A Proposal for the Core Curriculum for Credentialing and ... · MD RCMS, Norman Patton MD RCMS,...

WilliamsC,ChenJP,Viamonte,Jr.M,WalkerC,Allie,DE,et.al.Aproposalforthecorecurriculumfortrainingadvancedlevel

1 Dr. Harvey A. Koolpe contributed a tremendous amount of time and effort to help develop this proposal for the core curricula to train allied health professionals, who excel in the cardiovascular medical imaging procedural suites. Dr. Koolpe passed away on October 18, 2007. © Protected by the personal copyrights of the authors. Copies cannot be transmitted in electronic form, by facsimile, photographed, or photocopied for individual use without written permission from the authors and The International Society of Medical Imaging Physician Specialists. 11/5/2009 10:58:29 AM of 57

AProposalfortheCoreCurriculumforCredentialingandTrainingofCardiovascularSpecialistAssistantstoPerformInvasiveandInterventionalCardiovascularProcedureswithMedical

SimulationTrainingProgramsPartIV:AReportoftheInternationalCouncilforCertificationofCardiovascularSpecialist

Assistants,IncandtheCommitteeonTrainingStandards.

WritingCommitteeMembersCo‐Chairpersons

ChuckWilliams,BSRCSARPA/RARCISRT(R)(CV)(CI)CPFTCCTFSICP,JackP.ChenMDRCMSFACCFSCAI

FCCP,ManuelViamonte,Jr.MDRCMSRVMS,HarveyAKoolpeMD1RVMS,CraigWalkerMDRCMSRVMS,DavidE.AllieMDRCMSRVMS,DouglasC.MorrisMDRCMS,JacksonThatcherMDRCMS,

ConstantinCopeMDRVMS,DongmingHouMDRCMS,NeilE.HoltzRCISBSEMT‐PRCSA,PhyllisWilliams

RNCENASNRCSA,LorenaHendryPA‐CBSRCSA,JulieLoganRNRCSA,JeffDavisRRTRCISRCSAFSICP,MichaelGuiryPA‐CBSRCSA,RobinCopelandRNBSNRCSA,ShellyRyanRNRCSA,TressieBrooksRNBSN

RCSA,AmarPatelMDRCMSRVMS,AmyL.SeidelMDRCMSRVMS,BarryJ.HenryMDRVMS,David

SchultzMDRCMS,GaryLaneMDRCMS,N.HenryPevsnerMDRVMS,JamesR.LePageMDRCMSRVMS,JohnH.KatheMDRVMS,MichaelMcDanielMDRCMSRVMS,MichaelReiserMDRVMS,MichaelScottMDRVMS,MicheleVoeltzMDRCMS,NormanPattonMDRCMS,PuviSeshiahMDRCMS,RichardChen

MDRCMS,RobertBiedermanMDRCMS,WilliamA.MartinMDRCMS,EileenKoolpeMS,KathyA.GroceRNMSNRCSARCPT,LanierHallBSRPA/RART(R)RCSA,LisaHigginsRNMSNRCSA,PattieFreschettRN

BSNBBARCISRCSA,ReginaDeibleRNBSNRCSA,TimRohrschneiderBMScRT(R)RCSA

MedicalImagingPhysicianExtenders

AldoCarrilloBSRPA/RART(R)(CT)RCSA,BarryMcDanielRPA/RART(R)RCSA,BarryWallerRPART(R)

RCSA,BhawnaOberoiBSRSRPART(R)(M)RCSACVT,CalvinCarterRPA/RART(R)(VI)RCSA,CarolMcGeeRPA/RART(R)(CV)RCSA,ChristineTestaAPRNMSNRCSA,ChuckGibautBSRCPRCISRCSA,ClareBradyRPA/RART(R)RCSA,ClaudiaPoolsonBSRPA/RARRART(R)(CV)RCSA,ClaudioC.CantoRPA/RART(R)

RCSA,CraigWolfeRPA/RART(R)(VI)RCSA,DavidPyleRPA/RART(R)RCSA,DeanC.BurdgePA/RART(R)RCSA,DeborahPetersRPART(R)(CV)RCSA,DianeSteffenRPA/RART(R)RCSA,DonMonroeRPA/RART(R)RCSA,EileenFergusonRPART(R)(VI)RCSA,EileenTaylorRPA/RART(R)(VI)RCSA,E.J.MikeRPA

RT(R)RCSA,FernandoEscarzagaRPA/RART(R)RCSA,GeorgeBenettiRPA/RART(R)(VI)RCSA,GeraldIngrahamRPA/RART(R)(CV)RCSA,HarrySotoRPA/RART(R)RCSA,HeatherGrizzleRPA/RART(R)(VI)RCSA,J.GeorgeSanchezRPA/RART(R)RCSA,JeremySmallwoodRPA/RART(R)(VI)RCSA,JuanMunoz

RPA/RART(R)(CV)RCSA,JudyPutkamerRPA/RART(R)(M)RCSA,KarenSidorskyRPART(R)(CV)RCSA,KimGarwoodRPA/RART(R)RCSA,KimStracenerRPART(R)(VI)RCSA,LewisW.StarkRPA/RART(R)(CV)RCSA,LindaCook‐YentesRPA/RART(R)(CV)RCSA,MarceneComptonBSRPART(R)RCSA,MarcoA.

SerranoRPA/RART(R)RCSA,MichaelBowenAPRNMSNRCSA,MikeStringerRPA/RART(R)RCSA,MohammadHussainRPA/RART(R)RCSA,NathanBraunRPA/RART(R)RCSA,RichardMatthewsRPA/RA

RT(R)RCSA,RichardMoran,RPART(R)RCSA,RichardOblakRPA/RART(R)(CV)RCSA,ShirleyYearly



RPA/RART(R)RCSA,StephenKnightRPA/RART(R)RCSA,StevenK.ZegarRPART(R)RCSA,SusanGuinardRPA/RART(R)(CV)RCSA,SusanSteinbisAPRNMSNRCSA,TimD’AugustinoRPA/RART(R)(CI)RCSA,Tracy

SchneiderAPRNMSNRCSA,VickiWardRPA/RART(R)(VI)RCSA

CardiovascularTechnologistMembers

AaronPriceSgtUSARCISRCESRCSA,AmandaWaltersRT(R)ASRCSA,AdalbertoPerezSgt(P)CVTRCSA,AlexanderAndreuRT(R)ASRCSA,AndrewKremerHMCUSNRCISCCTRCSA,AnnaCollinsRCSACVT,

ArvillaWoodingtonBSRCSA,BarryHorseyRCISRCSA,BenjaminOchoaSSgtUSARCISRCESRCSA,Brent

RodriquezRCSARCPTRPFTBS,ChrisHebertRT(R)RCISRCSA,ChristinaHillRT(R)RCSA,ChristineKauffmanRT(R)ASRCSA,ChristopherGrahamSgtUSARCSACVT,ChristopherHaeslerSSgtUSARCSACVT,ChristopherLoganRCISRCESRCSA,CraigCummingsRCISRCSAFSICP,CynthiaLynadyRCISRCES

RCSA,DanielR.JonesRCISBSRCSA,DavidClappRT(R)RCSA,DereckCarverRCISASRCSA,DerreckJohnsonSSgtUSARCISRCESRCSA,DonnaHuntRCISRCSA,GregoryMonroeBSRCISRCSA,GregTraynorRCISEMT‐PRCSA,HarrellCarmichaelSFCUSARCISEMT‐BRCSA,HarveyMcKinleyRCISEMT‐PRCSA,

HoraceRGillinsBSRCSACVT,HowardSleathSgtUSARCISRCESEMT‐BRCSA,JamesSatrangRT(R)RCSA,JasonMaysASCVTRCSA,JasonWilsonRCISRCSA,JeffreyMaysRCISASRCSA,JeromeAberraSgtUSARCISRCESRCSA,JimToddBSRRTRCSA,JoeBrownRCPTRCSA,JohannaJiminezSgt(P)USACVTRCSA,

JonathonLopezSSgtUSARCISRCSEMT‐BRCSA,JoseNinoSgt(P)USACVTRCSA,JoshCarterRCISASRCSA,JulieL.WilliamsRCSART(R),JustinWhiteSSgtUSACVTRCSA,KacieReynoldsCVTASRCSA,KellyJ.

BroxtonRCISRT(R)ASRCSA,KevinWynnSgtUSACVTRCSA,MatthewHarrisSgt(P)USACVTRCSA,

MelissaBroddleRT(R)ASRCSA,MelissaWeissingerRT(R)RCSA,MichelleLuedeeRT(R)RCSA,MireyaCanateSSgtUSARCSACVTCSEMT‐B,MonicaBushSSgt(P)USARCISRCSA,NicoleGeigerRCISASRCSA,

OrlandoMarreroRCISMBARCSA,PatriciaThomasMBARCISRCSAFSICP,PatrickHoierRCSARCISRCSAFSICP,RachelKoolpeBSRCSA,RayLeniusMEdRCISRCSA,RonaldGomickSgt(P)RCISRDCSRCSA,RonaldB.WilliamsBART(R)(MR)RCSA,SheilaDebastianiRT(R)RCSA,TaekyungKimSSgtUSARCISCSEMT‐B

RCSA,TeresaB.WatersMBABSRT(R)RCSA,TrevorSmithHM1USNAASRCSARCISRCESCCTMTSRCSA,WayneCochranBSRCISRCSA,WesToddBSRCISRCSA,WilliamEmbilBSRCSA

CardiovascularNurseMembersAdeleSerioRNBSNRCISRCSA,DeborahCurlRNBSNRCSA,JeffMaysRNASNRCSA,JenniferMaleckiRNASNRCSA,JillKatheRNBSASNRCSA,KennethA.GorskiRNRCISRCSAFSICP,JaneC.WilsonRNBSN

RCSA,KimNesterRNBSNRCSA,KylieMacIntoshRNCVRCSA,LindseyFergusonRNRCSA,RhodaHammerRNMSBSNRCISRCSA,SandyWatsonRNRCSA,ShataundiaReeseRNBSNRCSA,SiroBuendia

RNRCSA,TerryScottRNBSNRCSA,TracySimpson,RNBSNRCISRCSAFSICP

Consultants

AshleyWilliamsBS,ChristinaMorris,JarrodA.WilliamsBA,KaseyKnightBS,KoltonWilliams,Lance

Larkins,LynnTaillonBS,StaceyFunicellioCMOA,TiffanyPratsBSBBA



I.Purpose Thepurposeofthisproposedcurriculumistodevelopthelearningobjectivesandcontentspecificationsthatdefinesthelevelofknowledge,skillsets,andexperienceofcardiovascularspecialist

assistantswithanopenopportunityforcardiovascularmedicalspecialistssothey,also,canbeattestedontheirperformanceonthemedicalsimulatorsdesignedforcardiovascularproceduresthatencompassthecirculatorysystemofthehumanbody.

ThesoleintentionoftheInternationalCouncilforCertificationofCardiovascularSpecialistAssistantsIncorporated(hereaftertermedCouncil)istoimprovethestandardsofcare,improvedtheeducationalprocess,andmostimportantlyimprovepatientsafetybyreducingmedicalerror.Also,the

otherpurposeistosetastandardforinternationalandnationaleducation,training,andformalcertification.

