Peripheral Matters | Multidisciplinary Training of Tomorrow’s Vascular Interventionalists: An Opportunity and a Responsibility
The future of vascular medicine and vascular intervention, as well as the education of vascular trainees, will be multidisciplinary to an extent realized by few other fields. This achievement has begun but much work remains.
The success of multidisciplinary clinical care has been well demonstrated in multiple disparate clinical areas. Perhaps nowhere has this been more clearly demonstrated than in the novel treatment of structural heart disease through the remarkable collaboration achieved between cardiology, cardiothoracic surgery and other clinical teams.
Although the rapid development of structural intervention could have resulted in development of a rift between surgical and nonsurgical subspecialties, it rather resulted in unprecedented multidisciplinary systems aimed at the safe and effective development of a novel science with a profound dedication to improving clinical outcomes.1 Indeed class I indications now exist in the ACC/AHA guideline for a multidisciplinary "heart team" approach to complex coronary disease as well.2 Multidisciplinary success has bred broad adoption.
A generation of cardiovascular trainees have benefitted from these robust multidisciplinary systems as cardiac surgeons trained cardiovascular fellows and cardiologists trained cardiothoracic surgery fellows to an extent not previously seen.
Vascular Care Across Disciplines
Revascularization strategies aimed at the treatment of peripheral artery disease (PAD) were pioneered by vascular surgeons utilizing an open surgical approach. Decades of sophisticated arterial reconstructive techniques evolved combatting the most complex pathophysiologies with great success.
Over time minimally invasive endovascular therapies developed and progressed. The evolution of these therapies allowed for treatment of even higher risk patients often with even more complicated disease. By TASC guidelines, prior recommendations for tackling more complex disease primarily with surgical intervention evolved into a primarily "endovascular first" strategy for nearly all arterial lesion types.3 This progression led to increased performance of revascularization procedures by clinicians other than surgeons. A rapid and sustained rise has occurred over the decades of endovascular procedures for PAD performed by interventional cardiologists, interventional radiologists and other providers.4
Not surprisingly the prior experiences of clinicians in these fields tempered and touched their clinical practice as well as their procedural performance. Without a doubt, vascular surgeons trained in and responsible for open surgical revascularization procedures carry that distinct knowledge, awareness and thoughtfulness with them when they plan, perform and follow-up endovascular procedures.
Interventional cardiologists developed decades of techniques to tackle small vessel complex arterial disease often in critically ill patients. Within this realm, an entire subfield developed to tackle the treatment of chronically totally occluded (CTO) coronary arteries in which the risk of procedural perforation can carry the risk of immediate death. These CTO techniques were adopted into an already growing field of peripheral vascular intervention on the most complex (TASC D) lesions.
Interventional radiologists carried their expert understanding of noninvasive imaging strategies as well as diverse procedural techniques to further elevate both diagnostic and interventional therapies for PAD.
The fields cross-pollinated in every direction. Devices developed for use in the coronary arteries are frequently implemented in peripheral intervention. Covered stents developed for coronary perforation have rescued tibial artery complications from causing compartment syndrome and loss of limb. Intravascular lithotripsy initially developed within the treatment of PAD is rapidly advancing within coronary intervention.
Despite such procedural overlap, the vascular interventional community has been marked by unfortunate boundary disputes between subspecialties within many medical ecosystems. Vascular surgery trainees are rarely exposed to the procedural environments or the mentorship of their network's interventional cardiology teams. Interventional cardiology trainees in vascular therapies are rarely exposed to the expertise of their local vascular surgeons whose community developed the very field to which they are dedicating their careers. Within the same facilities where cardiology fellows sit side by side with cardiothoracic surgical fellows during weekly structural heart meetings, complex coronary meetings and cardiovascular case reviews, vascular surgery trainees and their interventional cardiology and interventional radiology peers rarely overlap.
We have an absolute obligation to our trainees as a multidisciplinary vascular community to recognize and correct this issue. The next generation of trainees cares less than ever about the dogma of departmental separation. And the next generation of vascular patients has so much to gain from the potentially unique skill sets and advanced knowledge that can be imparted to their future clinical leaders by present day multidisciplinary training environments.
A New Program in Austin
The University of Texas (UT) at Austin Dell School of Medicine opened in the summer of 2016 as the newest of 18 colleges on the UT Austin campus. Established surgical and internal medicine residency programs existed at the time of the school's initiation. The cardiology fellowship began accepting applicants in 2018. The interventional cardiology fellowship received its ACGME accreditation in 2020 and the dedicated vascular surgery training program is in active development.
Any new institution has multiple challenges to overcome. However, the education of our first classes of vascular interventional trainees has benefited greatly from the lack of isolating legacy systems present within the institution. This lack of historical limitation on multidisciplinary practice allows us to serve as a beta model for a totally encompassing multidisciplinary vascular educational practice. As we like to say here at UT Austin, "what starts here changes the world."
