The clinical core rotations in vascular medicine have been developed to provide an exposure to the full spectrum of vascular diagnostics and therapeutics. The program has both ambulatory experiences and inpatient rotations. This in-depth exposure to all aspects of vascular care allows trainees to gain a comprehensive approach in diagnosing and treating vascular disorders.
Inpatient Vascular Medicine Consult Rotation:
The inpatient rotation on the vascular medicine consult service is an essential element of training, allowing the trainees to learn the medical management of a wide variety of vascular disorders that require hospitalization. This includes the evaluation and management of critical and acute limb ischemia, venous thromboembolic disease, acute aortic syndromes, other arterial disorders including aneurysm and dissection, renal vascular disease, atheroembolic disease, vasospastic disorders, and vasculitis. The goal is to ensure that trainees become proficient in the care of vascular disorders encountered during hospitalization. Another element of the rotation is to assist in the perioperative evaluation and management of vascular surgery. Trainees develop expertise in the perioperative management for vascular surgery including its attendant complications. Emphasis is placed on the utility of the perioperative assessment as an entry point to establishing long-term risk modification and routine vascular disease care.
During the rotation trainees independently evaluate all requests for consultation then discuss the case with one of the vascular medicine attending staff. Recommendations are provided under faculty supervision. During this experience, the trainees will serve as liaison to the other inpatient services in an educational capacity. It is expected that the trainees will develop skills and interest in educating others about vascular disorders.
Non-Invasive Vascular Laboratory Rotation:
A dedicated vascular laboratory rotation of ~3 months ensures that trainees develop expertise in the techniques performed in the non-invasive vascular laboratory. The goal is to insure that trainees are competent in the interpretation of non-invasive vascular laboratory studies. During the rotation, trainees are exposed to the full range of techniques including physiologic arterial and venous studies, arterial duplex, carotid duplex, and venous duplex studies. Arterial physiologic studies will include pulse volume recording, segmental limb pressures, Doppler waveform analysis, and provocative maneuvers such as exercise studies and thoracic maneuvers will be performed. Venous physiologic studies will also be performed and will include air phlethysmography and provocative maneuvers such as Valsalva or rapid cuff deflation. Other studies include venous duplex examinations to evaluate for thrombosis, assess for reflux, and map veins. Arterial duplex of the extremities will also be performed to assess for stenosis, graft patency, arteriovenous fistulas, hemodyalisis access and pseudoaneurysm including thrombin injections. Arterial duplex of the intra-abdominal vessels to evaluate for renal artery stenosis, mesenteric stenosis, and abdominal aortic aneurysm, including following endograft placement. Carotid duplex will assess for stenosis, occlusion, dissection, aneurysm, and intimal medial thickness.
Trainees interpret vascular studies with the vascular laboratory medical director (or another physician reading staff) during the dedicated rotation and the inpatient consult rotations. This dedicated exposure also includes “hands-on” training in performing studies with our technologists. Trainees will gain an appreciation of the technical issues that affect the quality of the examination and image optimization and learn the principle governing the technique. During this experience trainees fulfill the recommendation for interpreting vascular studies set forth by the Intersocietal Commission on the Accreditation of Vascular Laboratories. This includes interpretation of 100 venous, 100 extracranial carotid, 100 limb arterial, 75 visceral vascular duplex ultrasound, and 100 physiologic arterial studies. This experience allows trainees to meet or exceed the level of expertise of a registered vascular technologist and be able to obtain the ARDMS credential of Registered Physician in Vascular Interpretation.
Outpatient Clinic Experience:
The goal of the outpatient exposure is to ensure that trainees become proficient in the management of vascular disorders encountered in an ambulatory setting. This includes the evaluation and management of patients with conditions such as intermittent claudication, entrapment syndromes, chronic venous insufficiency, deep vein thrombosis and thrombophilias, carotid and subclavian arterial disease, lymphedema, vasospastic disorders (such a Raynaud’s phenomenon), and atherosclerosis risk factors, such as hypertension and dyslipidemias. This experience includes a multi-disciplinary approach to allow our trainees to encounter the full breath of vascular disorders and their management.
The essential element of the outpatient experience is to provide longitudinal care of patients with vascular disorders. This occurs in the vascular medical clinic located within the Cardiovascular Center at Boston Medical Center. Trainees perform evaluations and assist in the management of patients with vascular related problems under the supervision of one of the vascular medicine staff physicians. Trainees participate in the vascular medicine clinic on a twice per week basis during the entire year of clinical training. Additional outpatient exposure includes participation in the vascular surgery clinic during selected rotations. This exposure allow trainees to gain knowledge and skills in wound care. The outpatient experience also ensures an exposure to techniques in the management of chronic venous insufficiency including sclerotherapy and venous ablation. During selected rotations, trainees participate in lipid clinic and vascular rehabilitation allowing the acquisition of knowledge in the management of atherosclerotic risk factors and vascular rehabilitation.
