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Vascular-Interventional Radiology

General Objectives 

On completion of the Vascular and Interventional Radiology rotation, the resident will be competent to function as a General Radiologist to referring physicians in this subject area.  The resident will demonstrate the ability to perform some procedures, as well as advise referring physicians as to the appropriate investigation for their patient in this subject area.  The skills will be developed to a level appropriate for Royal College Certification. 
 
After completion of the mandated rotations, they should demonstrate the ability to perform the following interventional procedures:
§  Central venous access
§  PICC
§  Tunneled central venous catheter
§  Fistulagram
§  Diagnostic peripheral angiography
 
The resident would not be expected to perform other more complicated interventional procedures until further dedicated training in Angio/Interventional Radiology had been undertaken. The resident would be expected to have a thorough knowledge of the indications for these procedures and a clear understanding of the potential complications as well as benefits.  These procedures would include, but would not be limited to, the following procedures: 
§  Venous
§  Portocath
§  IVC Filter placement/removal
§  Vascular
§  Angioplasty/Stent
§  Endograft
§  Thrombolysis
§  Embolization
§  Non Vascular
§  GI interventions
§  Hepatobiliary interventions
§  TIPPS
§  GU interventions
§  Other
§  Oncologic intervention
§  Radiofrequency ablation
§  Transcatheter embolization and treatment
§  Fibroid embolization
 
SPECIFIC OBJECTIVES
At the completion of the Angiography/Interventional Rotations the resident will have acquired the following competencies, and will function effectively as:
 

Medical expert/clinical decision-maker

Basic Science Knowledge:
  1. Understand the role of angiography and interventional radiology in the diagnosis and treatment of patients.
  2. Learn vascular, biliary and urinary anatomy and common pathology
  3. Develop an understanding of patient triage, patient selection, risks, indications and contraindications for each procedure
  4. Understand techniques for arterial, venous, biliary and urinary access.  Should have basic vascular access technique.
 
Specific Requirements:
These rotations are completed at the UAH, RAH and GNH sites, with residents starting these rotations at alternate sites.  The month spent at RAH/GNH is where the resident is exposed to the bulk of peripheral vascular angiography and therapy, as well as a variety of interventional procedures based on fluoroscopic imaging.   At UAH, the resident is exposed to a large variety of tertiary care interventional procedures, including neuroangiography and pediatric interventional procedures
 
There is expected to be graded involvement of the residents in the preparation and performance of the procedures undertaken on the vascular/interventional radiology service.  There is graded supervision of the residents through the rotations, and the resident is expected to become more proficient, and act more as a consultant, at the end of these rotations. 
 
§  Demonstrate knowledge of the anatomy of the cardiovascular system for all ages, with knowledge of both fluoroscopic/angiographic anatomy, as well as cross-sectional/multiplanar anatomy.
§  Demonstrate knowledge of the anatomy relevant for interventional (non-vascular) procedures such as biliary drainage and nephrostomy tube placement.
§  Understand the nature of formation of radiologic images from an angiographic perspective, including physical and technical aspects, patient positioning, and contrast media, and utilization.
§  Knowledge of the theoretical, practical, and legal aspects of radiation protection related to fluoroscopic and angiographic imaging, including other imaging techniques and their possible harmful effects. 
§  Show competence in manual and procedural skills in a graded fashion as it relates to vascular/interventional procedures
§  Demonstrate appropriate ability to manage a patient independently during procedures, in close association with specialists or other physicians who have referred the patient. 
§  To understand when it serves the patient’s best interest to discontinue a procedure, or refer a patient to another physician.
§  Be able to obtain informed consent for vascular/interventional procedures, and explain possible complications to the patient and family members.
§  Understand the acceptable and expected results of Diagnostic and Interventional investigations and therapy, as well as unacceptable and unexpected results. This must include knowledge and ability to manage radiologic complications effectively. 
§  Understand the appropriate follow-up care of patients who have received angiography and interventional procedures.
§  The resident would be expected to have attained knowledge appropriate to function as a consultant to referring family physicians and specialists in the following areas.
 
§  Peripheral vascular disease – atherosclerosis, other.
§  Aortic aneurysms – thoracic and abdominal.
§  Aortic dissection
§  Aortic trauma
§  Vascular trauma
§  Venous thrombosis and pulmonary embolism
§  Carotid artery disease
§  Cerebral aneurysm
§  AVM or other causes of cerebral hemorrhage
§  Thoracic outlet syndrome
§  Carcinoma of the lung
§  Biliary obstruction and jaundice
§  Pancreatitis
§  Hepatic tumor and metastases
§  Pancreatic tumors
§  Renal tumors
§  Urinary obstruction
 

 

Communicator

 
Requirements:
§  Apply a sound and systematic style to produce a radiologic report regarding
§  Understand and identify the importance of communication with referring physicians, including and understanding when the results of investigations or procedures should be urgently communicated.
§  Communicate effectively with patients and their families, and have a compassionate interest in them.
§  Demonstrate knowledge, skills, and attitudes that incorporate issues related to gender, culture, and ethnicity pertinent to the performance of vascular/interventional procedures.
 

