New Certification Guidelines for Neuroendovascular Surgery

Deborah Brauser

July 30, 2017

Rigorous and standardized training programs are needed for neuroendovascular surgery (NES), including a focus on radiation biology and safety, notes a new consensus statement.

The report, jointly created by several organizations under the auspices of the Committee for Advanced Subspecialty Training (CAST) from the Society of Neurological Surgeons (SNS), highlights new NES training requirements for institutional accreditation and individual subspecialty certification for both trainees and current practitioners.

"We were able to get consensus across the three domains of people who are doing NES – neuroradiologists, neurologists, and neurosurgeons," coinvestigator Steven Giannotta, MD, Department of Neurosurgery, Keck School of Medicine at the University of Southern California, Los Angeles, told Medscape Medical News.

Dr Steven Giannotta

"At one time there were no standards for training, or there were differences in standards from the different disciplines. But we now have a consensus on how to train and certify expert practitioners," said Dr Giannotta.

The new guidelines "speak to a unified paradigm for training and set up basic parameters for the type of preneurointerventional fellowship education that would be appropriate to bring people up to speed and to take care of patients with neurological disorders," he added.

The report outlining the new NES processes was published online July 13 in Stroke.

Training Reappraisal

Catheter-based technology and radiologic imaging are both used during NES to diagnose and treat central nervous system conditions, as well as disorders of the head, neck, and spine.

"To perform these procedures, the practitioner needs an extensive knowledge of the anatomy of the nervous system, vasculature, and pathological conditions that affect their physiology," write the authors, noting also the importance of receiving substantial clinical and interventional experience.

"The growing adoption into clinical practice of NES represents an important paradigm shift and has prompted a major reappraisal of training methods."

Dr Giannotta noted that the new training guidelines "are much more of a consensus" than those published a few years ago because they are backed by a newly created organizational structure.

The new document was prepared by the Joint Section of Cerebrovascular Surgery for the American Association of Neurological Surgeons and Congress of Neurological Surgeons; the Society of NeuroInterventional Surgery; and the Society of Vascular and Interventional Neurology.

Together, the groups placed the new accreditation and certification processes under the SNS' CAST training program. A new Neuroendovascular Surgery Advisory Committee will be available to provide advice and assistance during development and implementation of new programs.

This latter group "comprises 3 persons from each of the neuroscience specialties of neurosurgery, neurology, and neuroradiology, working in concert with the CAST Chairman and Secretary."

Institutional Accreditation

A detailed list of new NES training requirements can be found online. Highlights include that an advanced training program should be at least closely affiliated with a neurologic residency training program accredited by the Accreditation Council for Graduate Medical Education (ACGME).

The institution needs an emergency department and a dedicated neurointensive care unit and should provide fellowship programs in neuroradiology, stroke and vascular neurology, and neurocritical care.

There should also be a "robust open surgical neurovascular program meeting ACGME accreditation requirements at the same institution, a designated Comprehensive Stroke Center, and access to both adult and pediatric patients," write the study authors. And at least 250 NES procedures per year should be performed within each program.

Other requirements include at least two board-certified, NES-specialized faculty members; appropriate equipment and resources; and research opportunities for trainees.

Once an application has been approved by CAST and the SNS, the institution's training program accreditation will be good for 5 years – as long as annual reports and case logs are submitted annually.

Individual Certification

There are three phases to the NES certification process for an individual:

  1. Preliminary speciality training,

  2. NES prerequisite training, and

  3. Advanced NES training.

The first phase states that an individual must satisfy the requirements of their primary specialty, whether neurosurgery, neurology, or radiology, along with training on stroke management.

During the second phase, certification candidates must prove technical competence in accessing and manipulating a catheter "within the vasculature supplying the brain and spinal cord," note the investigators.

Advanced training includes 12 months of dedicated NES fellowship experience and completion of at least 250 interventional treatment procedures as a primary operator.

Upon finishing a CAST-accredited NES training program, an individual will receive a CAST-issued certificate.

Individual NES certification is also available through the Practice Track Pathway, which is open to clinicians with prior training and experience in NES. Requirements for this pathway are also available on the SNS website.

Applications for this process will only be available through December 2020. After that, all individuals will need to go through the main training pathway.

Fighting False Advertising

The new guidelines unify practices, said Dr Giannotta. "We had three powerful voices of professional societies pull their combined knowledge about training, along with hospital resources.

"The whole point of this is the public good," he added. "Hospitals in large cities often have single practitioners who may or may not have been properly trained to do neurointerventional work signing up" to staff a single stroke center.