The collaboration between Dell Medical school and Ascension Texas Cardiovascular has led to immediate rapid progress in development of models for a multidisciplinary vascular system. Multidisciplinary vascular clinics were created in which vascular surgeons, interventional cardiologists and general cardiologists see patients side-by-side, allowing for immediate consultation, referral and multidisciplinary decision-making.
The educational opportunity for trainees in this environment is unsurpassed as they are given the opportunity to study pathology from multiple viewpoints concurrently. Cardiology fellows learn the treatment of vascular disease from vascular surgeons in their patients in real time. Vascular surgery trainees are immersed in the cardiac clinical care of their patients. The patient's cardiac and vascular care is delivered holistically and the trainee is beside the patient at the center of that practice.
The noninvasive vascular laboratory has also benefited dramatically from the expertise of all disciplines allowing for general cardiology patients without known prior vascular disease to be diagnosed effectively for vascular pathology within their general cardiologist's clinic. This environment simultaneously allows for vascular technicians practicing within the laboratory to develop expertise in the evaluation of stable disease, as well as the outcomes of both endovascular therapies and open surgical reconstructions. The technicians and the clinical fellows both benefit from exposure to the expertise in noninvasive study interpretation of physicians with diverse clinical backgrounds.
Practically, the noninvasive laboratory has grown exponentially, secondary to the pooling of resources with the preexisting cardiology imaging facilities. Scheduling resources, reporting software and even noninvasive equipment ranging from ultrasound machines to treadmills are shared between the cardiology and noninvasive vascular imaging laboratories.
Quality has followed scale, with Intersocietal Accreditation Commission (IAC) credentialing achieved within two years of the laboratory's founding. This has allowed for rapid development of a central noninvasive vascular laboratory along with outreach noninvasive vascular laboratories at a speed which may not have been achievable without collaboration with preexisting cardiology resources. For example, a site at which vascular outreach is just beginning may not for some time generate sufficient noninvasive vascular testing to support a full-time vascular laboratory. However preexisting cardiology imaging facilities allow for part-time vascular imaging to be performed within an outreach laboratory.
An Obligation to Our Trainees
Trainees benefit dramatically from such a multidisciplinary and far-reaching laboratory. Study volume increases. Pathology exposure is increased both in volume and in diversity. Cardiology and interventional cardiology fellows are given the opportunity to review vascular studies with the same software tools and clinicians with whom they review echocardiography. The study of noninvasive vascular imaging begins on day one of general cardiology fellowship. Two-thirds of our inaugural cardiology fellows will be pursuing Registered Physician in Vascular Interpretation (RPVI) accreditation during their general cardiology fellowship. Vascular surgery trainees benefit from the abundant volume of noninvasive vascular imaging performed across a large multidisciplinary practice too. Educational resources in ultrasound physics, techniques and principles are shared within the robust echocardiography and vascular imaging practices concurrently.
The exposure of trainees to clinical trials research practices that span a multidisciplinary environment also tremendously benefits education. The Ascension Texas Cardiovascular research program actively runs clinical trials including all fields of cardiology plus endovascular and surgical vascular practice. Even general cardiology fellows not (yet) dedicated to vascular therapies are introduced during monthly research meetings to the future of vascular therapies currently involved in clinical trial evaluation. These will be the therapies available to their future cardiology patients who will likely carry a high burden of vascular disease.
Vascular surgery and interventional cardiology fellows are given the opportunity to actively enroll patients into clinical trials utilizing the newest revascularization technologies in both surgical and endovascular therapy. All trainees are broadly exposed to the novel pharmaceutical and preventive strategies that can improve the risk of major adverse cardiovascular events and cardiovascular death in patients with vascular disease to an extent greater than any revascularization strategy.
Most obviously, trainees benefit from multidisciplinary exposure to procedural therapies. A trainee's future procedural toolkit and future adaptability to clinical and therapeutic situations can benefit greatly from exposure to diverse operators and diverse procedural environments. Similarly, exposure to mentorship and clinical practice from a variety of disciplines will create a next generation of vascular interventionalists with a broader understanding of the spectrum of potential care for vascular patients.
Across the country there is a broad variation in the level of exposure to vascular procedures that an interventional cardiology trainee achieves during fellowship. Without a doubt, interventional cardiology fellowships have a true and clear obligation to ensure that trainees emerge from fellowship with a meticulous understanding of where open surgical interventions (which a cardiology fellow cannot perform) dramatically benefit their future patients compared to endovascular options which they may have at their disposal. These trainees must also completely understand how their endovascular procedures may at best complicate and at worst eliminate a patient's opportunity to undergo a curative surgical repair. They also need to understand the role of open vascular surgery as a salvage strategy in face of complications arising from endovascular procedures. Who better to educate these fellows in these concepts than the vascular surgeons who perform these procedures?
