LETTERS TO THE EDITOR
Reply
William A. Gray, MD, FACC*
* Endovascular Care, Swedish Medical Center, Suite 1020, 1221 Madison, Seattle, WA 98104
(Email: william.gray{at}swedish.org).
Dr. Wheatley's letter appropriately raises several important issues related to carotid
stenting, and the potential operators and pathways to becoming expert in this emerging
field. However, my editorial (1) did not suggest cardiologists should be alone at the forefront of
the "new wave" of carotid stenting. New operators are not assigned; rather, they declare
themselves by virtue of interest, dedication, practice type, access to patients, training,
and, yes, skill sets. It is noteworthy, however, that the significant majority of carotid
stenting performed worldwide and in this country has been by cardiologists and that both
device development and the pivotal research owe much to that specialty (2). We would
not be having this and other debates about specialty involvement had cardiology folded
its tents under the barrage of criticism it received and had not proven the efficacy of
carotid stenting.
Inclusion of cardiac surgeons to the current potpourri of cardiologists, vascular
surgeons, radiologists, neurointerventionalists, neurosurgeons, and neurologists currently
claiming a role in carotid stenting is not a priori a nonstarter. However, cardiac
surgeons will be held to the same standards by most local hospital credentialing
committees. This generally means that they will need to have all the requisite catheter-based
skills (access, angioplasty, stenting, wire manipulation, etc.) that are generally
acquired by noncardiologists by the performance of peripheral intervention. Further,
they will need the rapid exchange and 0.014-inch wire experience necessary to move to
carotid equipment. Practically speaking, access to the carotid patients and the ability to
assess their clinical indications for carotid revascularization via interpretation of the
various imaging modes currently available, the performance and interpretation of cerebral
angiography, and judging the clinical appropriateness of any, and which, carotid
intervention (surgical or endovascular) involves new cognitive skills that are
achievable but require a dedicated effort. Finally, working on nonanesthetized patients
has 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 challenged
when it comes to making up the current deficits outlined above, Dr. Wheatley raises an
important point: acquiring these requisite skills will serve the surgeon well as other
technologies currently in development (percutaneous valve therapies, heart failure devices, and so
forth) emerge for patients they are currently operating on. These skills will better
position them to take part in, rather than to lose, the care of these patients. I would
suggest those skills could be achieved without performing carotid stenting, where the
consequences of complications may be irretrievable even by the surgeon and are
devastating for all involved.
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References
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- Gray WA. A cardiologist in the carotids J Am Coll Cardiol 2004;43:1602-1605.[Abstract/Free Full Text]
- Wholey MH, Al-Mubarek N, Wholey MH. Updated review of the global carotid artery stent registry Catheter Cardiovasc Interv 2003;60:259-266.[CrossRef][ISI][Medline]
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