II.Introduction ThefocusofthisprogramwillcoincidewiththeproposedUnitedStatesPublicHealthServiceActamendmentthatwillauthorizemedicalsimulationenhancementprograms.TheActhasbeencitedasthe“EnhancingSafetyinMedicineUtilizingLeadingAdvancedSimulationTechnologiestoImprove

OutcomesNowACTof2009”(111thCongress1stSession,HR855,February4,2009). Thescopeofthismaterialpertainstotrainingadvancedlevelalliedhealthcareprofessionalsandelectivelybyphysicians,whoperforminvasiveandinterventionalcardiovascularproceduresinamedical

simulationenhancementprogram.Thelogisticswillpertaintotheneedsofphysicians,whomeetthestandardsandqualificationsoftheCouncil,andthecardiovascularspecialistassistants,whoseekregistryasRegisteredCardiovascularSpecialistAssistantsorbythephysicians,whoseektechnical

CredentialsasaRegisteredCardiovascularMedicalSpecialist;aRegisteredVascularMedicalSpecialist;and/orbothofferedphysician‐basedcredentials.

III.Logisticsoftrainingandbeingcertifiedonthe“virtualpatient”A.CardiovascularSpecialists(physicians)andalliedhealthprofessionals,whoworkfulltimein

cardiaccatheterizationlaboratories,cardio‐thoracicsurgicalsuites,interventionalradiologysuites,andvascularsurgicaloperatingrooms,can:

1.Enhancetheirproceduralskills 2.Reinforcebestpracticesbyallowingexperiencedcliniciansand healthcareprofessionalstoperformprocedureson“virtual

patients.” 3.Reduceadverseeventsthatincreasemorbidityandmortality 4.Reducecosts

5.DecreaseradiationexposureB.Developmentofclinicalskillsprovidedbysimulation‐basedtrainingprograms 1.Benefitspatientsandotherhealthcareconsumers



2.Improvescontinuityandqualityofcare 3.Improveshealthoutcomes

4.Improvessafetyofthepatient 5.Reducesnumberofmedico‐legalcases 6.Reducescomplicationscausedbydeficientskillsandexperience

7.Reducescostsassociatedwithpatientcare 8.Reducesmedicalerrors9.Reducesnumberofmedicalprofessionalswhofunctionbelowexcellence

10.Reducesratesofmorbidityandmortality

C.Abilitiesofhealthcareprovidersinurbanandruralregionswouldbeenhancedthroughmedicalsimulationiftheemployersincorporatethetechnologyintotrainingandformal

certificationprotocols.D.Excellentleadershipwithguidanceprovidesthehealthcareentitieswithcuttingedge

medicaltechnology.

IV.QualificationsforTrainingandCertification A.CardiovascularSpecialists(Physicians) 1.Cardiologists‐Invasive a.Mustbeboardcertifiedand/oreligible b.Mustproducenecessaryrecordsthatindicatecompletionofanaccreditedfellowshipprogram. c.Musthavethreesupportinglettersofrecommendationfrommedicaldirectors,administration,andcredentialingcommittee d.Cannotacceptrecommendationsfromassociates 2.Cardiologists–Interventional a.Mustbeboardcertifiedand/oreligible b.Mustproducenecessaryrecordsthatindicatecompletionofanaccreditedfellowshipprogram. c.Musthavethreesupportinglettersofrecommendationfrommedicaldirectors,administration,andcredentialingcommitteed.Cannotacceptrecommendationsfromassociates 3.CardiologyFellows–InvasiveandInterventional a.Mustbefellowinaccreditedfellowshipprogram b.Mustproducenecessaryrecordsthatindicatecurrentparticipationinafellowshipprogram



c.Musthavefivesupportinglettersofrecommendationfrommedicaldirectors,administration,andcredentialingcommitteed.Cannotuserecommendationsfromfellowpeers. 4.Cardio‐thoracicsurgeons a.Mustbeboardcertifiedand/oreligible b.Mustproducenecessaryrecordsthatindicatecompletionofanaccreditedfellowshipprogram. c.Musthavethreesupportinglettersofrecommendationfrommedicaldirectors,administration,andcredentialingcommittee d.Cannotuserecommendationsfromassociates 5.Cardio‐thoracicsurgeryfellows a.Mustbefellowinaccreditedfellowshipprogram b.Mustproducenecessaryrecordsthatindicatecurrentparticipationinafellowshipprogram c.Musthavefivesupportinglettersofrecommendationfrommedicaldirectors,administration,andcredentialingcommitteed.Cannotuserecommendationsfromfellows. 6.Interventionalradiologists a.Mustbeboardcertifiedand/oreligible b.Mustproducenecessaryrecordsthatindicatecompletionofanaccreditedfellowshipprogram. c.Musthavethreesupportinglettersofrecommendationfrommedicaldirectors,administration,andcredentialingcommittee d.Cannotacceptrecommendationsfromassociates 7.Interventionalradiologyfellows a.Mustbefellowinaccreditedfellowshipprogram b.Mustproducenecessaryrecordsthatindicatecurrentparticipationinafellowshipprogram c.Musthavefivesupportinglettersofrecommendationfrommedicaldirectors,administration,andcredentialingcommitteed.Cannotuserecommendationsfromfellows



8.Orthopedicsurgeons a.Mustbeboardcertifiedand/oreligible b.Mustproducenecessaryrecordsthatindicatecompletionofanaccreditedfellowshipprogram. c.Musthavethreesupportinglettersofrecommendationfrommedicaldirectors,administration,andcredentialingcommittee d.Cannotacceptrecommendationsfromassociates9.Orthopedicsurgeryresidents a.Mustberesidentinaccreditedfellowshipprogram b.Mustproducenecessaryrecordsthatindicatecurrentparticipationinresidencyprogram c.Musthavefivesupportinglettersofrecommendationfrommedicaldirectors,administration,andcredentialingcommitteed.Cannotuserecommendationsfromfellowsorfellowresidents. 10.Radiologyresidents a.Mustberesidentinaccreditedfellowshipprogram b.Mustproducenecessaryrecordsthatindicatecurrentparticipationinresidencyprogram c.Musthavefivesupportinglettersofrecommendationfrommedicaldirectors,administration,andcredentialingcommitteed.Cannotuserecommendationsfromfellowsorfellowresidents.11.Vascularsurgeons a.Mustbeboardcertifiedand/oreligible b.Mustproducenecessaryrecordsthatindicatecompletionofanaccreditedfellowshipprogram. c.Musthavethreesupportinglettersofrecommendationfrommedicaldirectors,administration,andcredentialingcommittee d.Cannotacceptrecommendationsfromassociates12.Vascularsurgeryfellows a.Mustbefellowinaccreditedfellowshipprogram



b.Mustproducenecessaryrecordsthatindicatecurrentparticipationinafellowshipprogram c.Musthavefivesupportinglettersofrecommendationfrommedicaldirectors,administration,andcredentialingcommittee d.Cannotuserecommendationsfromfellows. 13.Othermedicalspecialties(interventionaloncologists,nephrologists,e.g.) a.Attendingphysicians (1).Mustbeboardcertifiedand/oreligible (2).Mustproducenecessaryrecordsthatindicate

completionofanaccreditedfellowshipprogram. (3).Musthavethreesupportinglettersofrecommendation

frommedicaldirectors,administration,andcredentialing credentialingcommittee

(4).Cannotuserecommendationsfromassociatesb.Fellowshipstatus (1).Mustbefellowinaccreditedfellowshipprogram (2).Mustproducenecessaryrecordsthatindicate

currentparticipationinafellowshipprogram (3).Musthavefivesupportinglettersofrecommendation

frommedicaldirectors,administration,andcredentialing committee

(4).Cannotuserecommendationsfromfellows.

B.Cardiovascularspecialistassistantsandalliedhealthcareprofessionals 1.Associatedegreeand/orequivalentwith5continuousyearsofclinicalexperiencewithatleastonecurrentCCIRCIS,RCES,and/orRCScredential 2.Bachelor’sdegreeand/orequivalentwith3continuousyearsofclinical

experiencewithatleastonecurrentCCIRCIS,RCES,and/orRCS credential

3.Master’sdegreeand/orequivalentwith3continuousyearsofclinicalexperience withatleastonecurrentCCIRCIS,RCES,and/orRCScredential

4.Doctoratedegreeswith3continuousyearsofclinicalexperiencein cardiovascularprocedures

a.PhDwithoneCCIcredential(RCIS,RCES,orRCS)



b.MDorDOwithforeignpostgraduatedegreeandfunctioningasa: (1).RRA(ARRT)withoneCCIcredential(RCIS,RCES,RCS)(2).RPA(CBRPA)withoneCCIcredential(RCIS,RCES,RCS) (3).RCIS(CCI)

(4).RCES(CCI)(5).RCS(CCI) (6).RT(R)withatleasttheCI,CV,orVIcredential 5.Radiologypractitionerassistants(CBRPAcertified)a.Minimum3continuousyearsincardiovascularproceduresb.MinimumofaBachelor’sdegreeand/orequivalent c.CurrentARRTcredentialswithatleastoneCI,CV,orVIadvancedspecialtycertificationand/ord.OneCCIRCIS,RCES,orRCScredentialand/ore.Full‐timephysicianextenderincathlab,interventionalradiology,orvascularsurgerysettingsf.BoardeligibleforARRTCardiacInterventionalorVascular‐

interventionalexamination6.PhysicianAssistants(PA‐Cs)a.MinimumofBachelor’sdegreeand/orequivalent

b.Minimumof3continuousyears“hands‐on”experiencein cardiovascularprocedures

7.Advancedpracticeregisterednurses(APRN)/registerednurseclinicalspecialistsa.MinimumofMaster’sdegree

b.Minimumof3continuousyears“hands‐on”experiencein cardiovascularprocedures

8.Registerednurse a.MinimumofanAssociate’sdegreeand/orequivalentb.Minimumof5continuousyearsof“hands‐on”experienceincathlabs,EP,echocardiography,orinterventionalradiologyc.MusthaveoneCCIcredential(RCIS,RCES,RCS)d.CCIboardeligible9.Registeredcardiovascularinvasivespecialist(CCIRCIS,RCES,orRCS) a.MinimumofanAssociatedegreeand/orequivalentb.Minimumof5continuousyearsofexperienceincardiovascularsettings(Cathlab,EPLabs,echocardiography)c.CCIboardeligible(Musthavecredentialpriortoexam)



10.Registeredradiologyassistants(ARRTcertified) a.Minimumof5continuousyearsofclinicalexperienceincathlabsettings,IRsuites,EPSuites,andvascularsurgerysuitesb.MinimumofaBachelor’sdegreeand/orequivalentc.CurrentARRTcredentials–CV,CI,VI,S,(atleastone) d.CurrentCCI–RCISRCESorRCScredentialscanbesubstitutedforadvancedlevelARRTcredentials11.Registeredradiologictechnologists a.Musthaveatleast7continuousyearsofclinicalexperienceinthefield(Cathlab,interventionalradiology,sonography,vascularsurgery)b.MusthaveatleastanAssociate’sDegreec.MustholdatleastoneoftheARRTadvancedcredentials(CV,CI,VI,S).d.MaysubstitutecurrentCCIcredentials–RCIS,RCES,RCSforARRT

credentialse.Maybeboardeligibleforeitheragency’scredentials12.Cardiovasculartechnologists a.Mustbeboardeligibleb.MusthaveanAssociate’sdegreeand/orequivalentc.Musthaveatleast7continuousyearsofclinicalexperienceincathlab,electrophysiologyunits,and/orechocardiography13.Otherrequirements a.Mustproviderecordstosubstantiateallqualificationsuponrequestwithinonemonth(30days)afterrequesthasbeenmadebyletter.

c.Completionoftwo(2)continuousyearsofclinicalanddidactictrainingin

invasive/interventionalcardiologyprocedures d.Mustcompleteoftwo(2)continuousyearsininvasive/interventional

carotidandperipheralproceduresinconjunctionwiththeinvasive

/interventionalcardiologyprocedures. e.Mustcompletetwocontinuousyearsofinternshipunderthedirectand

immediatesupervisionofboardcertifiedand/orboardeligiblephysicians

suchas: (1).Invasivecardiologists

(2).Interventionalcardiologists

(3).Interventionalradiologists (4).Cardio‐thoracicsurgeons (5).Electrophysiologists

(6).Orthopedicsurgeon



(7).Vascularsurgeons(8).Othercardiovascularphysicians

f.Mustpassthewrittenexaminationwithapassingscoreofatleastaneighty‐ seven(87)percentbeforebeinggrantedpermissiontotakethemedicalsimulationexaminationwhichrequiresanexcellentratingtopass.

g.MustcompleteanaccreditedcertificationexaminationdevelopedandadministeredbytheCouncil.

h.Mustcompletethe“hands‐on”examination(s)withanexcellentrating

administeredandassessedbyappointedexaminersbytheCouncil. i.Recertification 1).Mustrecertifyonmedicalstimulation(VirtualPatient)everyseven(7)

yearsatanassignednationalorinternationaltestingsitetomaintaincredentials.

