Overview
Vascular diseases are encountered daily by cardiovascular physicians in practice. Atherosclerosis and thrombosis are systemic disorders that account for substantial cardiovascular morbidity and mortality. Cardiovascular physicians, by virtue of their broad knowledge base as internists, and advanced imaging expertise in echocardiography, ultrasound and angiography, are uniquely qualified to diagnose, treat, and follow patients longitudinally with these disorders. Moreover, the last decade has witnessed an explosion in technological advances in imaging techniques and catheter-based interventions.
It is precisely because of the scope and breadth of these advances, a three-year cardiology fellowship in no longer adequate training to become expert in all the subspecialties of cardiovascular medicine. Additional training years for the subspecialties of electrophysiology, interventional cardiology, imaging and heart failure/transplant have already been established. Heretofore, training in vascular and endovascular medicine during a cardiovascular fellowship has been inadequate to accommodate the clinical demands of the contemporary paradigm. Indeed, the American College of Cardiology Revised Recommendations for Training in Adult Cardiovascular Medicine Core Cardiology Training II (COCATS 2) document has mandated the requirement for an additional year of dedicated training for training for noncoronary catheter-based vascular interventions. (Available at http://www.acc.org/clinical/training/cocats2.pdf)
Surprisingly, there are literally only a handful of such dedicated training programs currently available. Thus, there is a dire need for these fellowships. This program will provide comprehensive training, not only in the latest advanced interventional techniques, but, as importantly, in the non-invasive vascular laboratory, vascular clinic, and vascular consult services. Our philosophy is to train true vascular specialists, not merely to train cardiologists in peripheral procedures. There will be two Vascular fellows/year, and the Interventional Cardiology fellows will also rotate through the labs and clinics.
Peter A. Soukas, MD, FACC, FSCAI, FSVM, FACP, RPVI
Director, Vascular & Endovascular Medicine Fellowship Program
Director, Peripheral Vascular Interventional Laboratory
The Miriam Hospital
Associate Professor of Medicine, Clinician Educator
The Warren Alpert Medical School of Brown University
Tel: (401) 793-4102
Fax: (401) 793-4049
psoukas@lifespan.org
Omar Hyder, MD
Director, Vascular Imaging
Lifespan Cardiovascular Institute
Director, Interventional Cardiology Fellowship Program
Assistant Professor of Medicine, Clinician Educator
The Warren Alpert Medical School of Brown University
Tel: (401) 793-4102
Fax: (401) 793-4049
ohyder@lifespan.org
Jinnette Dawn Abbott, MD, FACC, FSCAI
Associate Chief, Faculty Development and Academic Advancement
Director, Interventional Cardiology at the Lifespan Cardiovascular Institute
Director, Cardiac Catheterization Laboratories, Rhode Island, and The Miriam Hospitals
Professor of Medicine, TST
The Warren Alpert Medical School of Brown University
Tel: (401) 444-5328
Fax: (401) 444-4652
jabbott@lifespan.org
Prerequisites
The Brown Vascular & Endovascular Medicine Fellowship is a COCATS 2 designated Level 2 & 3 program. Eligible fellows will have already completed Level 1 basic training in vascular medicine during their general cardiology fellowship program. This includes the equivalent of 2 months of training in the evaluation and management of vascular diseases, exposure to non-invasive diagnostic modalities, exposure to angiography and peripheral catheter-based interventions. Preference will be given to candidates who have already successfully completed a general cardiology and interventional cardiology fellowship.
The fellow should have received training in the evaluation and management of arterial, venous and lymphatic disorders. As outlined in the multi-society task force on competence, (JACC 2004; 44; 941-957), the necessary cognitive skills require that the fellow be knowledgeable about the following:
- Vascular biology precepts that govern normal blood vessel function
- Pathologic mechanisms that lead to vascular disease, including the molecular and cellular processes that result in atherosclerosis and thrombosis
- Systemic manifestations of atherosclerosis and the risk factors that contribute to its development
- Guidelines established to modify risk factors
- Pathophysiology, clinical manifestations, natural history, evaluation, and management of peripheral arterial disease, renal artery stenosis, extracranial cerebrovascular disease, aortic and peripheral artery aneurysms, and other arterial diseases
- Pathophysiology, clinical manifestations, evaluation, and management of venous thromboembolism
- Prothrombotic disorders including inherited and acquired hypercoagulable states
- Pathophysiology, clinical manifestations, evaluation, and treatment of chronic venous insufficiency and lymphedema
- Preoperative evaluation and perioperative care of the vascular surgery patient
- Noninvasive vascular tests including duplex ultrasonography of peripheral arteries and veins, carotid arteries, renal arteries, and physiologic tests of the peripheral circulation
- Magnetic resonance and computed tomographic angiography
- Conventional contrast angiography
Program Description
Facilities
The Miriam and Rhode Island Hospitals each have 4 catheterization laboratories, with two of four capable of performing endovascular procedures. These labs are fully equipped with digital subtraction angiography and hemodynamic monitoring. At the Miriam Hospital, the 2 rooms are Philip Integra FD-20s, and at the Rhode Island Hospital there is one Philip Integra FD-20 and one new Toshiba lab.