A basic exposure has been designed to provide trainees with an overview and general appreciation of the issues involved in peripheral angiography and intervention. This basic exposure allows trainees to gain an appreciation of the indications, technical considerations, potential complications, and interpretations of diagnostic angiography. An appreciation of the role of peripheral catheter-based interventions is gained. Therapeutic considerations including indications, technical issues, established benefits, potential complications, and potential alternatives to percutaneous therapy are emphasized. Trainees evaluate patients prior to, during, and following diagnostic studies and interventions performed in the interventional laboratory. This exposure consists of the equivalent of two months of training achieved by participating in activities in the peripheral invasive laboratory for ~1/2 day per week on an ongoing basis.
An advanced exposure to peripheral intervention is possible for select trainees to ensure sufficient expertise to function independently performing catheter-based peripheral vascular interventions. This more prolonged exposure allows trainees to gain the cognitive and technical skills required for functioning as an independent operator. Detailed knowledge of image-acquisition techniques, vascular anatomy, hemodynamics and radiation safety is acquired. Technical aspects of angiography and intervention include principles of vascular access, closure devices, and approaching anatomical obstacles such as calcification or tortuous vessels. Mechanical and physical characteristics of angioplasty equipment, appropriate device selection and their use are discussed. Recognition and management of complications, outcomes analysis and risk-benefit profiles are addressed at multiple venues (i.e. pre-assessment work-up and discussion, during the case, and at case-oriented conferences). Training includes selection and use of adjunctive devices including stents, distal protection, intravascular ultrasound, pressure wire, atherectomy, and thrombectomy. Trainees learn peri-procedural management of the patient including adjunctive pharmacotherapy and appropriate follow-up plans. Endovascular Fellows are expected to meet the guidelines for clinical competence in catheter-based peripheral vascular interventions set forth by the American College of Cardiology/American Heart Association/American College of Physician task force. This requires a minimum of 12-months of training and a minimum number of cases for both peripheral diagnostic angiograms and peripheral interventional cases.
Vascular Surgery Rotation:
A rotation on the Vascular Surgery Service of one to two months allows trainees to gain an appreciation of the technical issue involved in surgical vascular revascularization and reconstruction. This promotes a greater understanding of the indications, technical issues, complications and risks. The experience includes participation in the inpatient service as well as the outpatient clinic. During the rotation trainees directly observe operative procedures and participate in the peri-operative care of patients undergoing surgical revascularization. A more prolonged exposure to peri-operative cardiovascular risk stratification and risk reduction is achieved during the inpatient vascular medicine rotation.
Advanced Vascular Imaging Rotation:
Trainees also spend ~ 1-month rotation learning advance vascular imaging including magnetic resonance and computed tomographic angiography. This is designed to allow trainees to understand the role of these imaging techniques in the evaluation of common arterial and venous disorders such as atherosclerosis, aneurysm, dissection, thrombosis and vasculitis. Trainees learn the physical principles underlying these modalities and gain an understanding of their role in the management of diseases in the carotid, aortic, renal, mesenteric, peripheral and pulmonary circulations. Interpretation of imaging techniques and appropriate use of contrast with these modalities will be learned during the experience. This includes magnetic resonance techniques, such as spin-echo, time-of-flight, contrast-enhanced and phase-contrast imaging, and imaging reformatting. This also includes computed tomographic image display issues such as projections, reformatting, and three-dimensional reconstruction. The rotation is an extension to a joint program in cardiovascular magnetic resonance and computed tomographic imaging between Cardiovascular Medicine and Radiology at Boston Medical Center.
To help trainees fully appreciate the role of various specialists and the role for collaborative care, electives in related areas are available. These related areas include fields such a hematology, pulmonary, rheumatology, dermatology and vascular pathology. During elective time, trainees have the opportunity to work closely with one (or more) of these specialists in both the inpatient and outpatient setting.
- Hematology: An elective within hematology focusing on thrombosis and hemostasis may be arranged. Dr. Elaine Hylek, in his role as the Director of the Anticoagulation Service, provides a detailed exposure to the issues involved in evaluation and management of acute thromboembolic disease, thrombophilias, and many other issues with antithrombotic and anticoagulant therapy.
- Pulmonary: An elective in pulmonary medicine can be arranged focusing in on pulmonary thromboembolic disease and pulmonary hypertension. Working with Dr. Hap Farber in the evaluation and management of pulmonary hypertension would include diagnostic testing and therapeutic “trials” to assess response to therapies such as epoprostenol.
- Rheumatology: An elective in rheumatology can be arranged to focus on the evaluation and management of vasculitis. A more detailed exposure to large vessel vasculitis and its complications would be gained during a rotation with Dr. Peter Merkel.
- Dermatology: An elective in dermatology can be arranged to allow for a more detailed experience in wound care and venous ulcer management. There is a significant clinical interest in the evaluation and management of chronic venous disease within dermatology.