Cleveland Clinic Foundation;Warren R. Selman, MD (AANS), Department of Neurosurgery, CaseWestern Reserve University School of Medicine, Cleveland, OH;Eric J. Russell, MD (ASNR), Department of Radiology, NorthwesternUniversity, Chicago, IL; Philip E. Stieg, MD, PhD (AANS/CNSCerebrovascular Section), Department of Neurological Surgery,New York Presbyterian Hospital, New York, NY; Mark N. Hadley,MD (CNS), University of Alabama Division of Neurosurgery, Birmingham,AL; Joan C. Wojak, MD (ASITN), Neuroscience Center, Our Ladyof Lourdes Regional Medical Center, Lafayette, LA; Walter J.Koroshetz, MD (AAN), Neurosurgery, Massachusetts General Hospital,Boston, MA; Roberto C. Heros, MD (AANS), Department of NeurologicalSurgery, University of Miami School of Medicine, Miami, FL;Charles M. Strother, MD (ASNR), Neuroradiology, The MethodistHospital, Houston, TX; Gary R. Duckwiler, MD (ASITN), Departmentof Radiology, UCLA School of Medicine, Los Angeles, CA; JanetteD. Durham, MD, MBA (SIR), Department of Radiology, Universityof Colorado Health Sciences Center, Denver, CO; Thomas O. Tomsick,MD (ASNR), Radiology Department, University of Cincinnati, Cincinnati,OH; Robert H. Rosenwasser, MD, FACS (AANS/CNS CerebrovascularSection), Division of Cerebrovascular Surgery and InterventionalNeuroradiology, Department of Neurosurgery, Thomas JeffersonUniversity Hospital, Philadelphia, PA; Cameron G. McDougall,MD (ASITN), Barrow Neurological Institute, Phoenix, AZ; VictorM. Haughton, MD (ASNR), Department of Radiology, Universityof Wisconsin Hospital and Clinics, Madison, WI; Colin P. Derdeyn,MD (ASITN), Mallinckrodt Institute of Radiology and the Departmentsof Neurology and Neurological Surgery, Washington UniversitySchool of Medicine, St. Louis, MO; Lawrence R. Wechsler, MD(AAN), Stroke Institute, Presbyterian University Hospital, UPMCStroke Institute, Pittsburgh, PA; Patricia A. Hudgins, MD (ASNR),Neuroradiology, Emory University School of Medicine; Mark J.Alberts, MD (AAN), Department of Neurology, Northwestern UniversityMedical School, Chicago, IL; Rodney D. Raabe, MD (SIR), Departmentof Radiology, Sacred Heart Medical Center, Spokane, WA; CamilloR. Gomez, MD (AAN), Alabama Neurological Institute, Birmingham,AL; C. Michael Cawley, III, MD (CNS), The Emory Clinic/Neurosurgery,Atlanta, GA; Katharine L. Krol, MD (SIR), Vascular and InterventionalRadiology, Indianapolis, IN; Nancy Futrell, MD (AAN), IntermountainStroke Center, Salt Lake City, UT; Robert A. Hauser, MD, MBA(AAN), Neurology, The Harborside Medical Tower, Tampa, FL; andJeffrey I. Frank, MD, FAAN, FAHA (AAN), Department of Neurology,The University of Chicago, Chicago, IL.
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