2).Mustcompleterecertificationprocesswithanexcellentratingtomaintain

credential(s) 3).Mustcompleterecertificationormultiplerecertificationsatstandardsetoffees.

j.Annualrenewalofcredentials 1).Requiredeachyearforsixconsecutiveyearspriorto“hands‐on”

recertification,whichoccursduringtheseventhyearofpractice.

2).Feesforrenewala).SetbytheBoardofDirectorsoftheInternationalCouncilfor

CertificationofCardiovascularSpecialistAssistants,Inc. b).Basednumberofcredentialsreceived

V.PathwaystoProficiency A.Basicproficientrequirements1.Advancedcognitiveskills a.Excellentknowledgeofnormalandpathologicalanatomy b.Excellentknowledgeofhemodynamicsandcardiaccalculationsc.Excellentleadershipandcommunicationskills d.Superbdecisionmakingskills e.Excellentmanagementofadverseeventsandcomplicationsf.ExcellentknowledgeofACLSguidelines 2.Basicangiographicskills a.Excellentskillstoassesspatients b.Excellentabilitiestoplanangiographicproceduresc.Excellentknowledgewithimagemanagement



(1).C‐armcontrol(panning) (2).2‐DFluoroscopy/Digitalcineangiography (3).Optimalanglestoappropriatelyidentifyvascularanatomy(4).Radiationexposure,dosage,andsafety(5).Contrastmediausage(Ionic,non‐ionic,lowosmolality d.Excellentabilitytoselect,handle,andmanipulateangiographiccatheterse.Excellentabilitytoselect,handle,andmanipulateguidewiresf.Excellentabilitytoprepareandmanagedevicesasneededg.Excellenttactileinteractionwithdevicehandlingh.Excellentdecisiveskillstodeterminesequenceinangiographicprocedures3.Complexinterventionalskills a.Excellentabilitytoplanandrehearseinterventionalproceduresb.Excellentabilitytodeterminesequenceininterventionalproceduresc.Excellentskillswithhandlingballoonsduringpreandpostdilatation d.Excellentabilitytoselect,handle,andmanipulateguidingcatheterse.Excellentabilitytoselect,handle,andmanipulateangioplastyguidewiresf.Excellentabilitytoselect,handle,position,anddeploystentsg.Excellentabilitytoselect,handle,position,anddeployEPDfiltersh.Excellentabilitytoselect,handle,position,anddeploycoils4.Clinicalknowledge a.Understandsrolesoftheteammembers.

b.MaintainsACLScertification(PALSifinvolvedwithpediatricstudies)c.Developseffectiverapportwithpatientwhichincludesbedside

mannerd.Handlesadverseeventsprofessionallywithoutcausingalarmwithpatientorsupportstaff

e.Establishesprofessionalrapportwithsupportstaffteammembersthatconveysconfidenceanddirectionasanadvancedpracticeteammember

f.Remainsfocusedonthementalwell‐beingofpatientthroughoutprocedure

andonvitalsigns(bloodpressure,cardiacrhythms,andrespiratorystatusandhasplantomanageadverseornear‐fatalevents)

g.Abletohandleprocedureinducedcardiaceventssuchasbradycardia;



supraventriculartachycardia;1st,2nd,and3rddegreeheartblocks;atrialfibrillation,atrialflutter;ventriculartachycardiawithorwithoutpulse;

ventricularfibrillation;asystole,andpulselesselectricalactivity,i.e.h.Knowswhentoaskforhelporwhentodiscontinueaprocedurethatcannotbecompletedsafely

i.Exhibitsknowledgeofmanagingpatient’sdiscomfortwiththeuseof appropriateanalgesicandsedativemedicationsj.Hasextensiveknowledgeandexperiencewithemergencylabprotocolsand

proceduresk.Hasknowledgeandexperienceofalternativetechniquesk.Understandstheneedforastandardworkprotocol

5.Manipulativeskills a.Earlycognizance(1).Staysattentivelyfocused(2).Observeswithkeenness(3).Understandsmechanismsofskillperformedb.Lengthypractice(2years)(1).Directedconcentration(2).Formscorrectperformancec.Autonomousstage(1).Automaticityoccurs(2).Accuracyincreases(3).Dexterityincreases(4).Greaterunderstandingincreases(5).Speedincreases(6).Timemanagementcontinuestoimprove d.SkillVariabilities (1).Demonstrativeevents (a).Enhancesconfidence(b).Enhancespsychomotorskillacquisition (c).Improvestechnique(d).Improvesunderstandingofperformance(e).Influencesstudent’sskillacquisition(f).Reducesanxietyoverperformingunfamiliarskills(2).Feedback(a).Importantinearlystagesofpracticingsimpleclosed‐ loopskill

Charles Ody Williams� 6/11/08 8:49 PMFormatted: Indent: Left: 0.54", Hanging: 1.15", Space After: 0 pt, Tabs: 1.69", Left



(b).Improvementofrateofskillparallelsfrequencyand precision(c).Lackoffeedbackdeclinesperformanceinearly developmentofskills(d).Typesoffeedback1).Kinesthetic2).Verbal3).Visual (3).Knowledgeofresults (a).Requiresfeedback(b).Requireserrordetection(c).Mandateserrorcorrection (4).Mentalpractice(a).Mustbefamiliarwithpriortasks1).Priorexperiences2).Demonstrations(b).Requiresinstructionformentalpractice (c).Requiresbindingwithphysicalpracticetogainhighest levelperformancegains(d).Requirescomplexandsimpleskillstobeplacedinsub‐ units(e).Performingofmentalpracticeshouldbeaccomplished ineachperson’spersonaltimeandplace(f).Shouldnotexceedfive(5)minutes(5).Motivation (a).Influencesdevelopmentofpsychomotorskills(b).Accountsforindeterminacyduringeducationalprocess(c).Createsanatmosphereofuncertainty(d).Developsperplexity(e).Strategiesthatincreasemotivation 1).Varietyofpsychologicalstrategiesa).Personalgoalsb).Personalinterestsc).Valuesofskillsetsd).Personalchallenges2).Arousalofcuriosityfromapuzzlingproblem



3).Setschallengingstandards4).Combinesfactorsofnaturaltendencyfor completion(6).Physicalpractice (a).Improvesperformancethroughrepetitiveprocesses (b).Reducesfearandanxietythatsurroundstherequiredperformanceofskills(c).Helpseffectivenesswithdistributedpractices (d).Distributedpractices1).Shortfrequentpracticesoverlongerperiodsaremosteffective 2).PracticesmustbelongenoughtoenhanceImprovement3).Timeperiodbetweensessionslowerslevelofforgetfulness 4).Moreeffectivethanmassedpractices (7).Importantvariablesduringdevelopment (a).Requiresupmostmentalthought(b).Requiresuppermostphysicalinvolvement(c).Requiresqualityinstructionbyeducatorswhounderstandexpediency(d).Requiresself‐motivationofparticipanttoacquireskillsets B.IndicationsandSymptomsforProcedures

1.Indicationsforinvasivecardiacprocedures a.Unstableangina b.PostMIangina c.Postcardiacsurgeryangina

d.NonQ–waveMI

e.MIatyoungagef.Complicated“Q‐wave”MIs

g.PostMI‐Cardiacmechanicalcomplications(MR,VSD)h.PostMI‐CHFi.Idiopathicchestpain

j.Valvularheartdiseasek.ValvularheartdiseasewithCADl.LVdysfunction



m.Coronaryarteryanomaliesn.Postcardiactransplants

o.Donorsforcardiactransplantsp.Rightandleftcardiaccatheterizationq.Congestiveheartfailure

r.Cardiomyopathy(1).Restrictive(2).Constrictive

(3).Hypertrophicobstructive(4).Ischemic(5).Medication‐induced

s.Pulmonaryhypertensiont.Cardiogenicshock

2.Indicationsforinterventionalcardiacproceduresa.Cardiogenicshockb.Complicated“Q‐wave”MIsc.MIatyoungage

d.Non‐STEMIe.Postcardiacsurgeryanginaf.PostMIangina

g.PostMI‐Cardiacmechanicalcomplications(MR,VSD)h.PostMI‐CHFi.Pulmonaryembolization

j.Septaldefects k.STEMIl.Unstableangina

m.Valvularstenosisandinsufficiency

3.SignsandSymptoms,Indications,Treatment,andManagementforAcutePulmonaryThromboembolism

a.Symptoms(1).Acutedyspnea(2).Apprehension(3).Cough(4).Pleuriticchestpain(5).Syncope(6).Sweats(7).Wheezing

b.Signs



(1).Cyanosis(2).Diaphoresis(3).DistendedneckveinswithlargeAwave(4).ECGchanges

(a).ClassicS1Q3T3Pattern(b).Rightaxisdeviation(c).Rightbundlebranchblock(RBBB)(d).TWaveinversionsinV2andV3leads

(5).Elevatedfibrinopeptide–A(6).ELISAD‐Dimertest(notveryusefulduetolowspecificity)(7).Rightventriculargallop(8).Heartmurmur(9).Hemoptysis

(10).PEAcardiacarrest(11).Pleuraleffusion(12).Pleuralfrictionrub(13).Phlebitis(14).Rales(15).S‐3gallopwithincreasedP2sound(16).Tachypnea>16breaths/minute(17).Tachycardia(HR>100beats/minute

(18).Temperature>37.8°Cc.Riskfactors (1).Advancedage(2).Cerebralvascularaccident(stroke)

(3).Chronicobstructivepulmonarydisease(4).Congestiveheartfailure (5).Geneticriskfactors

(a).ActivatedproteinCresistance(FactorVLeiden) (b).Antiphospholipidantibodysyndrome (c).AntithrombinIIIdeficiencies

(d).Hypercoagulatestates(acquiredorcongenital)suchas: (1)Hyperhomocysteinemia (2)Lupusanticoagulantfactor

