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- Grayson H. Wheatley III, MD* ()
I read with interest the viewpoint by Dr. Gray (1), which reviews the case for carotid stenting.As an emerging technology, carotid stenting can be an important therapeutic modality forhigh surgical risk patients, and has the potential for expanded applications in additionalpatient groups.
What is the cardiac surgeon's role in the development and dissemination ofcarotid stents? Should one specialty alone be a gatekeeper for the introduction andperformance of new endovascular procedures? Dr. Gray argues that cardiologists should beat the forefront of the wave to deploy endoluminal stents for carotid artery disease owing totheir familiarity with complex percutaneous interventional procedures, and their ability tomanage carotid-body–related medical issues. Cardiac and vascular surgeons are similarlycapable of performing the technically demanding skills involved in carotid stenting, and theyare also qualified to handle the postprocedure medical sequelae. Cardiac and vascularsurgeons, in contrast to cardiologists, are capable of managing life-threatening and device-relatedsurgical complications. However, catheter-based skills are absent from thecurriculum of most cardiac surgery training programs. Hence, a majority of graduatingand practicing cardiac surgeons lack the necessary skills to routinely incorporateendovascular procedures into their practice.
Cardiac surgeons, cardiologists, interventional radiologists, and vascular surgeonsshould unite to develop multispecialty endovascular training programs anddetermine national credentialing standards for carotid stenting. Moreover, cardiacsurgeons must take advantage of this opportunity to address the broader issue ofendovascular training within our specialty. Vascular surgery has already incorporatedendovascular experiences into their training regimens. As a result, many graduatingvascular surgery residents possess catheter-based skills and are engaged in the practiceof “endovascular surgery.” The American Board of Thoracic Surgery should consideradding an endovascular component to the graduating certification requirements. Cardiacsurgeons can currently obtain training in catheter-based procedures only through alimited number of nonaccredited fellowships. If cardiac surgeons are to be realisticallyinvolved in catheter-based procedures (and they should), it is time that cardiac surgerytraining programs either: 1) add individuals to their faculty with advanced endovascularskills; 2) encourage existing faculty to retrain in catheter-based procedures; or 3) allowtheir residents to spend quality time during their residency with clinicians who haveextensive endovascular experience.
Who performs carotid stenting is a highly charged issue, and perhaps it will be thesentinel event that can bring diverse specialties together to create a national standard fortraining and credentialing in endovascular procedures. I believe the optimal solution willbe a multidisciplinary based approach, so that qualified physicians from a number ofspecialties will be able to offer carotid stenting to their patients. Working through theseissues now will also potentially make the introduction and dissemination of newercatheter-based therapies, such as percutaneous valves and cellular therapies for heartfailure, more straightforward and less contentious.
- American College of Cardiology Foundation