After bringing patients with stroke to these places, ambulances will start bringing in patients with other neurovascular problems in the expectation that patients will receive the same level of care, "even though the practitioner may have no expertise at all in managing that," said Dr Giannotta.

"It gives a false sense to the public that there is some sort of comprehensive stroke program at their community hospital. The problem is, you need to provide 24/7, 365 call, and one person can't do that," he said.

"Our guidelines give a baseline for training so they can do the other procedures. Instead of false advertising, the people will be adequately trained, there will be an adequate number of them, and there will be others who are part of the comprehensive team, including acute neurosurgical care."

Stroke Specialists Should "Lead the Charge"

In an accompanying editorial, investigators led by Stephen M. Davis, the Melbourne Brain Center at the Royal Melbourne Hospital and University of Melbourne, Australia, note that "we face a huge challenge to make endovascular thrombectomy rapidly accessible in different health systems, duplicating the results of the landmark clinical changes that have revolutionized stroke practice."

Therefore, it's up to "stroke physicians" or specialists to lead the charge, add the editorialists.

"We agree that training standards for neurointerventionists must be rigorous," they write. "The [new] 12-month fellowship training not only specifies expertise in all aspects relevant to acute ischemic stroke but also mandates the full spectrum of other vascular interventions." They report that Australian guidelines are similarly comprehensive.

Dr Davis and colleagues note that there is a serious shortage of neurointerventionists, and access to care is a "huge challenge."

In large rural centers, neurointerventionists should, ideally, "manage all neurovascular interventions, but we do see a role for a more limited practice focused on clot retrieval and stenting," they write.

"Stroke physicians have an ideal background and should be encouraged to take up this training." They add that neuroradiologists should also be encouraged to accept the integration of these colleagues as part of the neurointervention team.

In addition, the editorialists suggest the need for fewer primary stroke centers and more comprehensive centers with large volumes of stroke and endovascular capability. "Outcomes relate to case volumes," they write.

Finally, they note that these discussions focus on high-income settings and that there are several challenges in developing-world settings ― including the risk-benefit ratio when thrombectomies are performed by the less experienced.

"A more pragmatic approach to credentialing may be needed until formally trained neurointerventionists are present in large numbers," write Dr Davis and colleagues.

Problem of Distribution?

There were also two accompanying comments published in Stroke.

The authors of the first article note that vascular neurologist (VN) training in "the era of thrombectomy" does indeed need to be rigorous but should include learning to administer intravenous tissue-type plasminogen activator "and other evidence-based aspects of acute stroke care."

In addition, "we advocate a larger part in our VN curriculum for vascular anatomy and angiography and that we should create much more ambitious targets for the proportion of VNs trained" to carry out endovascular thrombectomy, write James C. Grotta, MD, Memorial Hermann Hospital-Texas Medical Center in Houston, and colleagues.

The second group of commentators, led by Mayank Goyal, MD, Department of Radiology and Clinical Neurosciences at the University of Calgary, Canada, write in their accompanying article that multidisciplinary teams are needed to ensure positive stroke treatment outcomes, and that "neurointerventionists cannot work effectively in isolation."

However, they reference Nobel Laureate Amartya Sen, who wrote in Poverty and Famines: An Essay on Entitlement and Deprivation that the ability to acquire food is related more to distribution and not volume.

With endovascular treatment becoming the standard of care in treating ischemic stroke, there's been wide debate on treatment availability shortages, they write.

"It is possible, even probable, that the current perceived shortage may be principally a problem of distribution rather than an issue of overall availability of angiography equipment or trained personnel."

If true, a sudden uptick in training neurointerventionists may actually worsen stroke outcomes, in part by "diluting the experience and ability to have high volume, well-oiled, sophisticated multidisciplinary teams," write Dr Goyal and colleagues.

"Will we be smart enough to broadly recognize these problems and their potential solutions or is there a need for legislative policy to guard against these issues of maldistribution?" they conclude.

Dr Giannotta has reported no relevant financial relationships. A full list of disclosures for the other report authors is in the original article. The editorialists report that in their EXTEND-IA study, Covidien (Medtronic) provided an unrestricted grant in aid. Dr Grotta and colleagues reported no relevant financial relationships, as did Dr Goyal and five of his six coauthors. The sixth coauthor reported receiving a grant from Alberta Innovates.

Stroke. Published online July 13, 2017. AbstractEditorial, Comment 1, Comment 2

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