Competencies for Endovascular Specialists Providing CLTI Care

Publication Date: April 25, 2022
Last Updated: May 10, 2022

Individual competencies

Table 1. Competencies for endovascular specialists

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  • Medical knowledge
    • Know peripheral arterial anatomy
    • Know the causes, epidemiology, and natural history of CLTI
    • Know the indications for noninvasive testing for patients with suspected or established CLTI
    • Know the indications for medical therapy and risk factor modification for CLTI
    • Know the indications and contraindications for peripheral angiography
    • Know the indications and contraindications for endovascular and surgical revascularization in CLTI
    • Know the risks and benefits of CLTI revascularization strategies, both endovascular and surgical, and how to tailor each based on patient preference, comorbidities, and anatomy
    • Know the endovascular technologies and techniques available to treat CLTI
    • Know the complications of CLTI revascularization procedures
    • Know the differentiating characteristics between arterial, venous, neurotrophic and atypical lower extremity ulcers
    • Know the basic management of non-CLTI wounds including ancillary testing and referral when appropriate
    • Know the aspects of podiatric care relevant to patients with CLTI
    • Know the principles of radiation safety
  • Patient care and procedural skills
    • Perform a focused history and physical examination in patients with CLTI
    • Interpret noninvasive vascular imaging, physiologic and perfusion testing in patients with CLTI, before and after revascularization procedures
    • Prescribe medical therapy before and after revascularization to mitigate cardiovascular risk and optimize limb outcomes
    • Select revascularization strategies that are patient-centric and guideline-based, utilizing other specialists where appropriate
    • Perform preoperative risk assessment for patients prior to vascular surgery
    • Evaluate and manage lower extremity wounds, including referring for ancillary testing and specialty care when appropriate
    • Evaluate and manage uncommon vascular disorders and those that may mimic CLTI
    • Perform endovascular revascularization in the aorto-iliac, femoropopliteal, and tibial territories
    • Select and perform alternate access
    • Manage complications related to CLTI procedures
    • Utilize limb surveillance testing after revascularization
  • Systems-based practice
    • Utilize an interdisciplinary and coordinated approach for CLTI patient management
    • Utilize cost-awareness and risk-benefit analysis in patient care
  • Practice-based learning and improvement
    • Identify and act on performance gaps identified through review of scientific studies, registries, and guidelines
    • Participate in quality improvement initiatives
    • Participate in scientific endeavors aimed at improving CLTI care
  • Interpersonal and communication skills
    • Communicate with and educate patients and families across a broad range of socioeconomic, ethnic, and cultural backgrounds
    • Communicate and work effectively with various professionals on the CLTI team
  • Professionalism
    • Practice within the scope of expertise and technical skills
    • Know and promote adherence to guidelines and appropriate use criteria.
    • Interact respectfully and with integrity with patients, families, and all members of the CLTI team

Volume and experience in endovascular training

The writing committee believes that technical proficiency for endovascular operators is improved by procedural volumes and experience. However, given limited data quality, heterogenous effect sizes, and differential and evolving findings, the writing committee also believes there is an absence of evidence to clearly define a procedural volume threshold whereby competence in endovascular interventions for CLTI is manifest. As such, the group has elected not to recommend a requisite minimal procedural volume at this time.

Published training statements from a variety of specialty societies have suggested that physicians perform a minimum of 100 diagnostic peripheral angiograms in order to display competence. There is less consistency in recommended interventional procedure volumes, but most societies recommend a minimum of 50 to 80 peripheral interventions, the majority of which should be arterial in nature. None of the recommendations address endovascular interventions for CLTI specifically, nor do they attempt to account for the varying degrees of complexity inherent to lower extremity arterial interventions based on lesion phenotype (e.g., stenosis versus calcified chronic total occlusion), segment (e.g., aorto-iliac versus tibial), and patient characteristics.

Better evidence to help formulate training guidelines and allow a systematic approach to endovascular competency will be a key multispecialty priority in coming years. For example, training programs could have their trainees log CLTI procedures, stratified by segment and complexity, and submit these data to a central repository to accurately quantify the number and types of procedures that endovascular trainees are performing in CLTI patients during their training programs. Similar processes, though not specific to CLTI, already exist for some procedural specialties. One could envision such an endeavor being a collaborative effort amongst medical organizations who support the educational endeavors of endovascular specialists.

National CLTI registries may also prove beneficial. While existing registries such as the Society of Vascular Surgery Vascular Quality Initiative (SVS VQI) collect procedural and outcome data on many CLTI patients, the ability to account for trainee involvement in procedures is currently limited. Modifications to data collection instruments that incorporate trainee participation could afford opportunities to generate volume thresholds for endovascular CLTI specialists.



Competencies for Endovascular Specialists Providing CLTI Care

Authoring Organizations