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Guidelines for Peripheral and Visceral Vascular Embolization Training

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Guidelines for Peripheral and Visceral Vascular Embolization Training Guidelines for Peripheral and Visceral Vascular Embolization Training Joint Writing Groups of the Standards of Practice Committees for the Society of Interventional Radiology (SIR), Cardiovascular and Interventional Radiological Society of Europe (CIRSE), and Canadian Interventional Radiology Association (CIRA) Jafar Golzarian, MD, Marc R. Sapoval, MD, PhD, Sanjoy Kundu, MD, David W. Hunter, MD, Elias N. Brountzos, MD, Jean-Francois H. Geschwind, MD, Timothy P. Murphy, MD, James B. Spies, MD, Michael J. Wallace, MD, Thierry de Baere, MD, and John F. Cardella, MD J Vasc Interv Radiol 2010; 21:436–441 EMBOLOTHERAPY or embolization 1. Vascular malformations: occlusion 3. Trauma: for control of dramatic hem- has rapidly developed in recent years of congenital or acquired aneu- orrhage, for example, related to and now represents an integral part of rysms (cerebral, visceral, extremi- splenic laceration or pelvic fractures. interventional radiology practice. Em- ties), pseudoaneurysms, vascular 4. Uterine artery embolization: devascu- bolotherapy is defined as the percuta- malformations, or other vascular larization of benign uterine leiomyo- neous endovascular application of one abnormalities that have potential mas and adenomyosis for symptom or more of a variety of agents or ma- to cause adverse health effects (1–18). alleviation or to reduce operative terials to accomplish vascular occlu- 2. Nontraumatic hemorrhage: treat- blood loss (3,4,14,54–57). sion. ment of acute or recurrent hem- 5. Oncologic embolization: to relieve Embolotherapy has evolved since its orrhage (eg, hemoptysis, gastro- symptoms, prevent or treat hem- clinical introduction to include a wide intestinal bleeding, postpartum orrhage, reduce operative blood loss, or improve survival and variety of applications that can be and iatrogenic hemorrhage, and quality of life (3,4,14,54–57). Ex- grouped into the following categories: hemorrhagic neoplasms) (18–53). amples include primary and sec- ondary hepatic malignancies, re- nal cell carcinoma, and primary and secondary bone malignancies. 6. Tissue ablation: ablation of be- From the Division of Interventional Radiology and France; and Department of Radiology (J.F.C.), Geis- nign neoplastic and nonneoplas- Vascular Imaging, Department of Radiology (J.G., inger Health System, Danville, Pennsylvania. Re- tic tissue that produces adverse D.W.H.), University of Minnesota, Minneapolis, ceived December 19, 2009; final revision received health effects to the patient (eg, Minnesota; Department of Cardiovascular Radiol- January 18, 2010; accepted January 19, 2010. Address ogy (M.R.S.), Hôpital Européen Georges Pompidou, correspondence to J.G., c/o Debbie Katsarelis, SIR, hypersplenism, refractory reno- Paris, France; Department of Medical Imaging (S.K.), 3975 Fair Ridge Dr., Suite 400 N., Fairfax, VA 22033; vascular hypertension, untreat- Scarborough General Hospital, Richmond Hill, On- E-mail: [email protected] able urine leak, proteinuria in tario, Canada; Second Department of Radiology end-stage kidney disease, renal (E.N.B.), Athens University Medical School, Attikon J.F.H.G. is a paid consultant for Bayer, Gideon, MDS University Hospital, Athens, Greece; Division of Nordion (Kanata, Ontario, Canada), Terumo (Somer- angiomyolipoma, varicocele, pel- Vascular and Interventional Radiology, Russell H. set, New Jersey), Biosphere Medical (Rockland, Mas- vic congestion syndrome, pria- Morgan Department of Radiology and Radiological sachusetts), and BioCompatibles (Surrey, United King- pism, and abdominal pregnancy) dom) and has research funded by Genentech (South Sciences (J.F.H.G.), Johns Hopkins Hospital, Balti- (9,10,14,16,58–68). more, Maryland; Division of Vascular and Interven- San Francisco, California), Boston Scientific (Natick, tional Radiology, Department of Diagnostic Imaging Massachusetts), Biosphere Medical, Philips, Bayer, 7. Flow redistribution: to protect normal (T.P.M.), Rhode Island Hospital, Providence, Rhode Gideon, and Biocompatibles. T.P.M. is