"As for interventional radiologists not being able to manage renal or infections complications, I beg to differ. Your statements are not only inflammatory but insulting and not grounded in reality. Many of these IR docs did a year of medicine including ICU, ID, and renal experiences and manage their own patients on a daily basis. These IR docs could manage infections or renal problems or hemodynamic problems. If it becomes a big problem they would turf it to ID or Renal, ICU, just like cardiologists do today in similiar situations."
Voxel -- there was no intention of being insulting or inflammatory on my part. 1-year of Internal Medicine or Surgery or a transitional year does not exactly make me, you, or anyone else an experienced clinician. No matter how much ID, renal, Unit time, or anything else you've done. I don't think IR docs don't have the time, inclination, or quite frankly the experience in the appropriate use of antimicrobial therapy. What about special considerations in giving contrast load to someone on metformin, or a patient who has CRI? How about an anaphylactic response to contrast? I don't exactly see radiologists running ACLS protocols on a daily basis. Sure, you can always call in consults and "turf" your problems, but the radiologists will have always have to depend on clinicians for these basic types of issues. That is not a slight against radiologists or IR specialists -- they are trained in other areas of expertise. As for cardiologists "turfing" to other fields -- you'd be surprised as to how much an IM board certified/board eligible, fellowship trained cardiologist can actually do outside of cards. Cardiologists send complicated or unstable cases to ICU, but it's a cardiologist taking care of the patient.
"What cannot be so easily translatable is picking which lesions and patients require or are appropriate for stenting in a clinical sense (vs bypass). This is a clinical skill that takes exposure and follow-up with peripheral vasculopaths to appreciate. An inappropriately done stent can transiently correct a problem, but can complicate peripheral surgeries & prematurely neccessitate amputation."
droliver -- no argument from me. As I stated in my original post, many interventional cardiology fellowships are expanding their curricula to provide such clinical depth, exposure and experience. Cardiologists are well aware of the fact that their percutaneous adventures in the coronary system have implications for patients who need to go under the knife later. Remember, most of the cardiologists picking up peripheral intervention now never went through any kind of formal training for managing these patients. They are translating their experience in coronary intervention to peripheral intervention. I certainly don't think this is right. But once the next generation of interventionalists comes out of training where they've had experience with these cases -- from diagnosis and evaluation to appropriate treatment (referral for surgery vs. doing a percutaneous procedure), then I think "the experience we have here with IR/Cardiology doing peripheral angioplasty/stents has been VERY frustrating" situation you describe might not be so much of a problem. Just an opinion.
"As you pointed out, endo-stents for AAA's are having their problems with endo-leaks & complications during the procedure. This highlights the fact that you cannot do a AAA repair without being prepared to open immediately. Again, cardiologist will not/cannot do them without backup & I just don't see anyone lining up to cover someone's ass on this especially when they don't think they should be doing them in the first place (I work with close to 15 vascular surgeons and they all say the same thing on this)."
droliver -- again, no argument from me. But as I touched on before, from what I understand, the technology for doint AAA stenting is evolving to a point where eventually ICards or IR docs may one day be able to do these types of cases. Much as the ACC is reviewing the thinking behind cardiothoracic backup in places doing coronary intervention, as experienced operators become experienced in peripheral intervention, these stipulations may come under scrutiny as well one day. Again, just an opinion.
"If domains are not respected, you will see cardiologists doing peripheral work, and IR and Vascular surgeons doing coronary work."
Voxel -- Coronary intervention is a whole other ballgame. This isn't just about sticking a catheter in some vessel. There is cardiac physiology & electrophysiology, the use of platelet inhibitors, the use of statins, glycemic control, and a whole slew of other things that distinguish coronary intervention from peripheral intervention. Much as I wouldn't want a cardiologist opening my chest to do a bypass, I wouldn't want anyone other than a cardiologist doing my PTCA.
With regards to carotid stenting, contraindications to surgery include patients with symptomatic severe stenosis that is not surgically accessible, or patients who are at high surgical risk because of severe cardiac disease. These patients are candidates for stenting, at least under protocols of most of the major trials looking at stenting. However, a large, NIH-sponsored trial is just beginning. The Carotid Revascularization Endarterectomy versus Stent Trial (CREST) will include about 2500 patients from 40 US centers, randomized to either carotid endarterectomy or carotid stenting. Results of that trial though, are not expected for about 5 years. But for now, I do believe the standard of care is endarterectomy, done by surgeons with a very low complication rate, in properly selected patients.
