Training of the Vascular Surgeon for Endovascular Procedures

GIORGIO M. BIASI, CLAUDIA PIAZZONI, GAETANO DELEO, ALBERTO FROIO, VALTER camesasca, angela LhOIA, grazia pozzi

In the last two decades the most crucial event in the evolution of vascular surgery has been the advent of endovascular techniques.

The introduction of endovascular therapies has had an extraordinary impact on vascular surgery, widening and transforming the horizons of vascular surgeons in many important ways.

The number of endovascular procedures has increased in the last few years and the need to gain endovascular skills has become necessary, as changing trends strongly indicate that endovascular procedures will replace traditional open operations in many vascular territories.

On the other hand, even though surgeons were the first to introduce catheter-derived procedures to the vascular field, other specialists with a historically greater experience of catheter manoeuvring and the ability to treat vascular diseases stepped into the scene of the treatment of peripheral vascular diseases. The question inevitably arose as to which specialist was most qualified to treat these cases through endoluminal access.

The question remains unresolved and in some cases turf battles are conducted to assert the supremacy of one specialist over the others and to identify who is responsible for the procedure.

In any case, the trend seems to be that endoluminal procedures will increasingly represent the treatment of choice for many vascular diseases and that these must be performed by appropriately trained vascular surgeons who have endoluminal devices as part of their armamentarium. It also seems that the numbers of vascular surgeons who are not inclined, or do not intend, to enter the endoluminal field will eventually diminish.

A primary mission of vascular surgery is to give the best possible care to the population, offering all types of treatment. To be successful with these radical modifications, vascular surgeons need to transform their traditional methods to face and treat vascular pathologies, adopting the knowledge and skill typical of other specialists (interventional radiologists, cardiologists, etc.) [2].

This dramatic change is only partly related to new techniques and procedural manoeuvres; it mostly concerns new indications [3].

This represents an inevitable evolution for vascular surgeons, consequently it has enormous implications for vascular fellowship organization.

There is currently a pressing need for full reform of traditional methods of training and certification. A dedicated training is therefore mandatory to prepare the specialist with competence to treat patients with a full range of vascular diseases: a new specialist with competence in vascular open surgery, catheter-manoeuvring ability and experience in imaging [6].

Some fellowship programmes in the USA are changing by replacing the year normally dedicated to research training with endovascular training. Other programmes have partnered with an interventional radiology fellowship to make their trainees more familiar with vascular imaging, catheters and guidewires. Others have been changed to incorporate an entire year of interventional radiology into vascular surgery training [7].

Newer methods are being explored, including computer simulation [8, 9].

The advantage of training by computer simulation is the ability to place a trainee in a graphic scenario and provide real-time feedback and discussion of actions and consequences without risk of harm.

It represents an emergent approach that has yet to be validated, but it could be considered an important and realistic tool for residency training.

These can be partial solutions to the problem of the educational training of the "new" vascular surgeon but many other steps have yet to be taken to create this new type of hybrid specialist [4, 10]. The association of vascular surgeons and interventional radiologists, working as partners in groups or institutes, is a sensible but less than perfect manner in which to address the question of retraining vascular surgeons. Probably the most important benefit derived from these partnerships will be to facilitate the education of a new generation of vascular surgeons for whom these techniques will be as familiar as the conventional open ones.

In Europe the organization and practice of vascular surgical services vary, and depend on local, regional and national traditions and needs, thus presenting a highly complex and often confusing, disorganized pattern. The training to become a vascular surgeon varies all over Europe, both in duration and content. The length of vascular training varies between 5 and 11 years, and the number of procedures undertaken by the trainees varies hugely among trainees and countries [1, 5, 11].

In several countries the training programmes are currently under revision, with formal incorporation of training in endovascular procedures as a hallmark.

However, this poses some difficulties that must be solved to train the specialist for the future:

• When should endovascular skill be acquired?

• Will other competences have to be sacrificed to give way to endovascular training or should endovascular training just be added to the present vascular training programme?

• Will endovascular training be performed only by vascular surgeon trainers or is it necessary for other specialists to be involved in the training process with the consequent need for some reciprocity?

• On the other hand, are radiologists and cardiologists presently being adequately trained to perform endovascular procedures and face their potential complications?

During the academic year 2001-2002 at the University of Milano-Bicocca, in Milan, Italy, Giorgio Biasi's team started a University-certified Master in Endovascular Techniques (MET), open to vascular surgeons, interven-tional cardiologists and radiologists who have received the specialization or relative certification of completion of the training programme (Fig. 1.10.1). The year-long MET course, now in its fourth year, starts on 1 November of each year and ends on 31 October of the following year, divided into two semesters. The training programmes are highly professional and different according to the background of the trainee: a vascular surgeon will spend 6 months in an interventional radiology department and 6 months in an interventional cardiology department. Reciprocal programmes have been devised for radiologists and cardiologists. The programme seems to have great success, with many applications from all over the world.

Fig. 1.10.1 Master in Endovascular Techniques

The intention is to provide the formation of a new figure: the "Endovascular Specialist". This is an extremely ambitious project considering that there is still no clear definition of an endovascular specialist, his/her limits and duties. Ideally, the training programme for the creation of such a specialist should start immediately after obtaining the medical degree. The programme should be divided into three different stages [3]:

Stage 1: Two years of this new vascular fellowship could be dedicated to vascular anatomy and physiology, angiology, diagnostic vascular lab and minor general, venous and arterial surgery procedures. The young vascular surgeons should also be trained in preventive medicine in order to treat lifestyles and risk factors. At this stage basic science training should also be considered that permits intelligent interpretation of emerging knowledge and technologies, such as genetic risk factors, gene therapy, drug-eluting stents, etc.

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