(3)ProteinCdeficiency (4)ProteinSdeficiency

(5)Prothrombingenemutation



(6).Hormonalreplacementtherapy(HRT)(7).Indwellingintravenousvasculardevices

(8).Inflammatoryboweldisease(9).Malignancy(10).Obesity

(11).Oralcontraceptives(12).Post‐operativesurgery (a).Abdominal

(b).Hip (c).Pelvic(13).Postpartumperiod

(14).Pregnancy(gestationalperiod)(15).Previoushistoryofthromboembolism(16).Primarypulmonaryhypertension

(17).Prolongedimmobility (a).Airplanetravel≥4hours (b).Motorvehicletravel≥4hours

(18).Severeburns(19).Trauma(spinaltrauma)

d.Differentialdiagnosis (1).Anginapectoris(2).Asthma(3).Bronchitis

(4).Congestiveheartfailure(5).Dissectionoftheaorta(6).Exacerbationofchronicobstructivepulmonarydisease

(7).Musculoskeletalchestwallpain(8).Myocardialinfarction(9).Pericarditis

(10).Pneumonia(11).Pneumothorax(12).Pulmonaryedema

(13).Ribfracturesortrauma(14).Viralpleuritis

e.Classificationofpulmonaryembolization(1).Class1‐Vesselsoccluded≤20%

(a).Asymptomatic (b).Bloodgases–Normal



(c).Hemodynamics‐Normal 1).Rightheartcatheterization

a).RA,RAmean b).RV,RVEDP c).PA,PAMean d).PCWP,PCWPmean

2).Leftheartcatheterization a).LV,LVEDP b).AO,AOMean

(2).Class2–Vesselsoccluded≥20≤30% (a).Anxiety

(b).ArterialPO2<80torr(c).ArterialPCO2<35torr(d).Hyperventilation

(3).Class3–Vesselsoccluded≥30≤50%

(a).ArterialPO2<65torr(b).ArterialPCO2<30torr(c).Dyspnea(d).Pulmonaryhypertension

(4).Class4–Vesselsoccluded≥50%

(a).Arterialhypooxemia(b).ArterialPCO2<30torr(c).ArterialPO2<50torr(d).Dyspnea(highlysuspicious)(e).ChestX‐ray–Negativefindings(d).Pressure–PAmean>20mm‐Hg(e).Pressure–Systolic<100mm‐Hg(f).Pulmonaryhypertension(g).Adverseevents

1).Respiratoryarrest2).Cardiacarrest3).Cardiogenicshock

f.Medicalimagingstudies(1).Non‐invasive

(a).ChestX‐ray

1).Abnormal



2).Findings‐Generala)Atelectasisb)Cavitationc)Decreasedvascularityd)Elevateddiaphragme)Fleischnerlinef)Hampton’shumg)Knucklesignh)LinearscarringI)Meltingsignj)Nodularscarringk)Non‐specificinfiltrate(s)l)Pleuraleffusionm)Pleuralopacityn)Prominentpulmonaryarterieso)Westermarksign

(b).Non‐contrastenhancedcomputedtomography

1).Atelectasis2).Consolidation3).DilatedMPA,RPA,LPA4).“Groundglass”opacification5).Hampton’shump6).Linearbands7).Pleuraleffusion

(c).Contrastenhancedcomputedtomography

1).Detects5th‐6thgenerationemboliinproximalpulmonaryarteries

2).Lowdetectionofsubsegmentalintraluminalfillingdefects

3).Poordetectionofemboliinlingularbranches4).Poordetectionofemboliinmiddlebranchesof

vessels(d).Nuclearmedicinescan

1).Probabilityscansa)Highprobabilityb)Low/intermediate



2).V/Qabnormalityvariances(postRobintest(un‐matchedperfusionventilation)

a)Hypercapneicbronchoconstrictionb)Hypoxicvasoconstriction

(e).Venography 1).Ultrasonography 2).Dopplerstudies 3).Computedtomography 4).MRI

(2)Invasiveandinterventionalmedicalimagingstudiesa).Angiography

1).Indicationsa)Ifindeterminatenuclearscan,perform<24

hoursb)Clinicalfindingsandnon‐invasivemedical

imagingstudiesdonotcorrelatec)Anticoagulationrisksexistandhigh

probabilityforPEexists2).Procedurestoconsiderpriortointervention

a)IVCfilterplacement(jugularveinapproach)b)IVCligationc)Pulmonaryembolectomy3).Proceduraltechniques

a)Catheters1)Grollmanpigtail(CookMedical)2)Angledpigtail3)Multipurpose4)Swan‐Ganz(EdwardsLifesciences)5)Balloon‐tippedtemporarypacing

catheterb)Projections

1)Postero‐lateral2)Ipsilateralposterioroblique

c)Pulmonaryvasoreactivityevaluations1)AdenosineIV–maximumdose

350µg/kg/minute



2)EpoprostenolIV–maximumdose16ng/kg/minute

3)Nitrusoxide–inhaledmaximumdose80ppmover10minutes

4).Possibleangiographicfindings

a)Abruptocclusionofpulmonaryarterybranchorbranches

b)Arterialcollateraltortuositiesc)Attenuationofarterialbrancheswith

“pruning”d)Intraluminaldefectse)Lackofvenousdrainagefromaffectedareaf)Wedge‐shapedhypovascularityofparenchyma

b).Risksandcomplicationsassociatedwithpulmonaryangiography/interventions 1)Complications

a)Angina b)Arrhythmias

1)1stdegreeheartblock 2)2nddegreeheartblock(MobitzI orMobitzII) 3)3rddegreeheartblock 4)Asystole 5)Atrialfibrillation(AFib) 6)Atrialflutter(Aflutter) 7)Prematureatrialcontractions 8)Prematureventricular

contractions 9)Rightbundlebranchblock(RBBB)

10)Ventricularfibrillation 11)Ventricularflutter 12)Ventriculartachycardia

c)Contrastmediaextravasation d)Contrastmediasensitivities

1)Itching



2)Urticaria e)ElevatedRVEDP>20mm‐Hg f)Hematoma g)Hypotension h)Impairedcardiacfunction i)Narcoticoverdose j)Nauseaandvomiting k)Pulmonaryedema l)Renaldysfunctionm)Respiratorydistress

2)Majoradverseevents a)Endocardialinjury b)Hematomarequiringbloodtransfusions c)Renalfailure=>dialysis d)Contrastmediasensitivities

1)Bronchospasm 2)Facialandlaryngealedema

e)Acutehypotension f)Cardiogenicshock g)Flashpulmonaryedema h)Respiratoryarrest i)Cardiacarrest j)CPR k)Death

6).Interventionalpulmonaryarterialproceduresandtherapy

a)Indicationsandriskstratificationsforinterventional pulmonaryarterialprocedures

1)Arterial–alveolarO2gradient≥50mm‐Hg 2)Cardiogenicshock 3)CirculatorycollapserequiringCPR 4)Clinicallyseverepulmonaryembolization 5)Contraindicationtoanticoagulativetherapy(HIT) 6)Contraindicationtothrombolytictherapy 7)Echocardiographicfindings

1)Pulmonaryhypertension 2)RVafterloadstress(↑RVEDP≥20mm‐

Hg)



8)PCWPmeanpressure≥20mm‐Hg 9)Systemichypotension≤90mm‐Hg 10)Systemichypotensionacutedrop≥40mm‐Hg

b).Systemicthrombolyictherapy 1)Heparin 2)Heparinresistance 3)Argotroban 4)Lowmolecularweightheparin

a)Enoxaparin b)Dalteparin

5)rt‐PA 6)Urokinase 7)Streptokinase 8)Warfarin

c).Percutaneousembolectomy,catheterfragmentation, andthrombectomy 1)Purpose

a)Debulkandfragmentocclusivethrombus b)Exposefreshsurfacesofthrombusto

endogenousurokinaseandother thrombolyicmedications

c)Improvecardiopulmonaryhemodynamics d)ImproveRVfunction e)Increasepulmonarybloodflowso

thrombosisareexposedtohigher concentrationsofinfusingthrombolytic medications

f)Rapidreliefofcentralobstruction g)Redistributionoflargercentralthrombus

intoperipheralbranches i)Softenthrombusmass

2)Percutaneousintroducedthrombectomydevices a)Characteristics

1)Easilyused 2)Readilypositionalwithin

pulmonaryarterialsystem 3)Easilysteeredoverangiographic

guidewires 4)Provideeasyremovalof

fragmentedthrombusintosmall fragments



5)Abilitytoreachdistalpulmonary arterialbranches

6)Havelowprofiledesignwiththe abilitytotreatlargearteries

7)Havelowcostfactors b)Typesofdevices

1)AmplatzMacerationAspiration Thrombectomycatheter(AMATC)

2)Amplatzthrombectomycatheter (BARD,Microvena)

3)Arrow‐TrerofolaPercutaneous Thrombolyticdevice(Arrow)

4)AspirexEmbolectomycatheter (StraubMedical)

5)Balloonangioplastycatheters 6)Greenfieldembolectomycatheter

(BostonScientificCompany) 7)Hydrodynamic”Hydrolyzer”

thrombectomycatheter(Cordis) 8)KenseyDynamicDevice–Trac‐

WrightSystem(DowCorning) 9)LangPercutaneousPulmonary

Thrombectomycatheter 10)Oasisembolectomy‐

thrombectomycatheter(Boston ScientificCompany

11)PulmonaryArteryStent Placement

a)Wallstentr

b)GianturcoZStent(Cook Medical)

12)Rheolyticthrombectomy “AngioJet”catheter(Possis Medical)

4.Symptomsandindicationsforinvasiveandinterventionalcarotidstudies

a.Invasive/interventionaltranscathetertherapyforcarotidrevascularization(1).Carotidstentwithdistalprotectiondeviceisfirstconsideration(CategoryA)

(2).Highrisk,anatomical/morphologynotapproachablea).Lesionisnotaccessibleforcarotidendarterctomy1).Intracranial



2).Ostialcommoncarotidlesionb).Lesionisodontoidlevelorhigher

(3).Knownhistoryofneckirradiation(4).Documentedhistoryradialneckdissection b.Surgeryisconsideredchoice(Riskfactorshigher)(CategoryB)

(1).Medicalhistory(a).Unstableangina(b).Severeocclusivecoronaryarterydisease

(c).Coronaryarteryrevascularizationneeded(d).Recentacutemyocardialinfarction(e).CongestiveHeartFailure(Class3or4)

(f).Severechronicobstructivepulmonarydisease(g).Contra‐laterallaryngealnervepalsy(2).Characteristicsofdisease

(a).Highlocationoflesion(b).Restenosisatprevioussiteofendarterectomy(c).Totalocclusionofoppositeinternalcarotidartery

(d).Medicalmanagementfactors/choices1).Carotidstentingwithdistalprotectiondevice2).Surgicalintervention

3).Patientdetermination4).Experiencelevelofvascularsurgeon

5).Experiencelevelofinterventionalists6).Experiencelevelofmedicalimagingspecialistassistant

c.Conventionalsurgicalrisks(CategoryC)(1).Surgicalaccessnotcomplicated(2).Endarterectomyischoicefortherapy

d.Carotidstenting‐highrisk(CategoryD)(1).Aorticanatomyisnotfavorable(2).Vulnerableplaquewithluminalthrombus

(3).Unabletocannulateostiumofvesselwithguidingcatheter(4).UnabletocrosslesionwithPTAguidewiresorPTAballoons(5).Sensitivitiestostainlesssteel

