LETTERS TO THE EDITOR
Cardiologist in the carotids
Grayson H. Wheatley, III, MD*
* Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern, 5939 Harry Hines Boulevard, HA-9, Suite 135, Dallas, TX 75390-8879
(Email: gwheat{at}parknet.pmh.org).
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 for
high surgical risk patients, and has the potential for expanded applications in additional
patient groups.
What is the cardiac surgeon's role in the development and dissemination of
carotid stents? Should one specialty alone be a gatekeeper for the introduction and
performance of new endovascular procedures? Dr. Gray argues that cardiologists should be
at the forefront of the wave to deploy endoluminal stents for carotid artery disease owing to
their familiarity with complex percutaneous interventional procedures, and their ability to
manage carotid-body–related medical issues. Cardiac and vascular surgeons are similarly
capable of performing the technically demanding skills involved in carotid stenting, and they
are also qualified to handle the postprocedure medical sequelae. Cardiac and vascular
surgeons, in contrast to cardiologists, are capable of managing life-threatening and device-related
surgical complications. However, catheter-based skills are absent from the
curriculum of most cardiac surgery training programs. Hence, a majority of graduating
and practicing cardiac surgeons lack the necessary skills to routinely incorporate
endovascular procedures into their practice.
Cardiac surgeons, cardiologists, interventional radiologists, and vascular surgeons
should unite to develop multispecialty endovascular training programs and
determine national credentialing standards for carotid stenting. Moreover, cardiac
surgeons must take advantage of this opportunity to address the broader issue of
endovascular training within our specialty. Vascular surgery has already incorporated
endovascular experiences into their training regimens. As a result, many graduating
vascular surgery residents possess catheter-based skills and are engaged in the practice
of "endovascular surgery." The American Board of Thoracic Surgery should consider
adding an endovascular component to the graduating certification requirements. Cardiac
surgeons can currently obtain training in catheter-based procedures only through a
limited number of nonaccredited fellowships. If cardiac surgeons are to be realistically
involved in catheter-based procedures (and they should), it is time that cardiac surgery
training programs either: 1) add individuals to their faculty with advanced endovascular
skills; 2) encourage existing faculty to retrain in catheter-based procedures; or 3) allow
their residents to spend quality time during their residency with clinicians who have
extensive endovascular experience.
Who performs carotid stenting is a highly charged issue, and perhaps it will be the
sentinel event that can bring diverse specialties together to create a national standard for
training and credentialing in endovascular procedures. I believe the optimal solution will
be a multidisciplinary based approach, so that qualified physicians from a number of
specialties will be able to offer carotid stenting to their patients. Working through these
issues now will also potentially make the introduction and dissemination of newer
catheter-based therapies, such as percutaneous valves and cellular therapies for heart
failure, more straightforward and less contentious.
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References
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1. Gray WA. A cardiologist in the carotids J Am Coll Cardiol 2004;43:1602-1605.[Abstract/Free Full Text]
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