Starting an Endovascular Program at VA Madhan Sundaram

Starting an Endovascular Program at VA Madhan Sundaram, MD FACC Southern Arizona VA Health Care System University of Arizona College of Medicine

Madhan Shanmugasundaram, MD FACC I have no relevant financial relationships

Outline • • • Importance of Endovascular program at VA Challenges Credentialing Competence in endovascular interventions My experience

Epidemiology • PAD – 6. 5 million Americans aged over 40 years (ABI < 0. 9) • Age adjusted death rate – 16. 2 per 100, 000 • Endovascular interventions have increased steadily in US Circulation. 2017; 135: e 146–e 603 J Vasc Surg 2009; 50: 54 -60

I am a Cardiologist why should I care? ? J Vasc Surg 2009; 50: 54 -60

Challenges • • Credentialing Competing with IR/ vascular surgery Setting up vascular medicine clinic Availability of timely noninvasive testing • ABI • Duplex/ CTA/ MRA • Procedure room (cath lab/ IR/ Hybrid lab) • Equipment/ Supplies

Credentialing • Hard part – Depends on who wrote the credentialing requirements for the facility!! – For us it was under vascular surgery or radiology – 1 st step was to create privileges under medicine/ cardiology – Apply for those privileges

Competence in Endovascular Interventions • Duration of training ---- 12 months • Diagnostic peripheral angiograms --- 100 cases (50 as 1 st operator) • Peripheral interventional cases --- 50 cases (25 as 1 st operator)

Credentialed now What? • Need to understand who else was performing these procedures • Opportunities to collaborate? – IR – Vascular • First few cases need proctoring – Vascular surgeon/ IR/ outside proctor – 5 proctored cases

Set up Referral • Critical to establish a referral base – Vascular medicine consult – Clinic • Start from within the division – Get support of your colleagues and fellows – Talk to PCPs/ Podiatry and other ancillary services who can help refer patients

Referral • Grand rounds/ conference – Important to educate physicians – Can also review services offered – Review work up needed (ABI/ CTA/MRA)

Procedure Room/ Time • Important to understand where these procedures will be done – IR – Cath lab – Hybrid OR

Staff training and room set up • Important step – – – Can be time consuming Room set up (power injector) Familiarize staff to equipment Help them understand key aspects of procedure Often device reps can help with training

Supplies • Significant rate limiting step! – Expensive – As a solo operator need to figure out what and how much to order – May run into the 3000$ credit card limit issue – Can do prior auth consult and post implant consult (rep to bring trunk stock) – Best is to work on a consignment contract

System Support/ Issues • Non-invasive laboratory – ABI/ Exercise ABI – CTA w/runoff / MRA • Scheduling for procedure – Mostly same instructions as for a cath procedure • Admission after procedure/ Intervention • Follow up imaging and clinic visits

Selecting “Right” Patients • Lots of opportunities – – – Claudicants Critical limb ischemia Acute limb ischemia Stroke/ asymptomatic carotid stenosis interventions EVAR

My Experience • • Biggest delay was credentialing Proctored cases (5) with vascular surgeon Vascular clinic (half a day) Trained staff with patient and room set up Worked with colleagues to get referral Grand rounds on PAD treatment options Consignment contract for supplies

Actual Case • Usually have CTA/ MRA to help localize lesion and order equipment • Prior auth consult and have rep bring in equipment for case and post implant place prosthetic consult

“Slow but Steady” • Has been a slow, at times frustrating process • After a few trial runs and “working out kinks” • Fairly straightforward process from clinic to actual procedure • After procedure – 4 week follow up in interventional fellows clinic

Thanks!