(6).Sensitivitiestonitinol(7).Sensitivitiestodrugelutingcoatingsonstents

e.Indicationsforacuteischemicstroketherapy (1).Acuteevent≤6hours

(2).Significantdisablingevent



(3).Majorlife‐threateningevent (4).Suspectedacuteocclusionofamajorartery

(5).Documentedacuteocclusionofamajorartery

f.Contraindicationsforacuteischemicendovasculartherapy (1).Alzheimer’sDisease

(2).Β‐amyloidangiopathy (3).Bleedingdiathesis (4).Cardiovascularvascularaccidentwithinpast3months

(5).Documentedarterio‐venousmalformation (6).DocumentedintracerebralhemorrhagebyCT (7).Durationofevent≥6hours

(8).Extendedhyperglycemia (9).Extensionofacuteischemia≥1/3areaofmiddlecerebralartery (10).Historyofasubarachnoidhemorrhage

(11).Historyofintra‐cerebralhemorrhage (12).INR≥1.7 (13).Malignanthypertension≥185/110,135mm‐Hg

(14).Onsetofevent–unknown (15).Thrombocytopenia≤100,000cells/mm3

(16).Thrombosisoflargecerebralaneurysm

5.SymptomsandIndicationsforvertebralbasilarartery revascularization a.Symptomsofvascularinsufficiency (1).Alteredstateofconsciousness

(2).Diplopia(3).Globalaphasia(4).Globaldysarthria

(5).Linguisticimpairment(6).Mentalconfusion(7).Syncope

(8).Vestibulardysfunction(a).Dizziness(b).Vertigo‐true

1).Peripheralb).Positional(9).Visualdisturbances

b.Indications–Clinicallyprovenvertebralinsufficiencyexistsc.Interventions–highrisk

(1).Maycausecritical/graveissuestobrainstem



(2).Reservedforcriticalstenosisoracuteocclusion(3).Mayrequirethrombolytictherapy

d.Neurology/Neuroradiologyconsults‐highlysuggestede.Neurologicevaluation–Sensory/Physical‐Charted(1).Pre‐procedure

(2).Pre‐ballooninflations(3).Post‐ballooninflations(4).Post‐procedure

(5).Nursemanagement–Floor(a).Continuouswithvitalsignmonitoring(b).Continuoustelemetry

(c).Priortodischargefromunit/facility(d).Follow‐upthroughphonecallsfromclinic1).OnceaweekX4

2).Onceamonthevery3monthsX43).Twiceayear(every6months)(6).Follow‐upclinicvisits

a).30daysafterprocedureb).Thenevery3monthsfor1yearc).Thenevery6months–indefinitely

d).Includesneurologyevaluations

6.SymptomsandIndicationsforinnominateandsubclavianarterialrevascularization

a.Bloodpressuredeficiencyinupperextremity b.Embolizationoffinger(s) c.Improveperfusionintointernalmammaryarteries

(1).Pre‐coronarybypassgrafting(CABG)(2).PostCABG

(a).Post‐opischemia(b).Coronary‐subclavianstealsyndromed.Re‐establishantegradeflowtodialysisgraft

e.Re‐establishflowtoaxillarygraftf.Severe/chronicupperextremityclaudicationg.Symptomaticischemiaofposteriorintra‐cranialarea

h.Symptomaticsubclavianstealsyndromei.Vulnerableplaquethreateningcerebralcirculation(stroke)

7.IndicationsforAorticRepairandRevascularization a.AscendingAortaandAorticArch



(1).1°consideration–Protectionofthebrain (2).Minimizeglobalischemiaduringsurgicallyinducedcirculatory

arrest (3).Preventairembolization(4).Reduceatheromatousplaquemigration

(5).Dissection>Emergentsurgeryb.Aneurysms (1).ImagingStudies‐Chestradiography

(a).Possiblewideningofmediastinum (b).Possibledisplacementofcalcifiedintimaofaorta(intimalflap)

(c).ChangesinaorticknobwhencomparedtopreviousStudies (d).Possibleperi‐aortic“haziness”

(e).Possibleleftlunginfiltrateandpleuraleffusion(2).Trans‐esophagealechocardiogram(a).LVfunction

(b).Aorticvalvedisease1).Threeleaflets2).Bicuspid

3).Stenosis4).Regurgitation (c).MRI

1).“Goldstandard” 2).Sensitivity≥90% 3).LVfunction

(d).Aorticvalve1).Threeleaflets

2).Bicuspid

3).Stenosis4).Regurgitatione).Greatvesseldisease

1).Anatomicalorigin2).Occlusivediseasea)Innominate

b)Leftcommoncarotidc)LeftSubclaviand)Carotidbifurcation

f).Notconsideredforstableintubatedpatients



(3).Multi‐detectorCTScanwith3‐Dpost‐processing a).Sensitivity≥83%

b).LVfunctionc).Aorticvalvedisease1).Threeleaflets

2).Bicuspid3).Stenosis4).Regurgitation

d).Greatvesseldisease1).Anatomicalorigin2).Occlusivedisease

a).Innominateb).Leftcommoncarotidc).LeftSubclavian

d).Carotidbifurcation(4).Ascendingaortographywithselectivecoronaryangiography

a).Requiredif≥40yearsofage

b).Required≤40yearsofage 1).AbnormalECG 2).Historyofangina

3).Historyoftobaccoabusec).Familialhistoryofcoronaryarterydisease

(5).Percutaneouscoronaryinterventionofsignificantcoronaryarterialocclusivedisease.

a).≥2weeksbeforeaorticrepair

b).Reducesriskofiatrogeniccoronarythromboticsequelae(6).Coronarybypassgraftrevascularization(CABGR)

a).Performedifeasilythroughaleftthoracotomyb).Performedseveralweekspriortoaorticaneursymal repairifleftthoracotomyisnotafeasibleapproach

(7).PulmonaryDisease a).Historyofexerciseintolerance b).(+)Pulmonarytests

c).PulmonaryConsultationneeded d).Pulmonaryinfectiontreatedpriortoprocedureorsurgery

e).Tobacco(smoking)cessation≥one(1)monthpriortoprocedure



f).COPDnotacontraindicationunless1).Dysfunctionincreases

2).O2dependenceoccurs3).CO2retentionoccurs(8).Considerationsforpercutaneousprocedures

a).Nothingcurrentlyexceptforcoronaryarterial interventions b).Standardworkupforrightandleftheartand/or

aorticstudiestoaidsurgeonsandotherspecialists withappropriatemedicalplanofcare

c.Thoraco‐abdominalaorta(1).Anatomicrequirements–Thoracicaorticaneurysmstent/graft

placements (a).Neckofaneurysm≥1.5‐2.5cmdistalofostiumofleft

subclavianartery(b).Neckofaneurysm≥1.5‐2.5cmproximalofostiumofceliac

artery

(c).Diameterofaneurysmnecksabletoaccommodate on‐handdevice(2).Luminalpathophysiology(aorta&Iliacvessels)

(a).Activeplaqueburden(b).Atheroscleroticplaqueburden (c).Calcification

1)Moderate 2).Severe (d).Tortuosity

1).Moderate 2).Severe(3).Preoperativeevaluation

(a).Assessmentrequirements 1).Cardiopulmonaryfunction a).Chronicobstructivepulmonarydisease

b).Pulmonaryhypertension 1)Malignant–non‐responsive 2)Medicaltherapy–responsive

c).Myocardialfunction 1)Historyofpreviousmyocardialinfarction 2)Leftventricularfunction

a)Normal



b)Impaired(EF35‐50%)c)EF≤35%

3)Congestiveheartfailure 2).Renalfunction a).Normal

b).Impaired(GFR<60) (b).Detailevaluations(imagingstudies) 1).Chestandabdominalradiograph

a).Possiblewideningofmediastinum b).Possibledisplacementofcalcifiedintimaofaorta(intimalflap)

2).Transesophagealechocardiograma).LVfunctionb).Aorticvalvedisease

1)Threeleaflets2)Bicuspid3)Stenosis

4)Regurgitation 3).MRI/MRAa).“Goldstandard”

b).Sensitivity≥90% c).LVfunction

4).Aorticvalvediseasea)Threeleafletsb)Bicuspid

c)Stenosisd)Regurgitation5).Greatvesseldisease

a)Anatomicaloriginb)Occlusivedisease1)Innominate

2)Leftcommoncarotid3)LeftSubclavian4)Carotidbifurcation

6).Visceralvessels a)Anatomicorigin 1)Normal

2)Congenitalvariants b)Occlusivedisease/tortuosity



1)Celiac 2)SMA

3)Renals i.Singlevessel ii.Multiplevessels

4)Ilio‐femoral 7).Notconsideredforstableintubatedpatients

(c).Multi‐detectorCTScanwith3‐Dpostprocessing

1).Sensitivity≥83%2).LVfunction3).Aorticvalvedisease

a)Threeleafletsb)Bicuspidc)Stenosis

d)Regurgitation4).Greatvesseldiseasea)Anatomicalorigin

b)Occlusivedisease1)Innominate2)Leftcommoncarotid

3)LeftSubclavian4)Carotidbifurcation

5).Visceralvessels a)Anatomicorigin 1)Normal

2)Congenitalvariants b)Occlusivedisease/tortuosity 1)Celiac

2)SMA 3)Renals i.Singlevessel

ii.Multiplevessels 4)Ilio‐femoral

(d).Aortographywithselectivecoronaryangiography

1).Requiredif≥40yearsofage 2).Required≤40yearsofage a).AbnormalECG

b).Historyofangina c).Historyoftobaccoabuse



d).Familialhistoryofcoronaryarterydisease e).Hypertension

3).Percutaneouscoronaryinterventionofsignificantcoronaryarterialocclusivedisease.

a).≥2weeksbeforeaorticrepair

b).Reducesriskofiatrogeniccoronarythromboticsequelae4).Coronarybypassgraftrevascularization(CABGR)

a).Performedifeasilythroughaleftthoracotomy b).Performedseveralweekspriortoaortic aneursymalrepairifleftthoracotomyisnota

feasibleapproach5).PulmonaryDisease a).Historyofexerciseintolerance

b).(+)Pulmonarytestsc).PulmonaryConsultationneeded d).Pulmonaryinfectiontreated

priortoprocedureorsurgery6).Tobacco(smoking)cessation≥one(1)monthpriortoprocedure

7).COPDnotacontraindicationunless1).Dysfunctionincreases

2).O2dependenceoccurs3).CO2retentionoccurs(e).Considerationsforpercutaneousprocedures

(1).Standardworkupforrightandleftheartand/oraorticstudiesto aidsurgeonsandotherspecialistswithappropriatemedicalplanof

care

(2).Comorbidities (3).Proceduralrisks (4).Considerations

a).Landingzonesites b).Locationoforiginsofmajoraorticbranches c).Suitableaccesssites

d).Degreeoftortuousity 1).Accesssites 2).Aorta(abdominal,thoracic)

e).Typesofaorticdissections 1).DeBakeyclassifications



a)TypeI 1)Ascending

2)Tranverse 3)Descending 4)Abdominal

5)Extensionintoiliacs a)TypeII–ascending b)TypeIII–descending

2)Stanfordclassifications– a).TypeA(DebakeyTypesI&II) 1)Ascending

2)Tranverse 3)Descending 4)Abdominal

5)Extensionintoiliacs b).TypeB–(DeBakeyTypeIII)Descending

(5).Detailedevaluation a).Ascending,tranverse,andthoracicaorta 1).Spiralcomputedtomographicangiography

