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The Value of Peripheral Vascular Fellowship Programs
Dr. Soukas is a recognized expert on the interventional treatment of critical limb ischemia with controlled micro-dissection and needle lumen re-entry devices, novel design peripheral stents, as well as orbital, laser and directional atherectomy devices. Dr. Soukas’ many clinical research interests include the interventional treatment of peripheral vascular disease. In his role as Director of the Vascular & Endovascular Medicine Fellowship Program, he is training the next generation of critical limb ischemia (CLI) specialists.
J.A. Mustapha, MD: What is your general feeling on self-training for peripheral vascular (PV) procedures? Should it continue to be the trend or should we start to direct those that want to be endovascular specialists toward a proper endovascular PV training?
Peter A. Soukas, MD: Years ago, endovascular treatment for PV consisted primarily of angioplasty and stents, so didactic weekend courses and proctored cases was felt to be adequate training. The scope and breadth of endovascular therapies for the treatment of PV disease has exploded over the past decade and mandates, I believe, a dedicated year of specialized training to have adequate case volumes and range of experience to deal with complications. A specialized year will allow development of the requisite cognitive skills, non-invasive laboratory expertise, clinic, case volume and variety to safely and competently perform PV interventions.
In 2004, the ACC/ACP/SCAI/SVMB/SVS clinical competence statement on vascular medicine and catheter-based peripheral vascular interventions task force on clinical competence outlined both formal training and alternative routes to achieving competency in PV catheter-based interventions.1 Recall, however, that the task force specifically noted that the alternative routes were only to be available for up to 5 years following the publication of the document. The COCATS 4 Task Force 9 specifically notes that Level III training to perform PV interventions is not obtained during cardiovascular fellowship.2 PV interventions are considerably more varied and complex than coronary intervention, and thus meet the threshold for a full year of training to achieve competence, as is the current requirement for interventional cardiology certification.
Dr. Mustapha: What year did you begin your PV fellowship program and what prompted you to start the fellowship?
Dr. Soukas: I was recruited from St. Elizabeth’s Medical Center in Boston, where I directed the PV fellowship program, to establish a dedicated vascular & endovascular medicine fellowship at Brown in 2010. I was excited to come home to Providence and have the opportunity to join the outstanding faculty at Brown.
Dr. Mustapha: Dr. Soukas, you’re one of the few program directors for PV fellowship training.
Please give us a brief summary on what you put your fellows through during their year of training at your institution.
Dr. Soukas: The fellowship is rigorous. We start the week with our multidisciplinary vascular conference, where the fellows present interesting and challenging cases. The fellows perform cases all day on Mondays, Tuesdays and Thursdays, and attend clinic on Wednesday and Fridays. In addition, the fellows are intimately involved in our multiple clinical research trials, and run our in-patient and consult services.
Our fellows become expert in carotid, brachiocephalic, renal, mesenteric, and lower extremity interventions using all the latest technologies. They perform endovascular aneurysm repair (EVAR), endovenous ablations, both arterial and venous pharmacomechanical catheter-directed thrombolysis, and inferior vena cava (IVC) filter implantation/removal, with a focus on advanced therapies for critical limb ischemia (CLI). All procedures are performed with ultrasound guidance.
Dr. Mustapha: How many PV fellows have trained in your program? Are you able to share any success stories of those fellows that have trained with you — where are they today?
Dr. Soukas: I trained 25 fellows during my tenure in Boston and 6 in Providence. I am very proud of all my fellows and many have gone on to become lab directors and academic thought leaders in our field. Dr. Christopher Owens is the Chief of Vascular Surgery at the San Francisco VAMC and the national PI of the DANCE trial, while his co-fellow, Dr. Kapil Lotun, is the Director of Vascular Medicine and Structural Heart Program at the University of Arizona Medical Center in Tucson. Dr. Mallik Thatipelli is the founder and chief scientific officer of Angiosafe, Inc. Drs. Anish Thomas, Gabriel Delgado, and Satish Madiraju have all presented at national meetings and started their own successful PV programs.