Our Trainees, Our Future
In short, an interventional cardiology fellow should not do a common femoral artery intravascular lithotripsy or atherectomy procedure until they have personally witnessed the robust and durable clinical benefit of plaque removal with surgical endarterectomy. Those same fellows should also have their approach to tibial vessels tempered by the experience of scrubbing with a vascular surgeon to perform an emergent fasciotomy on a patient with limb threatening compartment syndrome induced by a tibial perforation.
The benefits of multidisciplinary education go both ways. Vascular surgery trainees should be given the opportunity to be exposed to the complex techniques for CTO and bifurcation lesions often implemented within coronary arteries in which failure and complication can result in death. This can dramatically enhance their future scope of endovascular technique and widen their practice. Similarly, a vascular surgery trainee should understand the common clinical complexity of cardiovascular patients. They should understand that claudication of a bedbound patient is a completely different clinical scenario than claudication that limits the cardiac rehabilitation of a patient who recently experienced a myocardial infarction. They should understand that to revascularize a patient whose cardiac rehabilitation is limited by claudication may truly be a life prolonging clinical intervention. Exposure to cardiology practices can also enhance a vascular surgery trainee's understanding of the robust cardiovascular medical therapies which indeed may extend the lives of their future patients more so than any revascularization procedure, be it surgical or endovascular.
Patients and trainees, however, are not the sole beneficiaries of this health care delivery and training model. The faculty of each participating department also benefits significantly from this environment. A nontangible but extremely important aspect of this model is the fact that by sharing the responsibility of educating both surgical and interventional cardiology trainees, the faculty of both departments create a strong bond that goes beyond their interactions related to the multidisciplinary patient care alone. We want our students to grow and to lead and to change the future of vascular intervention.
The care of vascular patients is multidisciplinary. If we deny our trainees exposure to multidisciplinary clinicians and mentors, we are without doubt doing them and their future patients a vast disservice. Initiating their careers with a dedication to multidisciplinary systems and with a freedom from the interdepartmental infighting that plagued prior generations will allow the next generation of vascular patients to benefit from therapeutic systems and initiatives that we likely cannot yet comprehend.
In our program at UT Austin, trainees are exposed from the time they interview to a faculty that approaches vascular disease as a true team. We look forward to the vascular therapeutic ecosystem that our next generation of vascular interventionalists build together. We are certainly not alone in this practice internationally, but we are absolutely honored to play a role in developing this tradition as the only viable mechanism for training tomorrow's future vascular interventionalists.
This article was authored by Peter P. Monteleone, MD, FACC, (@monteleonemd) and Pedro G. Teixeira, MD, (@pedrogrt) at Ascension Texas Cardiovascular and The University of Texas at Austin, Dell Medical School, and Priya Kothapalli, MD, (@prkothapalli) Fellow in Training, at The University of Texas at Austin, Dell Medical School.
- Writing Committee M, Otto CM, Nishimura RA, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021;77:e25-e197.
- Fihn SD, Blankenship JC, Alexander KP, et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol 2014;64:1929-49.
- Jaff MR, White CJ, Hiatt WR, et al. An update on methods for revascularization and expansion of the TASC lesion classification to include below-the-knee arteries: A supplement to the inter-society consensus for the management of peripheral arterial disease (TASC II): The TASC Steering Comittee. Ann Vasc Dis 2015;8:343-57.
- Wallace JR, Yuo T, Marone L, Chaer RA, Makaroun MS. Outcomes of endovascular lower extremity interventions depend more on indication than physician specialty. J Vasc Surg 2014;59:376-383 e373.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Interventions and Imaging, Interventions and Vascular Medicine, Echocardiography/Ultrasound
Keywords: ACC Publications, Cardiology Magazine, Accreditation, Anniversaries and Special Events, Atherectomy, Cardiac Rehabilitation, Cardiologists, Cardiology, Cardiovascular Diseases, Compartment Syndromes, Coronary Disease, Coronary Vessels, Credentialing, Critical Illness, Decision Making, Delivery of Health Care, Dissent and Disputes, Echocardiography, Ecosystem, Endarterectomy, Endovascular Procedures, Faculty, Family Characteristics, Fellowships and Scholarships, Femoral Artery, Follow-Up Studies, Freedom, Heart Diseases, Internal Medicine, Internship and Residency, Laboratories, Lithotripsy, Mentors, Myocardial Infarction, Peripheral Arterial Disease, Pharmaceutical Preparations, Physics, Radiologists, Radiology, Interventional, Referral and Consultation, Schools, Medical, Software, Specialties, Surgical, Stents, Surgeons, Texas, Tibial Arteries, Ultrasonography, Vascular Diseases, Vascular Surgical Procedures
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