2).Magneticresonanceangiography 3).3‐Dreconstructions 4).Aortographywithpelvicarteriography

a)Goldstandard b)Anatomicalreview i.Lesions

ii.Accessvessels 5).Dimensionalmeasurements a)Aidsinselectionofdevice

b)Diameter c)Length b).Abdominalaorta

1).3‐DCTwithCTA 2).3‐Dreconstructions a).Dimensionalmeasurements

1)Aidsinselectionofdevice 2)Diameter 3)Length

b).Software‐driven 3).Magneticresonanceangiography



4).Aortographywithpelvicarteriography a)Problemresolution(CTnotspecific)

b)Contrastmedia‐renalinsufficiency 5).Dimensionalmeasurements a)Diameter

b)Length c)Selectionofdevice (f).DeploymentofStent/Graft

(1).Thoracicaorta a).Instrumentationrequirements1).Blood‐recyclingcellsaversystem

2).Cardiopulmonarybypass(onstandby) 3).Digitalimagingwithroadmapping 4).EKGandBloodpressuremonitoringequipment

5).Highqualityfluoroscopicequipment 6).Intravascularultrasonography7).On‐standbyequipment

a)Blood‐recyclingcellsaversystem b)Cardiopulmonarybypass 8).Pulseoximetryunits

9).Transesophagealechocardiographyunit b).Anesthesiarequirements

1).Generalanesthesiaunits 2).Intubationequipment 3).Possiblealternativeanesthesia

a)Local b)Regional c).Accesssites

1).Femoralartery 2).Iliacartery(surgicalaccess) 3).Infrarenal(surgicalaccess)

d).Medicalmanagement 1).Anticoagulation(heparin) 2).Bloodpressurecontrol(inducedhypotension)

3).Inducedasystole(adenosine) e).Post‐surgicalevaluation 1).CV‐ICU12‐24hours

a).Extubation b).Stablehemodynamics



2).Imagingevaluation a).CTstudypriortodischarge

b).CTstudy@6months c).CTeveryyear 3).Diagnosticevaluation

a).Devicefailures b).Endoleaks 1)OneormorerequireCT

followupat1‐3months 2)Reinterventionmaybe warranted

3)∆’sinlesionmorphology 4).Post‐implantationsyndrome a).Febrileillness

b).Leukocytosisc).IncreasedC‐reactiveprotein 1)Noinfectionpresent

2)Physiologicalreactiontograftmaterial (2).Abdominalaorta

a).Clinicalapproach 1).Lowriskanatomy

a)Lowriskpathophysiology–surgery b)Highriskpathphysiology–endovascular

stent/graftrepair

2).Highriskanatomy a).Lowriskpathophysiology‐surgery b).Highriskpathphysiology–endo‐vascular

stent/graftrepair b).Instrumentationrequirements1).Blood‐recyclingcellsaversystem

2).Cardiopulmonarybypass(onstandby) 3).Digitalimagingwithroad‐mapping 4).EKGandBloodpressuremonitoringequipment

5).Highqualityfluoroscopicequipment 6).Intravascularultrasonography7).On‐standbyequipment

a)Blood‐recyclingcellsaversystem b)Cardiopulmonarybypass



8).Pulseoximetryunits 9).Transesophagealechocardiographyunit

c).Anesthesiarequirements 1).Generalanesthesiaunits 2).Intubationequipment

3).Possiblealternativeanesthesia a)Epidural b)Local

d).Accesssites 1).Percutaneous–femoralartery 2).Cutdown–femoralartery

e).Anticoagulation(heparin) f).Postsurgicalevaluation 1).CV‐ICU12‐24hours

a).Extubation b).Stablehemodynamics 2).Imagingevaluation

a).CTstudypriortodischarge b).CTstudy@6months c).CTeveryyear

3).Diagnosticevaluation a).Devicefailures

b).Endoleaks 1)OneormorerequireCTfollowupat1‐3months

2)Reinterventionmaybe warranted 3)∆’sinlesionmorphology

4)Post‐implantationsyndrome a).Febrileillness b).Leukocytosis

c).IncreasedC‐reactiveprotein 1)Noinfectionpresent 2)Physiologicalreactiontograft

material (g).Managementofendoleaks 1).Typesofendoleaks

a).TypeI‐Proximalanddistalflowaroundstent/graft



b).TypeII‐Retrogradeflowofaorticbranchvesselsintoaneurysm‐Morphologicaltypes

1)1st–Retrogradeflowthroughsingle aorticbranchintoaneurysmalsac

2)2nd–Retrogradeflowintooneaortic

branchintothesac,endoleakcavity, andoutanotheraorticbranch c).TypeIII‐Mechanicalfailureofthestent/graft

d).TypeIV‐Increasedporosityofgraftfabric 2).Identificationandclassificationofendoleaks a).DynamicCTangiography

1)Canidentifyifconditionexists 2)Cannotseparatetypes 3)Cannotdeterminedirectionofflow

b).Dedicatedangiography 1)Distinguishestypes 2)Determinesdirectionofflow

3)Mayrequireprolongedcontrastmediainjectiontodeterminecollateralendo‐

leaks(SMA)

4).Angiographicevaluation a)PA–Proximalattachmentarea

b)Lateral–Proximalattachmentarea c)RAO45°‐Graft&distalattach‐ ment

d)LAO45°‐Graft,distalattachment, andlumbararteries e)LAO10°‐SMA–IMAcollaterals

c).Treatmentforendoleaks 1)Pre‐discharge–CTangiography(CTA) 2)Followups–30days–CTA

a)NoendoleakCTA‐6–12months b)Endoleak–CTA–6months 3)Treatment

a)TypeI i.PTA(balloons,stents),

extendercuffs

ii.Thrombosesofsac b)TypeII–Translumbarendoleak



embolization(coils&glue) c)TypeIII

i.Correctmechanicaldefect ii.Thrombosesac iii.Possibleremoval

d)TypeIV–Correctcoagulation factors d)Limbkinking‐iliacs

1)Stent 2)Stentgrafts 3)Existenceofthrombosis

a)Thrombectomy b)Thrombolysis

8.Indications&ConsiderationsforVisceralArterialRevascularization a.Symptoms1.Abdominalpain(a).Postprandial

(b).Cramping(c).Location

1).Epigastric

2).Mid‐abdominal(d).Cachexia(e).Diarrhea

(f).Regurgitation (g).Constipation b.Considerations

1.Degreeofvisceralarterialocclusivedisease (a).Celiacarterialsystem (1).Stomach

(2).Proximalhalfofduodenum(proximaltoLigamentofTreitz)

(b).Superiormesentericarterial(SMA)system

(1).Distalduodenum(distalofLigamentofTreitz) (2).Jejunum (3).Ileum

(4).Cecum (5).Ascendingcolon (6).Hepaticflexure

(7).Proximaltwo‐thirds(2/3)transversecolon



(c).Inferiormesentericarterial(IMA)system (1).Distalone‐third(1/3)transversecolon

(2).Splenicflexure (3).Sigmoidcolon (4).Rectum

(5).Superioranalcanal 2.PathwaysandDegreeofVisceralArterialCollateralization (a).CeliacTrunkOcclusiveDisease

(1).Pancreatico‐duodenalarteries (2).SMABranches (b).SuperiorMesentericOcclusiveDisease

(1).Pancreaticoduodenalarteries (2).Mammaryarteries (3).Gastroepiloic

(4).Middlesacralarteries (5).Externaliliacarteries (6).Hypogastricarteries

(7).Riolan’sarches(splenicflexure) (c).InferiorMesentericOcclusiveDisease (1).SMA=>ArcofRiolan(Splenicflexure)

(2).Lumbosacralarteries (3).Middlesacralarteries

(4).Externaliliacs(5).Internaliliacs 3.Stenoticoroccludedoftwoorthreeofmajorostiaofvisceralarteries

4.Lesionsusuallyostialorproximal

9.Signsandsymptomsthatinfluenceinvasive/interventionaltrans‐cathetertherapy(TCT)forpercutaneousperipheralrevascularization.

a.Categoricalclassificationsofacutelimbischemia

(1).Viablelimb(a).Limbnotthreatened(b).Intactcapillaryreturn

(c).Nomuscleweakness(d).Nosensoryloss(e).Dopplerultrasoundstudies

(a).Arterial‐audible(Distalvesselpressure≥30mm‐Hg(b).Venous‐audible(2).Threatenedlimb

(a).Iftreated,salvageability



(b).Intactbutslowcapillaryreturn(c).Mild(partial)muscleweakness

(d).Incomplete(mild)sensoryloss(e).Dopplerultrasoundstudy1).Arterial–notdetected

2).Venous–detected(f).Irreversible1).Majortissuenecrosis

2).Possiblepartialsalvageability(lineofdemarcation)3).Likelihoodofamputation–high4).Capillaryreturn–non‐existent

5).Muscleweakness–moderate/high‐paralysis6).Sensoryloss‐moderate/high‐anesthetic7).DopplerUltrasoundstudies

a).Arterial–non‐detectionb).Venous–non‐detectionb.Categoricalclassificationsofchroniclimbischemia

1.Grade0(a).Asymptomatic–Treadmill/stresstest‐normal(b).Mildclaudication

(1).Treadmillexercisetest–completed(2).Postexercisedistalpressure‐≤50mm‐Hg

(3).∆P(Brachial–Leg)>25mm‐Hg<Brachial2.GradeI(a).Moderateclaudication–betweencategories1&3

(b).Severeclaudication‐Treadmillexercisetest–Unabletocomplete3.GradeII(a).Ischemicpainatrest

(1).Restingdistalpressure<60mm‐Hg(2).Ankle/metatarsalpulsevolume–transient(3).Pressure‐toe<40mm‐Hg

(b).Minortissueloss(1).Ulcer–non‐healing(2).Gangrene‐focal

(3).Pedalischemia–diffuse(c).Salvageability–good/fair(d).Otherfindings

(1).Restingdistalpressure‐<40mm‐Hg(2).Ankle/metatarsalpulsevolume–none/transient



(3).Pressure‐toe<30mm‐Hg4.GradeIII

(a).Majortissueloss(1).Extendsabovemetatarsalarea(2).Foot–non‐functional

(3).Salvageability–poor/none(b).Otherfindings(1).Restingdistalpressure–<40mm‐Hg

(2).Ankle/metatarsalpulsevolume–none/transient(3).Pressure‐toe<30mm‐Hg

VI.ConsiderationsforVascularAccessA.Requiresknowledgeofsterileprocedure,draping,andlocalanesthesiaB.RequiresdexterityandproficiencywithaccessmethodC.Vascularapproaches1.Arterialapproaches

a.Axillaryb.Brachial c.Femoral

d.Pedal (1).Dorsalispedis(2).Posteriortibial

e.Wrist (1).Radial (2).Ulnar

f.Retrogradefemoralg.Translumbar2.Venousapproaches

a.Antecubitalb.Antegradesaphenous c.Axillary

d.Basilice.Cephalic

f.External(short)saphenous g.Femoralh.Internaljugular

i.Internal(long)saphenousj.Popliteal



f.SubclavianD.Requiresknowledgeandexperienceofangiographicmaterials

1.Guidewiresa.Hydrophilicwiresb.Steerablewires

2.Sheathsa.Standardlengthsheaths b.Longsheaths

3.Catheters (1).Cerebralangiography(a).Intracranial

(b).Extracranial(2).Neckarteriographyandvenography(3).Upperextremityarteriographyandvenography

(4).Thoraciccavityarteriographyandvenography(5).Abdominalangiographyandvenography(6).Pelviccavityarteriographyandvenography

