CLINICAL PRIVILEGE WHITE PAPER Radial artery harvesting

Transcription

1 Procedure 87 CLINICAL PRIVILEGE WHITE PAPER Radial artery harvesting Background During coronary artery bypass (CAB) surgery, a surgeon uses a healthy artery or vein to route the blood supply around the blocked artery. This healthy vessel must be harvested from another part of the body. One choice for the surgeon is the radial artery, which is located in the arm. Radial arteries have a relatively large diameter, are easily accessible, do not tear easily, are muscular, and are easy to work with. They also seem to avoid the atherosclerotic degeneration that may be rampant in other arteries of the patient. For bypasses, the proximal portion of the radial artery, starting at the elbow, is harvested. It is available for bypass grafting because its primary function, supplying blood to the hand, is also done by the ulnar artery. Before the radial artery is removed, a special, two-dimensional ultrasound examination noninvasively assesses the radial and ulnar arteries from the elbow to the hand. Vascular medicine and surgical specialists can then study the interior contour of the radial artery, making sure that the surface is smooth and clear of atherosclerotic disease so that it can be safely used for bypass grafting. One problem with radial arteries is that they are very reactive and prone to spasm. To avoid spasm, the vessels must be harvested very carefully, with as little touching and manipulation as possible. Radial arteries were not considered viable for bypass for many years because of the spasm problem, but this has generally been resolved using calcium channel blockers. Although it is not the procedure of choice for every patient, the radial artery does have advantages for some patients, especially those who are having CAB grafting repeated. The radial artery may have some other advantages as well. Generally patients receiving radial artery grafts have shorter recovery times and less postoperative pain. Involved specialties Cardiothoracic surgeons Positions of societies and academies STS The Society for Thoracic Surgeons (STS) is the largest membership society for thoracic surgeons in the world. The Society represents the practice areas of cardiothoracic, general tho- A supplement to Briefings on Credentialing 781/ /00 1

2 racic, pediatric thoracic, and transplant surgery and is committed to saving, extending, and improving the quality of life for all Americans. The STS defines thoracic surgery as the practice of medicine directed toward the surgical treatment of diseases of the chest, including coronary artery disease cancers of the lung, esophagus, and chest wall abnormalities of the great vessels and heart valves birth defects of the chest and heart tumors in the organs contained in the chest cavity transplantation of the heart and lungs The STS further states that unlike general surgeons who may operate on most parts of the body, thoracic surgeons concentrate solely upon the following categories: Cardiac surgery the surgical management of diseases of the blood supply to the heart, heart valves, and the arteries and veins in the chest General thoracic surgery a surgical field focusing on treatments for lung cancer emphysema, esophageal swallowing problems, esophageal cancer, and gastroesophageal reflux Congenital heart surgery a broad yet highly specialized practice of medicine directed toward the correction of heart defects and furnishing cardiovascular support to infants and children Thoracic surgeons are among the most highly educated specialists. After college and medical school training, soon-to-be thoracic surgeons devote at least five years to a general surgical residency pass the certifying examination of the American Board of Surgery devote two to three years to thoracic surgery residency pass the certifying examination of the American Board of Thoracic Surgery (ABTS) The STS does not publish credentialing and privileging criteria for thoracic surgeons. 2 A supplement to Briefings on Credentialing 781/ /00

3 Positions of other interested parties ABTS According to the ABTS, thoracic surgery encompasses the operative, perioperative, and surgical critical care of patients with acquired and congenital pathological conditions within the chest. This includes the surgical repair of heart lesions, and congenital and acquired condition of the coronary arteries, valves, and myocardium. It also includes pathologic conditions of the lung, esophagus, and chest wall, abnormalities of the great vessels, tumors of the mediastinum, and diseases of the diaphragm and pericardium. Management of the airway and injuries to the chest are also within the scope of the specialty. The scope of thoracic surgery encompasses knowledge of normal and pathologic conditions of both cardiovascular and general thoracic structures. This includes congenital and acquired lesions (including infections, trauma, tumors, and metabolic disorders) of both the heart and blood vessels in the thorax, as well as diseases involving the lungs, pleura, chest wall, mediastinum, esophagus, and diaphragm. In addition, the ability to establish a precise diagnosis, an essential step toward proper therapy, requires familiarity with diagnostic procedures such as cardiac catheterization, angiography, electrocardiography, imaging techniques, endoscopy, tissue biopsy, and biologic and biochemical tests appropriate to thoracic diseases. It is essential that the thoracic surgeon be knowledgeable and experienced in evolving techniques, such as laser therapy, thoracoscopy, and thoracoscopic surgery. The ABTS offers certification in thoracic surgery and the certification requirements include the following: Certification by the American Board of Surgery Completion of a minimum of 24 months of residency training in thoracic and cardiovascular surgery in a program accredited by the Residency Review Committee for Thoracic Surgery (RRC/TS). This must include 12 months of continuous senior responsibility. Satisfactory performance on the ABTS examinations A currently registered full and unrestricted license to practice medicine granted by a state or other United States jurisdiction Education and adequate operative experience in both general A supplement to Briefings on Credentialing 781/ /00 3

