Ask the Expert: A Responsible Approach to Carotid Artery Stent Training

A national and international thought leader in the field of vascular medicine, Dr. Jaff recently served as the Medical Director of the Vascular Ultrasound Core Laboratory at the Cardiovascular Research Foundation in Morristown, New Jersey. He has lectured extensively throughout the world, and has authored numerous publications in the field. Dr. Jaff currently serves on the Editorial Board for Catheterization and Cardiovascular Intervention, Journal of Endovascular Therapy, Journal of Invasive Cardiology, and Angiology. He is currently President of the Society for Vascular Medicine and Biology.

There is a certain level of urgency to getting physicians trained for CAS procedures. Could you speak to this?

Throughout the US today, there are only about 300 physicians trained to perform carotid artery stenting procedures. It’s been estimated that we’ll need 3,000 physicians to meet the growing demand for this procedure in the next three years. So you can see that there is a serious training need.

The title of this article is “A Responsible Approach to Carotid Artery Stent Training.”What does “a responsible approach” refer to?

The concept of responsible training refers to building up as complete a “fund of knowledge” in carotid artery stent (CAS) as possible by providing training not just in the procedure and the device, but also in anatomy, complications and patient selection. The concept also includes transferring this fund of knowledge to physicians via the most advanced techniques and technologies—including hands-on simulation training.

Why is a responsible training approach especially important in CAS?

In the next few years, CAS will have unprecedented visibility compared to other procedural innovations. To begin with, several specialties are competing with each other over who performs CAS. Also, patient demand is building for this less-invasive procedure as compared to the traditional, surgical alternative. With the resulting high visibility, we’re going to see intense scrutiny by the Centers for Medicare and Medicaid Services (CMS), private payers and the medical community as a whole. So, quality training in this procedure is vital to advancing its adoption and acceptance. Unfortunately, unqualified physicians can create problems by performing this procedure, especially early after the “release” of the procedure. In emphasizing responsible carotid training, we acknowledge that we can’t control every practitioner. However, we can provide cutting-edge training to a large number of qualified physicians and staff. We can ensure that physicians coming into simulation, didactic and case observation training programs have an active peripheral vascular disease (PVD) practice and are properly credentialed at their local hospitals in peripheral vascular procedures. We can also prepare those physicians who are not yet credentialed in PVD practice. For the past several years, for example, Boston Scientific’s training program has included robust offerings in PVD training, providing physicians a great pathway for gaining PVD experience.

You mentioned simulation training. What is the special value of simulation training for CAS?

Hands-on simulation is the most exciting component of CAS training. It’s risk-free, so there are no consequences for the patient or the physician if an error is made. The physician can develop skills, experience and confidence in a realistic, yet safe environment. Simulation training can replicate more variables and complications than a practitioner would normally encounter. This can shorten the learning cycle by months or even years. Physicians can consult with the trainer and revisit any phase of the training at any time, so their training is truly customized. Also, by its very nature, this format is highly accessible. The simulation modules that have been constructed and are provided by Medical Simulation Corporation, including those that were specifically constructed for CAS, are available at national and regional workshops, major medical conferences, or in on-site mobile training units at hospitals.

How does simulation training differ from traditional training?

The typical clinical training path for a physician has been to “observe,” “review,” and then “do,” beginning with easier clinical cases and progressing to more difficult ones. In this model, however, you can’t test your limitations and discover problems or complications without disastrous results. In a full simulated event, you’re not just deploying the catheter; you’re also monitoring the patient’s overall physiology and condition, including blood pressure, medications, cardiac rhythm and so on, any of which can trigger different variables. During a simulated carotid artery stenting procedure, for example, you can induce a stroke. Because strokes are very infrequent during CAS procedures, when they do occur, operators may not know what to do. So, why not introduce this situation in simulation? You can then deal safely with such questions as, “What kind of balloon,” “What kind of stent” or “Should we use a drug?” “How do I get a catheter to the intracranial vessels?” “How much lytic agent should be used?” Simulation gives the physician the best opportunity to interact with an unexpected event, and it’s one of the great advantages of the format.

What does Boston Scientific’s CAS simulation training program look like?

CAS is a new area of treatment management for most of the specialties that want to enter it. This is a key reason that Boston Scientific’s support of the training program offered by Medical Simulation Corporation is knowledge-based in both cognitive and technical areas. The training is delivered in a multi-faceted mix of online and virtual simulation training, case observation courses, one-on-one training and didactic sessions—all with metrics to measure performance. Once physicians complete the simulations, case observations and other aspects of their diagnostic and stenting training, they begin real-world implanting. The current recommendation from leading experts is for the physician to be proctored for 10-15 cases, and then monitored for up to 25 cases.

Can you elaborate on the cognitive and technical areas?

The cognitive curriculum includes physiology, anatomy, stroke management, cerebral anatomy, flow patterns, artery management, patient risk and other topics. With the exception of neurointerventionists and neurosurgeons, most interventionists and surgeons don’t study head and neck anatomy extensively. But this area of knowledge is crucial for CAS procedures since there are significant complications and a significant potential downside to treating this anatomy. Technically, physicians receive training in diagnostic procedures, therapeutic procedures and post-procedure patient management. Some of the technical skills required for CAS are fairly simple for interventional cardiologists to learn since they can adapt their experience with the rapid exchange .014 and .018 systems, the principal delivery systems that will be used in CAS.

Sponsored by Boston Scientific Corporation.