The Vascular Team Approach: Getting a Leg Up on PAD with Education & Training

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 - Sahil A. Parikh, MD, FSCAI
Sahil A. Parikh, MD, FSCAI

Interventional cardiologists are taking the lead in quality initiatives for peripheral artery disease (PAD) revascularization. That includes developing guidelines, appropriate use criteria and promoting a vascular team model.

In the past 50 years, we have seen incredible reductions in morbidity and mortality from atherosclerotic coronary artery disease (CAD) as a result of improved detection, medical therapy and revascularization. These same innovations have benefited patients with PAD, one of the cardinal manifestations of systemic atherosclerosis.

As percutaneous revascularization strategies for CAD have evolved, similar technological advances have been applied to peripheral arterial revascularization for symptomatic PAD. In fact, in the last decade, there has been increasing attention on PAD because of the improved therapeutic options for revascularization, most of it performed with percutaneous or endovascular techniques. Some of these innovations include newly designed stents specific to the needs of the elastic peripheral arteries; new generations of drug-eluting stents; and drug-coated balloons, which adapt some of the advantages of vascular drug delivery without requiring a permanent implant.

Consequently, the growth of peripheral arterial interventions has been dramatic. In a recent analysis, the number of annual procedures performed in the Medicare fee-for-service database exceeded the number of coronary artery procedures. Recent data suggest that, in contemporary practice, approximately 40 percent of procedures are performed by an interventional cardiologist, 40 percent by vascular surgeons and a smaller proportion by interventional radiologists.

Irrespective of specialty, however, these procedures are increasingly performed in interventional suites such as cardiac catheterization laboratories as opposed to the operating room. They are frequently delivered on an outpatient basis in independent procedural laboratories, where reimbursement incentives are slightly different from traditional hospital-based venues. With the growth of the procedure volume in this area, there has been increasing scrutiny in the appropriate indications for percutaneous revascularization procedures.

The Centers for Medicare & Medicaid Services (CMS) has announced that a Medicare Evidence Development & Coverage Advisory Committee will review the indications for PAD revascularization. This panel will focus on patients across the disease spectrum, including those with asymptomatic PAD, intermittent claudication or critical limb ischemia. While many of us in the field are concerned about regulatory oversight reducing our ability to treat patients, this type of oversight is expected and perhaps is a consequence of our success in bringing new treatments to these patients.

There have been several movements within the Society for Cardiovascular Angiography and Interventions (SCAI) and the American College of Cardiology to improve procedural quality by issuing expert consensus and appropriate use criteria documents regarding PAD revascularization. New multisociety guidelines for the management of lower extremity PAD will be issued in the next 12 to 24 months. Finally, there is an increasing understanding that multispecialty, collaborative, team-based continuing medical education regarding the best practices in peripheral arterial intervention will be critical to high-quality revascularization and optimal patient outcomes. The heart team model has been embraced in the diagnosis and treatment of CAD. Vascular teams must also become the norm for treatment of PAD.

Fortunately, there is plentiful evidence that our field is moving in the direction of vascular teams. At the SCAI 2015 conference in San Diego, for example, the Peripheral Track achieved record attendance, which the program planners attribute in large part to the meeting-wide, case-based format and to attendee participation in teams.

What better way is there not just to learn about the whole spectrum of PAD treatment but also to be prepared to apply those lessons in your own practice than to discuss real cases together in an environment that fosters debate and collegiality? SCAI’s new Complex Peripheral Vascular Intervention course, debuting in September, will continue the theme of welcoming teams, tackling tough cases and encouraging the building of vascular teams across specialties. This approach will help us achieve the same impressive results for PAD as we have for CAD.

Dr. Parikh