(7).Lowerextremityarteriographyandvenography4.Contrastmediaandfluoroscopyforguidance5.Fluoroscopytoidentifytheappropriatefemoralpuncturesite

6.Micropuncturetechniques7.Vascularultrasound

8.Distalprotectiondevices

VII.AngiographyA.Musthaveknowledgeofsizeandstyleofcatheters1.Diagnosticcatheters2.Interventionalcatheters

3.Sheaths(Long,short)B.Musthaveknowledgeofcathetersusedtoperformangiographicproceduresaslisted: 1.Aorticstent/stent‐graftinterventionalstudies

2.Aortography(Ascending,Arch,Descending,Abdominal) 3.Cerebralandneckangiography/interventionalprocedures

4.Gonadalangiography/venography‐interventionalprocedures 5.Hepato‐portalvenography/interventionalstudies6.Leftheartandcoronaryangiography

7.Lowerextremityarteriographyandvenography/interventionalprocedures8.Pelvicarteriographyandvenography–interventionalprocedures



9.Pulmonaryangiography–interventionalprocedures10.Renaldialysisshunt/graftangiograms/interventionalstudies

11.Rightheartcatheterizations–hemodynamics/cardiopulmonarycalculations11.Selectivebronchialarteriography/interventionalprocedures12.Selectiverenalangiography/interventionalprocedures

13.Selectivevisceralangiography/interventionalstudies(celiac,SMA,IMA)14.Upperextremityarteriographyandvenography/interventionalprocedures C.Mustrecognizepressuredampeningquickly,understandsimplications,andnon‐seatingof

cathetersD.Mustobservesostialpressuresbefore,during,andaftercontrastmediainjectionsinjections

E.Mostensuresadequatevesselopacificationwithappropriateamountofcontrastmediaand forceduringsystoleanddiastolecycleswithoutinjectinganairembolusorthrombusF.Mustrespondrapidlytopost‐injectionadverseevents

G.Mustdetermineangiographicviewsthatpermitsqualityimagingwiththelesseruseof contrastmediaandradiationexposureH.Mustcommunicateexpectationswithpatienteffectivelythroughoutprocedure

I. Must couple knowledge with dexterity to cross normal or diseased aortic valves withappropriatetechniques,projections,catheters,andguidewireoptions

K.Mustunderstandnecessityofproperpanningsequenceswithexcellenthandcoordination

L.Mustunderstandimportanceofpanningwhencollateralvesselsfilldistalareasofcontra‐lateralandipsilateraloccludedarteries

M.MustunderstandhowtouseexchangewirestochangecathetersN.Mustspecifyadequatemeteredcontrastmediainjectionratesforcoronaryangiography,

injections.

O.Mustcorrelateshemodynamicvalueswithcontrastmediastudiesoftheheartchambersandpulmonarycirculation

P.Mustbeabletooperateintra‐balloonpumpsandmanagepatientsincardiogenicshock

Q.Musthaveskillstomanagepossiblecomplicationsataccesssite

VIII.CardiovascularHemodynamics,Physiology&PathophysiologyA.SystemInstrumentation1.Fluid‐filledpressurerecordingsystems

a.Calibrationoftransducersb.Troubleshootingsystemc.Physicsoffluidfilledelectro‐mechanicalpressuresystems

d.Knowledgeofoperation2.Pressurewiresystems



a.Physicsoffluidfilledelectro‐mechanicalpressuresystemsb.Calibrationofpressurewire/guidingcatheter

c.Troubleshootingpressurewiresystemd.KnowledgeofoperationofequipmentB.CardiacPhysiology

1.Leftheartpressures(AO,LV,LVEDP,LA)2.Rightheartpressure(RA,RV,RVEDP,MPA,RPA,LPA,PWCP)3.Oximetry

4.Cardiacoutput/index5.VascularResistance(SVR,PVR)6.CardiacPharmacology

7.ExercisephysiologyC.CardiovascularPathophysiology

1.Cardiogenic

a.Ischemicb.Non‐ischemicc.Myocarditis(bacterial,mycotic,parasitic,rickettsial,viral)

2.HypotensiveCardiacDiseasea.Vaso‐vagalreflexreactionsb.Non‐cardiacetiologies

(1).Allergies(a).Antibiotics

(b).Contrastmedias(c).Analgesics(e.g.Dilaudid,Fentanyl,Morphine)(d).Benzodiazepines(e.g.Valium,Versed)

(2).Volumedependent3.Peripherala.Arterialatheroscleroticocclusivedisease

(1).Cerebral(a).Intracranial(b).Extracranial

(2).Neck(3).Upperextremities(4).Thoraciccavity

(5).Abdominalcavity(6).Pelviccavity(7).Lowerextremities

b.Venousdisease (1).Cerebral



(a).Intracranial(b).Extracranial

(2).Neck(3).Upperextremities(4).Thoraciccavity

(5).Abdominalcavity(6).Pelviccavity(7).Lowerextremities

IX.CardiovascularPharmacologyA.Pre‐Procedurepreparationfordiagnosticandinterventionalstudies.

1.Preparationofthepatientandpreviouslyprescribedmedications.

a.NoPOclearliquidsexceptsufficientamounttotakeoralmedications3hourspre‐procedureandnofullliquidsorsolidfoodfor7hoursforelectiveprocedures

b.Scheduledoralmedicationsandanti‐anginalmedicationsshouldbecontinued.Aspirin,clopidogrel,nonsteroidalanti‐inflammatorymedicationsneednotbediscontinue

c.IfaheparinIVinfusionisbeingadministeredforunstableorcrescendoangina,discontinuanceisnotnecessary

d.IVaccessshouldbeobtained.

e.IVfluidsmaybenecessarytomaintainhydrationoftherenalbodiesexceptforpatientswithahistoryofCHForpulmonaryedema. (1).MostcommonIVfluid0.9%NaClSolution

(2).OtherIVsolutions (a).0.45%NaClsolution

(b).Dextrose5%/0.45%NaClsolution (c).LactatedRingers (3).RateofIVinfusions

(a).CHF/Pulmonaryedema–Keepveinopen(KVO) (b).Normalhydration‐75cc/hr (c).Dehydration–125–150cc/hrfor1hourthen

75cc/hrIV2.Diabeticpatientsshouldhavebloodglucoselevelsshouldbedonebeforetheprocedure

a.Ifbloodglucosereadingsareover200,shortactingliprooraspartinsulinshouldbegiven.(1unitofinsulinper50pointsabove200)

b.IfhypoglycemiaD5WIVinfusionmaybewarrantedindiabetics



c.Betablockersmaymaskusualsymptomsofhypoglycemiad.Ifsuddenchangesinconsciousnessorotherphysiologicalparameters

occur,thenadministrationofD50mustbegivene.Ifprocedureisdelayedsignificantly,bloodglucoselevelsshouldbe

repeatedpriortoprocedure

3.INRlevelsshouldbelessthan2.0,oralanticoagulationmedicationsshouldbediscontinueda.Ifchronicanticoagulationexists,admissiontoahospitalsoIVadministration

ofweight‐basedheparinmaybegivenover48hourspriortoprocedureb.Anticoagulationmayrequirereversalwithfreshfrozenplasmac.IfVitaminKisadministered,patientmustbeassessedforinduction

ofahypercoagulationstated.Alternativevascularaccessshouldbeconsidered(radialapproach)4.Diureticsareusuallyheldpriortoprocedure

5.Anti‐anginalsandantihypertensivemedicationsmaybegivenwithsmallsipsofwater.(Vitalsignsarerecordedbeforemedicationsaregiven)

B.Pre‐medicationsadministeredpriortoprocedure

1.Allergypreparation(contrastmedia)‐SCAIguidelinesa.Antihistamines(H1Blockers,e.g.diphenhydramine)b.Histamines(H2antagonists,e.g.cimetidine,famotidine)

c.Steroids(e.g.prednisone,hydrocortisone)d.Bronchodilator(albuterolinhaler)

e.Standardprotocolforprophylaxisshouldbeestablished2.Betablockers‐discontinueinallergicpatientsifpossible3.Pre‐proceduresedation

a.Benzodiazepines(1).Oral(diazepam)(2).IV(diazepam,midazolam)

b.Antihistamines(1).H1Blocker‐diphenhydramine(Oral,IV)(2).H2histamineantagonists,cimetidine,famotidine(IV)

c.Analgesics(1).Sublimaze(2).HydromorphoneHCl

(3).Morphinesulfate

C.Medicationsusedduringprocedure1.ContrastMediaa.Ionic

b.Nonionic



c.Lowosmolalityd.Nonionicandlowosmolality

e.Costcontainmentfactorsf.Indicationsandbenefitsg.Complications

(1).Nephrotoxicity(2).Myocardialdepression(3).Dysrhythmias

(4).Thromboticeventsh.Knownrenalimpairmentorfailure(1).GFR<60

(2).Creatinine>1.4(3).Sodiumbicarbonatehydrationshouldbeused

2.Medicationsduringprocedures

a.Oxygen(maintainpulse‐oxlevelsbetween96‐100%)b.Sedatives(diazepam,midazolam)c.Analgesics‐PainManagement(Sublimaze,hydromorphone,morphine)

d.Reversalagents(1).NalozoneHCl(narcotics)(2).Flumazenil(benzodiazepines)

e.Bradycardia‐Atropinef.Supraventriculartachycardia

(1).Adenosine(2).AmiodaroneHCl(3).Calciumchannelblockers(e.g.DiltiazemHCl,VerapamilHCL)

(4).Ibutilidefumarateg.Hypertension

(1).Nitroglycerin(sublingualorIV)

(2).BetaBlockers(e.g.metoprololHCl,propanololHCl)(3).Nitroprussideh.Hypotension

(1).Dopamine(2).Dobutamine(3).Epinephrine

(4).Norepinephrine(5).Phenylephrine(onlypressorusedwithSVLVOFO‐HOCM)(6).Vasopressin

i.Nausea(1).Metoclopramide



(2).OndansetronHCl(3).PromethazineHCl(maylowerlevelofconsciousness,cause

transienthypertensionorhypotension,disturbedcoordination,andrestlessness)

(4).Droperidol(maycausehypotensiveevent)

(5).HydroxyzineHCl(onlyIMorPO.)j.Anaphylaxis/allergicreactions(SCAIguidelines)(1).Albuterolinhaler(bronchospasm)

(2).Hydrocortisone(3).H1antihistamines(diphenhydramineHCl)(4).H2histamineantagonists(cimetidine,famotidine)

(5).ACLSguidelinesforrespiratoryarrestandcardiacarrestk.Ventricularectopy(1).LidocaineHCl

(2).AmiodaroneHCl(3).ProcainamideHCll.Anticoagulants

(1).Heparinsodium(2).Bivalirudin(3).Glycoproteinllb/lllaplateletaggregationinhibitors

(a).Abciximab(ACSwithplannedPCI<=24hours)(b).Eptifibatide(ACSwithplannedPCI<=24hours)

(c).Tirofiban(ACSorPCI)(d).Clopidpgrel(Loadingdose600‐900mg,then75mgPOODfor3months=>indefiniteduration)

m.Renalinsufficiency/renalfailure(GFR<=60)(1).Acetylcysteine(600mgPO)(2).SodiumbicarbonateIVinfusion

(3).Hydration(4).Hemodialysisafterprocedure,ifpatientisondialysisn.Fibrinolytics

(1).Alteplase(2).Reteplase(3).Streptokinase

o.Seizures(1).Diazepam(2).Phenytoin

(3).Clonazepam



X.Post‐ProcedureCareA.Technicalcognition1.Evaluationanddocumentationofvascularintegrity2.Immediatepost‐proceduralpatientcare

