Last fall, the U.S. Food and Drug Administration (FDA) announced approval of carotid stenting -- a technique for treating potentially life-threatening blockages in the arteries of the neck that lead to the brain. Just as stents (tiny mesh tubes) are often used following coronary angioplasty to keep arteries open, they can also be used to prop open carotid arteries in the neck. This procedure is rapidly being incorporated into interventional cardiology, vascular surgery, interventional radiology and vascular medicine practices. But how can physicians in each of these specialties best learn to successfully perform this potentially risky procedure?
A committee of nationally recognized cardiovascular leaders, including Emory Heart Center cardiologist Christopher Cates, MD, has published a clinical competence statement simultaneously in the current issues of multiple respected medical journals, including the Journal of the American College of Cardiology (JACC), that specifically answers that question.
The consensus statement, prepared by the Society for Cardiovascular Angiography and Interventions, the Society for Vascular Medicine and Biology, and the Society for Vascular Surgery, sets a consistent standard for physician training and credentialing. It calls for physicians to be fully credentialed to perform peripheral interventions and to be actively performing endovascular procedures before undertaking focused carotid stent training. The statement also makes clear that carotid stenting placement should be limited to institutions that can offer independent neurological assessment and can ensure that optimal outcomes are being achieved and reported so that patient safety is protected.
"In addition, the consensus statement says virtual reality (VR) training should be incorporated into carotid stenting training. This is based on mounting evidence that VR training is a better, faster and safer way for physicians to learn endovascular procedures than the traditional training route," says Dr. Cates, Director of Vascular Intervention at Emory University Hospital and Emory Crawford Long Hospital.
He points out that, unlike surgery, carotid stenting makes the physician's job more difficult because tissues are not seen and felt directly.
"Learning the hand-eye coordination of instruments, catheters and guide wires is very complex," Dr. Cates says. "The clinical competence statement recognizes that VR can play an important role in helping physicians develop the required new skills for carotid stent placement. Doctors are able to learn how to perform carotid stenting on a VR simulator, working in life-like settings, until they are proficient."
Using simulators that look like human mannequins, physicians thread a catheter through an artificial circulatory system and view angiograms of the "patient", instead of practicing on patients. Emory has already trained over 130 physicians in carotid angiography using this VR technique.
Carotid artery disease -- a buildup of atherosclerotic plaque (fatty material) in major vessels of the neck that supply blood to the brain -- is an important risk factor for stroke. Stroke is the nation's third leading cause of death and a major cause of serious, long-term disability. According to the American Stroke Association, every 45 seconds, someone in America has a stroke. In all, about 700,000 Americans suffer from stroke each year.