4 thoracic surgery and cardiovascular surgery are essential parts of any approved thoracic surgery residency program, irrespective of the area of thoracic surgery in which a candidate may choose to practice. Operative case criteria The operative experience requirement of the ABTS has two parts. One is concerned with the intensity or volume of cases, and the other with the distribution of cases (index cases). Surgical volume (intensity) The ABTS operative experience requirements include an annual average of 125 major operations performed by each resident for each year that the program is approved by the RRC/TS. In a two-year program, this requirement is met if a resident performs a total of 250 major cases over the course of his or her residency; in a three-year program, the resident must perform 375 major cases. This guideline on intensity of cases conforms to the Special Requirements in Thoracic Surgery as published by the Accreditation Council for Graduate Medical Education (ACGME) and the RRC/TS. Index case (distribution) requirements for all residents entering their residency in July 1999 or earlier: Lungs, pleura, chest wall: 50 Pneumonectomy, lobectomy, segmentectomy: 30 Other: 20 Esophagus, mediastinum, diaphragm: 15 Esophageal operations: 8 Other: 7 Congenital heart: 20 Acquired valvular heart: 20 Myocardial revascularization: 35 Pacemaker implantations/closed EP: 10 Bronchoscopy and esophagoscopy: 25 Index case requirements that are effective for residents beginning residency in July 2000: Lungs, pleura, chest wall: 50 4 A supplement to Briefings on Credentialing 781/ /00

5 Pneumonectomy, lobectomy, segmentectomy: 30 Other: 20 Esophagus, mediastinum, diaphragm: 15 Esophageal operations: 8 Resections: 4 Other esophageal: 4 Congenital heart: 30 Full credit: 10 First assistant: 20 Adult cardiac: 100 Acquired valvular heart: 20 Myocardial revascularization: 60 Re-operations: 5 Other: 15 Pacemaker implantation/closed EP: 10 Bronchoscopy and esophagoscopy: 30 VATS (video assisted thoracic surgery): 10 Endoscopic procedures may be counted for credit whether they are performed as independent procedures or immediately preceding a thoracic operation. Major vascular operations outside the thorax should be listed. Clinical Practices of the University of Pennsylvania, Philadelphia, PA According to Emile R. Mohler, III, MD, director of vascular medicine at the Clinical Practices of the University of Pennsylvania, Philadelphia, PA, cardiothoracic surgeons who perform radial artery harvesting are usually trained in the procedure during their cardiothoracic fellowship program. Surgeons who have not had this training would be required to observe cases being done and then would be proctored in their initial cases by an experienced radial artery practitioner. For bypasses, there are three alternatives for harvesting: the internal mammary artery, an artery located in the chest; the greater saphenous veins, large veins found in the legs; and the radial artery, which is located in the arm. Surgeons prefer to use one of the two arteries because they tend to be better than the veins for durability and longevity. Mohler, whose involvement in the radial artery harvesting procedure as a vascular medicine specialist is to scan the artery with ultrasound to determine whether it is suitable for use, explains that the radial artery is not superior to the mammary artery in the bypass procedure but is an alternative. The mammary A supplement to Briefings on Credentialing 781/ /00 5