3.Monitoringandlocationofpatientforpost‐proceduralcare4.LengthofbedrestandimmobilizationofextremityB.Managementofcomplications

1.Adversecontrastmediasensitivitiesa.Urticaria(mild,moderate,severe)b.Anaphylactoidreactions(mild,moderate,severe)

c.AnaphylacticShock(1).Respiratorydistressandarrest(2).Cardiacarrest

d.CurrentACLSandPALSguidelines2.Adversemedicationsensitivities.a.Urticaria(mild,moderate,severe)

b.Anaphylaxis(mild,moderate,severe)c.Anaphylacticshock(1).Respiratorydistressandarrest

(2).Cardiacarrestd.CurrentACLSandPALSguidelines3.KnowledgeofECGrhythmsandcardiacdysrhythmias

4.Systolicanddiastolicleftventriculardysfunction5.Accesssitesa.Hematoma

b.Hemorrhage(retroperitoneal,external)c.A‐Vfistulaed.Pseudo‐aneurysms

e.Thromboticandembolicevents6.Neurologiceventsa.Transientischemicattack(TIA)

b.Blurredorlossofvisionc.Lossofsensoryfunction

d.StrokeorCVAe.Lossofmotorfunctionf.Paresisorparalysis

C.Hemodynamicandangiographicinterpretation1.Hemodynamicanalyses



a.Principlesandmethodsofcalculatingcardiacoutputs(1).Angiographic

(2).Approximate(3).Fick(4).Thermodilution

(5).Sphygmomanometryandtonometry b.Calculationsofstenoticvalvularareas(handmethod,computer‐assisted)

c.Calculationofintracardiacshuntratios(1).Oxygensaturationdetermination(2).Qp:Qsratiodetermination

(3).Correlationwithechocardiographyd.Analysesandexplanationofpressurewaveformsandmeasurements

(1).Rightheart(2).LeftHeart(3).Stenoticvalvulargradients

(4).Stenoticarterial–arterialgradients(5).Aorticpressure‐hepaticvenouswedgeratio 2.Communicative(bedsidemanner)skills

a.Discussesdiagnosiswithapatientandfamilymembersb.Discussesprognosis,alternativetreatmentregimens,and

needforcomplianceofmedicalmanagementplansasexpectedunderHIPAAguidelinestomaintaincontinuityandstandardsofcarewith:

(1).Patient(post‐sedatedstate)

(2).Familymembers(3).Referringphysician(4).Consultingsurgeons

(5).Directlyinvolvedalliedhealthcareteammembers3.Finalcompletediagnosticreporta.Structureofmedicalrecord

(1).Hasallrequireddatabeencollectedonthepatient?(a).Problemlist 1)Servesastableofcontentsofillnesses

2)Linksproblemsofapatienttostructuresofcare,education,andcompliance(b).Requiredforcompletediagnosis

1)Etiologicidentification 2)Abnormalanatomy



3)Physiology (a)Clinicalmanifestations

(b)Molecularbiology (c)Pathophysiology (d)Prognosis

(e)Treatment 4)Organstatus 5)Relationofprognosisanddisease

(c).Requirestransferofmedicalknowledgeofthepatienttothecareofthepatient

(d).Mustincludeabnormalitiesnotrelatedtocomplete

diagnosis 1).Reflectslowerlevelsofresolution2).Completepossiblecausesofeachproblem

3).Solvedproblemsincreasedtohigherlevelofresolution

(e).Mustreflectuppermostresolution

(f).Mustbekeptup‐to‐date(g).Createplansforeachproblem 3.Completionofplans

a.Mustbedisplayedinpatient’schartforeasierreview b.Requiresthreepartsforplanswithexcellence

(1).Diagnosticplans (a).Determineseverityofproblemaspartof completediagnosisthroughappropriate

diagnosticprocedures (b).Yieldsusefulinformationforspecifictreatmentfordefinitiveproblemduringfollow‐ups

(c).Elevateslowerlevelproblemstoberesolvedatathigherlevelsofresolution

1).Requirescreationandlistingofdifferential

diagnosis2).Requiresprocedureusedtoclarifyproblemtobelisted

(2).Therapeuticplans (a).Requiredforeachmedicalplan (b).Includesallmedications(currentandformer)

(c).Includesallplannedinvasive,interventional,andsurgicalprocedures



(d).Numberingandtitlingofordersonordersheetmatchnumberofeachlistedproblem

(1).Sensibleidentification (2).Enablesotherphysicianstolinka writtenorderandmanagedproblem

(3).Helpsallotherrelatedalliedhealthcaregiverstounderstandtheprocessplannedmethodsofcare

(3).Educationalplans (a).Indicateslevelofphysician‐patientcommunication (b).Indicatesviewsofattendingphysicianmanaging

thecareofapatient (c).Helpsphysicianextenders,nurses,technologists i.e.clarifyphysician’sviewsforapatient’scare

(d).Providesthehighestelementsofstandardsof careandcontinuityofcare

4.Progressnotesa. Recordobservationsinprogressnotesb. Numberandtitleequivalentlylabeledlistofproblemsonlist

ofproblemsandinallplansc. Determineschangeincharacteristicsofproblem(s)followedd. Listchangesinsymptoms,laboratoryvalues,physicalexaminations.i.e.e. Usedatatoorganize:

(1).Newsubjectivedata(2).Newobjectivedata(a).Bloodpressure

(b).Cardiovasculardisease(c).Functionalcapacity(d).Neurologicchanges

(3).Newassessmentofnewdata(4).Newplans(a).Diagnosticstrategies

(b).Therapeuticmodifications(c).Educationalstrategies1).Compliance

2).Non‐compliance(d).Flowsheets

5.Flowsheets

a.Establishesinter‐relationshipbetweenmultipleitems b.Displaysdatafromtreatmentofspecificproblems



c.Assessesrelationshipofvariableswitheasinessd.Indicatedclinicalpathways

(1).AbdominalAorticAneurysmRepair (2).CardiacCath/PCI/Stent (3).CardiacSurgery

(4).CarotidEndarterectomy‐VascularSurgery (5).Carotid/CerebralAngiography/PTA/Stent (6).CerebralVascularAccident

(7).CerebralHemorrhage (8).Craniotomy (9).EndofLife

(10).EPS/Ablation(11).Pacemaker/ICD (12).PeripheralVascularDisease/Arteriography/PTA/Stent

(13).ThoracicAorticAneurysmRepair(14).VisceralAngiography/PTA/Stent

XI.RadiationSafetyGuidelines,DoseLimits,Safety,BiologyA.Radiationsafetyguidelines/radiationdoselimits1.Maximumpermissibledoses(MPD)

a.Physicianresponsibilitiesaretoreduceradiationdosestopatients,supportstaff,andhim(her)selfthroughexcellentknowledgeofgeneralexposureguidelinesforoccupationalworkersandnon‐occupational

persons.b.Supportstaffteammembersareresponsibleforadheringtothegeneral

guidelinesforoccupationalandnon‐occupationalpersons

c.Generalexposureguidelinesforoccupationalworkers.d.Tissueweightingfactorsalongwithsensitiveorgans2.Fluoroscopyvs.digitalimagingradiationexposure

a.Basicfluoroscopy–5R/min(Mostsystemsfunctionbetween2‐3R/min)

b.Digitalimagingangiography@15fpsfor7‐8secondscangenerate

exposurelevelsthatexceedlevelsproducedwithfluoroscopyc.Highdosefluoroscopy(1).Nolimitonexposure(R/min)

(2).Mosthaveacontinuousaudiblesoundwhenused(3).Requiresconstantmanualpedalusage3.Radiationdosage



a.Patientexposure(1).Sourcetotabletop‐notbelessthen18inches(45.72cm)

(2).Usepropercollimation(shuttersshouldalwaysbenoticeableatedgesofviewingfieldduringfluoroscopyandimaging)(3).Useleastamountoffluoroscopy

(4).Useleastamountofdigitalimagingtime(6‐8secondsperrun)(5).Uselowestclinicallyacceptableframerate(15fps)(6).Uselowestacceptablemagnificationforcoronaryangiography

(17‐18cmor20‐22cm)(7).Performpregnancytestonallfemalepatients(12and60yearsofage)b.UnderstandsConsumer‐PatientRadiationandSafetyActof1981

(1).Statementofpurpose(2).Definitions(3).Promulgationofstandards

(4).ModelStatute(5).Compliance(6).Federalradiationguidelines

(7).Stateradiationguidelines(8).Applicabilitytofederalagenciesc.Occupational(staff)exposure

(1).ALARA(2).Angulationofimagingviews(caudalviews)

(3).Brachialandradialarterialaccesscasesdoublethedosetooperators(4).Distance(Inversesquarelaw)(5).Primarybeamexposure

(6).Recordtotalfluoroscopictime(7).Recordtotaltimeofangiographicruns(8).Scatterradiation(2°exposure)(a).Fromlateralfiltrationareasofx‐raytube(3meters)

(b).Frompatient (9).Uselowestframespersec(15fps)andacceptablemagnificationforventriculographyandcoronaryangiography

d.Shielding

(1).Wraparoundleadaprons(a).Twopiece(Blouseandkilthighlyrecommendedforergonomicreasons‐e.g.cervicalandlowerback

repetitiveinjuries)(b).Recommendsleeveonleftarmareaofblousetoprotectlefthumerusareafromradiation



(2).Thyroidcollars(3).Leadglasses

(4).Movableleadbarriers(a).Tablesidetoprotectlowerextremities(b).Ceilingsuspendedtoprotectuppertorso

B.RadiationSafety1.Methodsofmeasurementa.Filmbadgeb.Geiger‐Műller(G‐M)detector(nuclearmedicine)

c.Ionizationchamber‐typesurveymeter(cutiepie)d.Opticalstimulatedluminescencedosimeterse.Proportionalcounters

f.Thermoluminescentdosimeter‐ringbadgesg.Thermoluminescentdosimeters(TLD)2.UnitsofMeasurement

a.Absorbeddose(Rad,r)1Gray(Gy)=100radsb.Doseequivalent(Rem)1Sievert(Sv)=100Remsc.Exposure(Roentgen,R)

d.EffectiveDoseEquivalent(EDE)3.Typesofradiationinjurya.Nonstochasticdeterministiceffects(direct‐thresholddoses)

(1).Earlyeffects(a).Decreaseinwhitecellcount(b).Epilation

(c).Erythema(2).Acuteradiationsyndromes(a).Cerebralvascular

(b).Gastrointestinal(c).Hematopoietic(3).Lateeffects

(a).Atrophyoforgans (b).Cataractformation(c).Fibrosis

(d).Lossofparenchymalcells(e).Sterility(infertility)b.Stochastic(probabilistic)effects

(1).Assumptionnothresholdexists(2).Probabilityofinjuryisproportionaltodoseatanylevel

(3).Delayedcarcinogeniceffects



(a).Bonemarrow(leukemia)(b).Breast

(c).Lymphatic(d).Salivaryglands(e).Skin

(f).Thyroid(4).Mutageneticeffect(reproductivecellsbeforeconception)(5).Teratogeneticevents(inuterofetalexposure)

A Proposal for the Core Curriculum for Credentialing and ... · MD RCMS, Norman Patton MD RCMS,...

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Transcript of A Proposal for the Core Curriculum for Credentialing and ... · MD RCMS, Norman Patton MD RCMS,...