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- William A. Gray, MD, FACC* ()
Dr. Wheatley's letter appropriately raises several important issues related to carotidstenting, and the potential operators and pathways to becoming expert in this emergingfield. However, my editorial (1) did not suggest cardiologists should be alone at the forefront ofthe “new wave” of carotid stenting. New operators are not assigned; rather, they declarethemselves by virtue of interest, dedication, practice type, access to patients, training,and, yes, skill sets. It is noteworthy, however, that the significant majority of carotidstenting performed worldwide and in this country has been by cardiologists and that bothdevice development and the pivotal research owe much to that specialty (2). We wouldnot be having this and other debates about specialty involvement had cardiology foldedits tents under the barrage of criticism it received and had not proven the efficacy ofcarotid stenting.
Inclusion of cardiac surgeons to the current potpourri of cardiologists, vascularsurgeons, radiologists, neurointerventionalists, neurosurgeons, and neurologists currentlyclaiming a role in carotid stenting is not a priori a nonstarter. However, cardiacsurgeons will be held to the same standards by most local hospital credentialingcommittees. This generally means that they will need to have all the requisite catheter-basedskills (access, angioplasty, stenting, wire manipulation, etc.) that are generallyacquired by noncardiologists by the performance of peripheral intervention. Further,they will need the rapid exchange and 0.014-inch wire experience necessary to move tocarotid equipment. Practically speaking, access to the carotid patients and the ability toassess their clinical indications for carotid revascularization via interpretation of thevarious imaging modes currently available, the performance and interpretation of cerebralangiography, and judging the clinical appropriateness of any, and which, carotidintervention (surgical or endovascular) involves new cognitive skills that areachievable but require a dedicated effort. Finally, working on nonanesthetized patientshas been a test for several specialties entering this field who are generally accustomed to it.
Although it appears that cardiac surgery may, in fact, be one of the specialties most challengedwhen it comes to making up the current deficits outlined above, Dr. Wheatley raises animportant point: acquiring these requisite skills will serve the surgeon well as othertechnologies currently in development (percutaneous valve therapies, heart failure devices, and soforth) emerge for patients they are currently operating on. These skills will betterposition them to take part in, rather than to lose, the care of these patients. I wouldsuggest those skills could be achieved without performing carotid stenting, where theconsequences of complications may be irretrievable even by the surgeon and aredevastating for all involved.
- American College of Cardiology Foundation