The Non-Invasive Vascular Laboratories at both hospitals are ICAVL accredited, and the outpatient non-invasive vascular laboratory is also ICAVL accredited. The vascular technologists are RVT certified. The outpatient vascular clinics are located at the University faculty offices.
Patients
Fellows will be exposed to adult patients from both the Miriam and Rhode Island Hospitals. These are the principal academic teaching hospitals of the Warren Alpert School of Medicine of Brown University. Both facilities support multiple residency and fellowship programs, including accredited general cardiovascular, electrophysiology, and interventional cardiology fellowship programs. Fellows will also see patients in the outpatient vascular clinics of the faculty.
Duration of Training
The fellowship will be a dedicated one-year program. Upon completion of their year of training, fellows are eligible to sit for and take the Vascular Medicine and Endovascular Medicine Board Certifications Exams, as well as the Registered Physician Vascular Interpretation Exam.
Conference Schedule
- Multi-Disciplinary Vascular & Endovascular Medicine Conference – weekly
- Cath Conference – weekly
- Vascular Didactic Conference – weekly
- Journal Club – monthly
- Interventional Research Conference – monthly
- Non-Invasive Lab Conference – monthly
- Morbidity & Mortality Conference – monthly
Curriculum
General Vascular Medicine Topics
- PAD: Pathophysiology, Clinical Manifestations, Natural History, Evaluation and Management
- VTE: Pathophysiology, Clinical Manifestations, Natural History, Evaluation and Management
- CVI: Pathophysiology, Clinical Manifestations, Natural History, Evaluation and Management
- Hypercoagulable Disorders
- Vasculitis
- Vasospastic Disorders
- Unusual Vascular Conditions
- Lymphatic Disorders
- Thoracic Outlet Syndrome: Pathophysiology, Clinical Manifestations, Natural History, Evaluation and Management
Interventional Topics
- Carotid Artery Disease: Pathophysiology, Clinical Manifestations, Natural History, Evaluation and Management
- Subclavian/Vertebral Disease: Pathophysiology, Clinical Manifestations, Natural History, Evaluation and Management
- Renal Artery Disease: Pathophysiology, Clinical Manifestations, Natural History, Evaluation and Management
- Aorto-iliac Disease: Pathophysiology, Clinical Manifestations, Natural History, Evaluation and Management
- SFA Stenting Data
- Atherectomy Devices
- Interventional Treatment of VTE
- Vascular Access/Vascular Closure Devices
- CTO Devices
- IVC Filters
- EVAR/TEVAR
- Dialysis Graft Angiography/Intervention
- Arterial Thrombosis: Pharmaco-mechanical thrombolysis
- Varicose Vein Treatment: EVLT, RF Ablation, Phlebectomy, Sclerotherapy
Specific Interventional Vascular Procedures
Arterial
- Carotid Artery Stenting with Distal and Proximal Embolic Protection
- Vertebral Artery Stenting with Distal Embolic Protection Devices
- Subclavian Artery PTA/Stenting
- Renal Artery PTA/Stenting with EPDs using BMS/covered stents
- Aorto-iliac PTA/Stenting with BMS/covered stents
- PFA/SFA/Pop PTA/Stenting with nitinol/covered stents
- CFA orbital/plaque excision/laser atherectomy/ CB PTA
- Atherectomy Devices: Orbital/Laser/Plaque Excision/Pathway Devices
- CTO Devices: Frontrunner/Outback/Pioneer/Wildcat/Crosser Devices
- Femoral/Brachial/Radial/Popliteal/Pedal Access/Antegrade Access
- Vascular Closure Devices: Perclose, AngioSeal, Mynx, StarClose Devices
- Embolization: Amplatzer Plug/Coils/Particles
- EVAR/TEVAR Implants
- Pharmaco-Mechanical Thrombolysis: Trellis/EKOS/AngioJet Devices
- Catheter Directed Thrombolysis with tPA
- Thrombin Injection of Pseudoaneurysms
Venous
- Subclavian/Central Vein PTA/Stenting
- Iliac vein PTA/Stenting
- Popliteal/Brachial/Tibial Vein Access
- Varicose Vein Ablation with EVLT/RF
- Ambulatory Phlebectomy
- Sclerotherapy
- IVC Filter Implantation/Retrieval
- Pharmaco-Mechanical Thrombolysis: Trellis/EKOS/AngioJet Devices
- Hemodialysis Angiography/PTA/Stenting/Declots
Level 2 & 3 Training Requirements
Summary of Training Requirements
Fellows planning a career in vascular medicine require a distinct and comprehensive training program. In addition to fulfillment for board eligibility in cardiovascular medicine, the fellow will need to pursue an additional year of dedicated training in vascular medicine and endovascular medicine. This includes participation on the inpatient vascular medicine consult service, (aggregate 2-3 months); at least one-half to one full day a week of outpatient vascular medicine clinic; at least 3 months aggregate time in the non-invasive laboratory, preferably one-half day a week each in the hospital and outpatient non-invasive laboratories; one-half day research. The fellow would also spend 4-5 months aggregate time in the interventional laboratory. Elective rotations may be allocated to vascular surgery, MR/CT imaging, and hematology.