Collaborator

 
Requirements:
§  Demonstrate the ability to function as a member of a multidisciplinary health care team in the practice of angiography and interventional procedures.
§  Ability to interact with referring specialists, in order to obtain appropriate information prior to the procedure and also impart appropriate and relavant information after the procedure.
 

Manager

 
Requirements:
 
§  Ability to work effectively in a busy environment that often requires multi-tasking
§  Ability to appropriately triage cases in order to maximize efficiency
§  Understand safety issues and economic considerations pertaining to the studies performed.
§  Ability manage time effectively in order to obtain adequate exposure to multiple cases and read appropriately
 

Health Advocate

 
Requirements:
 
§  Understand and communicate the benefits and risks of radiologic investigations and treatment, with specific regards to radiation, contrast and side-effects of medications utilized
§  Recognize when radiologic diagnostic or therapeutic procedures will be detrimental to the health of a patient.
§  Educate and advise on the use and misuse of radiologic imaging and radiologic interventions.
 

Scholar

 
Requirements:
 
§  Demonstrate competence in the evaluation of the medical literature as it pertains to angiography/interventional diagnosis and therapy.
§  Demonstrate the ability to be an effective teacher of issues related to interventional and angiographic imaging to medical students, residents, technologists and clinical colleagues.
§  Maintain log of procedures in order to assess performance and to evaluate outcome of complications
 

Professional

 
Requirements:
 
§  Accurately assess one’s own performance, strengths, and weaknesses.
§  Understand the ethical and medico-legal requirements of a radiologist.
 

 
RESIDENT DUTIES:
 
The residents will be expected to progress in a graded supervised fashion in their performance of procedures through these rotations, and to take an increasing role from junior to senior status in the preparation and management of patients for procedures. 
 
Specific Duties:
 
§  Consents/pre-procedure assessment preparation:
Initially the resident will be accompanied by the supervisor during acquisition of consent and preparation of the patient for the proposed procedure.  As the resident progresses through the rotation, the resident will be expected to acquire informed consent for procedures independently.  Assessment of the indications and contra-indications for the procedure is essential to the appropriate performance of procedures.
 
§  Procedure Attendance:
The resident will demonstrate a responsible attitude by his/her diligent attendance to the service. During the course of the rotation, the resident is encouraged to become independent in the care of patients and also have ability to perform minor procedures, but must remember that the ultimate responsibility lies with the staff radiologist.
 
§  Dictation of Procedures:
 As the resident becomes familiar with the procedures and the dictation format, case dictations will be performed by the resident. All dictations are reviewed by the supervising radiologist to ensure accuracy and appropriateness of communication to others in the medical community.
 
·         Procedure Log
The resident will be expected to keep a log of all procedures performed and attended.  This includes consults.  Patient ID, Date, Procedure type, Intervention performed and any complications should be recorded.
 
 
RESIDENT EVALUATION:
 
§ The resident’s day-to-day performance will be evaluated.  A mid-rotation informal (verbal) evaluation should  be obtained by the resident from the preceptor
§ It is the responsibility of the resident to ensure that at the end of the rotation the appropriate evaluation form is completed by the supervising radiologist and reviewed by the resident within one-to-two weeks of the end of the rotation.  This evaluation is to be forwarded to the Program Director.
 
 
RECOMMENDED READING:
 
§  Teaching Atlas of Vascular and Non-Vascular Interventional Radiology – Funaki (must read)
§  Teaching Atlas of Interventional Radiology: Non-vascular interventional procedures – Kadir (must read).
§  Vascular and Interventional Radiology – Valji
§  Vascular and Interventional Radiology – Kaufman (Either one of Kaufman or Valji should be read)
§  Abrams Angiography:  Vascular and Interventional Radiology – Abrams (Reference text).
§  Introduction to Cerebral Angiography -  Osborn (Reference text).
§  Atlas of Normal and Variant Angiographic Anatomy – Kadir (Reference text).
§  Handbook of Interventional Radiology and Angiography – Wojtowycz (Reference text).
§  Handbook of Interventional Radiological Procedures – Kandarpa, Aruny (Reference text)