6 artery may have already been used and is now clogged up, he says. Or the mammary artery may be supplying one vessel and the surgeon wants to use the radial artery to do another graft. A surgeon who has been trained to harvest mammary arteries or saphenous veins may not be qualified to perform the radial artery harvesting procedure. The expertise required for harvesting the artery out of the arm is different as well as the expertise required in attaching it as a free artery. The procedure should not be beyond the skills of an experienced surgeon, says Mohler, but there is a learning curve there. CRC draft criteria Minimum threshold criteria for requesting clinical privileges for radial artery harvesting Basic education: MD or DO Minimum formal training: The applicant must be able to demonstrate successful completion of an ACGME/American Osteopathic Association (AOA) accredited residency training program in general surgery followed by a minimum of 24 months of residency training in thoracic and cardiovascular surgery in a program accredited by the Residency Review Committee for Thoracic Surgery. If radial artery harvesting was not included in the residency training, then the applicant must have completed a formal training program in radial artery harvesting that included proctored cases. Required previous experience: The applicant must be able to demonstrate that he or she has successfully performed at least 20 radial artery harvesting procedures in the past 12 months. Note: A letter that evaluates competency must come from the director of the applicant s residency training program and/or from the preceptor of the applicant s initial radial artery harvesting procedures or from the chief of surgery at the institution where the applicant was last affiliated. Reappointment should be based on unbiased, objective results of care according to the organization s existing quality assurance mechanisms. Reappointment Applicants must demonstrate that they have maintained competence by showing evidence that they have successfully performed at least 20 radial artery harvesting procedures in the past 12 months. In addition, continuing education related to radial artery harvesting should be required. 6 A supplement to Briefings on Credentialing 781/ /00

7 For more information For more information regarding this procedure, contact: American Board of Thoracic Surgery One Rotary Center, Suite 803 Evanston, IL Telephone: 847/ Fax: 847/ Web site: Clinical Practices of the University of Pennsylvania Presbyterian Medical Center 39th and Market Streets Philadelphia, PA Telephone: 800/ Web site: Society of Thoracic Surgeons 401 North Michigan Avenue Chicago, IL Telephone: 312/ Fax: 312/ Web site: Clinical Privilege White Papers Advisory Board James F. Callahan, DPA Executive vice president and CEO American Society of Addiction Medicine Chevy Chase, MD Sharon Fujikawa, PhD Clinical professor, Dept. of Neurology University of California, Irvine Medical Center Orange, CA John N. Kabalin, MD, FACS Urologist/Laser surgeon Scottsbluff Urology Associates Scottsbluff, NE Publisher/Vice President: Suzanne Perney Executive Editor: Dale Seamans John E. Krettek Jr., MD, PhD Neurological surgeon Vice president for medical affairs Missouri Baptist Medical Center St. Louis, MO Michael R. Milner, MMS, PA-C Senior physician assistant consultant Phoenix Indian Medical Center Phoenix, AZ Beverly Pybus Senior consultant The Greeley Company Marblehead, MA Associate Editor: Rena Cutchin Managing Editor: Edwin B. Niemeyer Richard Sheff, MD Practice director Quality and credentialing The Greeley Company Marblehead, MA Herman Williams, MD Senior consultant External peer review The Greeley Company Marblehead, MA The information contained in this document is general. It has been designed and is intended for use by hospitals and their credentials committees in developing their own local approaches and policies for various credentialing issues. This information, including the materials, opinions, and draft criteria set forth herein, should not be adopted for use without careful consideration, discussion, additional research by physicians and counsel in local settings, and adaptation to local needs. The Credentialing Resource Center does not provide legal or clinical advice; for such advice, the counsel of competent individuals in these fields must be obtained. Reproduction in any form outside the recipient s institution is forbidden without prior written permission. Copyright 2000 Opus Communications, a division of HCPro, Marblehead, MA A supplement to Briefings on Credentialing 781/ /00 7

8 Privilege request form Radial artery harvesting In order to be eligible to request clinical privileges for radial artery harvesting, an applicant must meet the following minimum threshold criteria: Education: MD or DO Minimum formal training: The applicant must be able to demonstrate successful completion of an ACGME/AOA-accredited residency training program in general surgery followed by a minimum of 24 months of residency training in thoracic and cardiovascular surgery in a program accredited by the Residency Review Committee for Thoracic Surgery. If radial artery harvesting was not included in the residency training, then the applicant must have completed a formal training program in radial artery harvesting that included proctored cases. Required previous experience: The applicant must be able to demonstrate that he or she has successfully performed at least 20 radial artery harvesting procedures in the past 12 months. References: A letter that evaluates competency must come from the director of the applicant s residency training program and/or from the preceptor of the applicant s initial radial artery harvesting procedures or from the chief of surgery at the institution where the applicant was last affiliated. Reappointment: Reappointment should be based on unbiased, objective results of care according to the organization s existing quality assurance mechanisms. Applicants must demonstrate that they have maintained competence by showing evidence that they have successfully performed at least 20 radial artery harvesting procedures in the past 12 months. In addition, continuing education related to radial artery harvesting should be required. I understand that by making this request I am bound by the applicable bylaws or policies of the hospital, and hereby stipulate that I meet the minimum threshold criteria for this request. Physician s signature: Typed or printed name: Date: 8 A supplement to Briefings on Credentialing 781/ /00