Non-Invasive Vascular Laboratory Requirements
Expertise in the non-invasive laboratory is a vital aspect of training for the vascular specialist. The fellow will receive instruction in the principles of ultrasound physics, Doppler characteristics, and be able to interpret both arterial and venous duplex ultrasound, as well as physiologic tests of the arteries and veins. The minimum required studies follow the guidelines recommended by the ICAVL, which include 100 venous, 100 carotid artery, 100 arterial duplex, and 100 physiologic arterial examinations. Visceral, (renal and mesenteric) artery and venous duplex ultrasonography will be included, as well as dialysis graft ultrasonography.
Interventional Vascular Laboratory Requirements
Physicians from various subspecialty backgrounds have the interest and expertise to perform invasive endovascular procedures, but there currently exist no common pathway certification process. Hospital credentialing committees have increasingly insisted on a year of formal training to bestow hospital privileges, relying on societal guidelines recommendations to help insure similar standards and to optimize quality outcomes. The most recent ACC/ACP/SCAI/SVMB/SVS Clinical Competence Statement (JACC 2004; 44; 941-957) also mandated a year of formal training upon the five-year anniversary of its publication, 08/18/2009. It is therefore essential that the cardiology community support programs such as the Brown fellowship program. The Graduate Medical Education office of the Warren Alpert School of Medicine of Brown University has approved the fellowship.
The fellow will acquire the following skills during the fellowship year:
- Mechanisms that regulate blood vessel function and hemostasis
- Pathophysiology, clinical manifestation, natural history, evaluation, and treatment of peripheral arterial disease, renal artery stenosis, mesenteric ischemia, extracranial cerebrovascular disease, aneurysmal disease, arterial dissection, and arterial and venous thromboembolism
- Noninvasive vascular tests such as segmental blood pressure measurements, arterial and venous duplex ultrasonography, and computed tomographic and magnetic resonance angiography
- Accuracy and limitations of diagnostic tests
- Radiation physics, safety, and radiographic imaging equipment
- Principles of image acquisition and display
- Advantages, disadvantages, and potential complications of iodinated and noniodinated contrast agents
- Advantages, disadvantages, potential outcomes, and complications of interventional procedures
- Indications, alternatives, and contraindications for catheter-based interventions The vascular interventionalist should have the following technical skills:
- Ability to safely gain vascular access from multiple sites (femoral, popliteal, and upper extremity arteries, as well as femoral, upper extremity, and neck veins)
- Ability to obtain hemostasis including application of compression and vascular closure devices
- Ability to manipulate guidewires and catheters
- Ability to place and deploy angioplasty equipment (e.g., balloons, atherectomy devices, stents, distal protection devices)
- Ability to recognize and treat procedure-related complications (e.g., dissection, pseudoaneurysms, embolism, vessel perforation or occlusion, stent thrombosis, adverse hemodynamic events)
- Ability to perform catheter-directed thrombolysis/thrombectomy
- Ability to perform vascular interventions in each of the following: aorta and lower extremity arteries, brachiocephalic and upper extremity arteries, mesenteric and renal arteries, central and peripheral veins, and pulmonary arteries
Minimum Requirements to Achieve Competence in Peripheral Catheter-Based Interventions
Training requirements for cardiovascular physicians
- Duration of training-12 months
- Diagnostic coronary angiograms-300 cases (200 as the primary operator)
- Diagnostic peripheral angiograms-100 cases (50 as primary operator)
- Peripheral interventional cases-50 cases (25 as primary operator) – No fewer than 20 diagnostic/10 interventional cases in each area, excluding extracranial cerebral arteries
- Aortic aneurysm endografts- 10 cases (5 as primary operator)
- Percutaneous thrombolysis/thrombectomy- 10 cases (5 as primary operator)
- Extracranial cerebral (carotid/vertebral) arteries-30 diagnostic – (15 as primary operator)/25 interventional (13 as primary operator)
This table is consistent with current Residency Review Committee requirements.
*After completing 24 months of core cardiovascular training and 8 months of cardiac catheterization.
*Coronary catheterization procedures should be completed prior to interventional training.
*The case mix should be evenly distributed among the different vascular beds. Supervised cases of thrombus management for limb ischemia and venous thrombosis, utilizing percutaneous thrombolysis or thrombectomy, should be included.
Vascular areas are: 1) aortoiliac and brachiocephalic arteries; 2) abdominal visceral and renal arteries; and 3) infrainguinal arteries
Application information
Please reference the attached application form and submit to our office.
If you have any questions please contact:
Elizabeth Spurlock
Program Coordinator
Division of Cardiology
The Miriam Hospital
164 Summit Avenue
Providence, RI 02906
Tel: 401-793-4102
Fax: 401-793-4049