Dr. Mustapha: What type of confidence and quick thinking do your fellows show throughout their year of training? Is there a major difference between Day 1 and Day 300 of training?
Dr. Soukas: Our fellows come to the program having completed an interventional cardiology fellowship program, so they start the fellowship with a solid foundation of technical skills. As my own mentor Dr. Ken Rosenfield once said, PTCA ≠ PTA [percutaneous transluminal coronary angioplasty ≠ percutaneous transluminal angioplasty], so they have a steep learning curve to acquire the cognitive learning and skill set necessary to become competent peripheral interventionists. It is gratifying to see their remarkable progress throughout the year of training, gaining confidence and knowledge with every case.
Dr. Mustapha: There are so many different devices available for endovascular revascularization. What is your opinion on the ability of the fellows to get a good handle on all (or the majority) of these devices by the time they finish training in a one-year program?
Dr. Soukas: Luckily, we have a high-volume program with >500 PV interventional cases annually, encompassing a broad array of pathologic conditions. Our fellows become facile with all the available atherectomy, stent, and balloon devices, pharmacomechanical thrombolysis technologies, various endovascular aneurysm repair (EVAR) devices, and multiple carotid artery stents and embolic protection devices. In addition, they are trained in deep vein thrombosis/pulmonary embolism (DVT/PE) interventions, IVC filters, advanced CLI access, endovenous ablations, intravascular and endovascular ultrasound, etc.
Dr. Mustapha: At the end of a year of PV training, do you think a fellow is a competent endovascular specialist for any form of endovascular work, or do they leave your institution with a defined endovascular conduit skillset?
Dr. Soukas: Our fellows do have the broad skill set to perform virtually any form of endovascular work given our broad-based, high-volume practice. That said, there are programs around the country that are more limited in their scope of practice, and thus fellows from these programs would be well advised to seek additional proctoring to obtain the necessary volumes and training to perform those cases safely.
Dr. Mustapha: If you can go back in time, would you mandate that we all, including yourself, get an additional year of PV fellowship training prior to practicing endovascular revascularization? Or would you say that it is okay to continue to self-train, as is the case today? Please help us understand where to go from here.
Dr. Soukas: I certainly do support the concept of a mandatory year of PV fellowship training, given the complexity and breadth of cases a PV operator is called upon to perform. It is thus vitally important that we dramatically increase the number of dedicated PV fellowship programs across the country, in order for the interventional cardiology/vascular management community to not only remain competitive, but to also provide the highest quality care to our patients. Core competency and curricular milestones, as outlined in the COCATS 4 Task Force 10 training3, serve as a template for the standardization of such training. The training must also include dedicated time in the clinic and non-invasive lab as well.
References
- Creager MA, Goldstone J, Hirshfeld JW Jr, Kazmers A, Kent KC, Lorell BH, et al; American College of Cardiology; American Heart Association; American College of Physician Task Force on Clinical Competence. ACC/ACP/SCAI/SVMB/SVS clinical competence statement on vascular medicine and catheter-based peripheral vascular interventions: a report of the American College of Cardiology/American Heart Association/American College of Physician Task Force on Clinical Competence (ACC/ACP/SCAI/SVMB/SVS Writing Committee to develop a clinical competence statement on peripheral vascular disease). J Am Coll Cardiol. 2004 Aug 18;44(4):941-957.
- Creager MA, Gornik HL, Gray BH, et al. COCATS 4 Task Force 9: training in vascular medicine. J Am Coll Cardiol. 2015; 65(17): 1832-1843. doi:10.1016/j.jacc.2015.03.025.
- King SB, III, Babb JD, Bates ER, et al. COCATS 4 Task Force 10: training in cardiac catheterization. J Am Coll Cardiol. 2015; 65(17): 1844-1853. doi:10.1016/j.jacc.2015.03.026.
Dr. J.A. Mustapha can be contacted at jihad.mustapha@metrogr.org.