an owner of, or tissue (eg, gastroduodenal artery and Island; Department of Radiology (J.B.S.), George- shareholder in, Sentient Bioscience (Providence, right gastric artery embolization in town University Medical Center, Washington, DC; Rhode Island). None of the other authors have identi- fied a conflict of interest. hepatic artery chemoembolization Department of Diagnostic Radiology (M.J.W.), The and radioembolization, or proxi- University of Texas M. D. Anderson Cancer Center, © SIR, 2010 Houston, Texas; Department of Interventional Radi- mal superior gluteal artery coil ology (T.d.B.), Institut Gustave Roussy, Villejuif, DOI: 10.1016/j.jvir.2010.01.006 embolization during particle em- 436 Volume 21 Number 4 Golzarian et al • 437 bolization of the anterior division accredited training pathways to achieve clude the use of microcatheters for of the internal iliac artery for tu- the necessary education to perform subselective catheterization and the mor devascularization) (30,69)or embolization procedures in the body handling and delivery of particulate to facilitate subsequent other treat- is through the Accreditation Council agents and embolization coils. The use ments (eg, right portal vein embo- of Graduate Medical Education–ac- of embolic agents beyond those de- lization to induce left lobe hyper- credited fellowship programs in vas- scribed as “basic” may require addi- trophy before surgical resection) cular and interventional radiology or tional training and proctoring as stip- (70–71). its international equivalent. It is recog- ulated by the manufacturer or by the 8. Endoleak management: including nized that embolization requires a appropriate governing body. Conse- direct sac puncture or collateral skill set only available through such quences of inadequate training or ex- vessel embolization for endoleaks rigorous and comprehensive Ameri- perience can lead to major adverse (72–76). can Board of Medical Specialties–ac- events if the disease or imaging and 9. Regional therapy delivery: vehicle credited medical imaging and inter- embolization techniques are not fully for delivery of drugs or other agents vention training or its international understood by the operator. These ad- that may include oncolytic viruses, equivalent. The 1-year duration of verse events could include nontarget ␤ chemotherapy, -emitting spheres, training is the minimum for attaining embolization that can result in major or other agents used to treat an or- competency in embolization catheter- morbidity depending on the territory gan or specific target lesion. ization techniques and to acquire suf- treated (eg, stroke or blindness for ep- 10. Enterocutaneous tracts and lym- ficient knowledge of the spectrum of istaxis embolization, bowel or bladder phatic abnormalities: embolizing ab- diseases that can be served by embo- infarction for uterine artery emboliza- normal communications between or- lization, including the natural history tion). gans, from cavities or organs to the and risk–benefit analyses associated The clinical relationship between a skin surface, thoracic duct leaks, with provision of the procedures; patient who needs an embolization lymphedema. training on specific aspects of the tech- procedure and an interventional radi- nical procedures; and the performance Embolization has grown dramati- ology physician should be structured characteristics in indications for use so that the physician should see every cally in scope and complexity over the for the numerous embolic materials past three decades, and with this patient for a preprocedural clinical available. This comprehensive train- evaluation and consultation before growth, there is now a need to define ing is critical to ensuring that patients treatment and for a postprocedure standards for those practicing in this receive safe and effective care. longitudinal clinical follow-up after field, including: appropriate training It is expected that, as part of the the procedure. Some of the clinical with monitoring of outcomes; provi- accredited training process in diagnos- skills and responsibilities required for sion of pre-, intra-, and postprocedure tic imaging and vascular and interven- patient care particular to embolization patient care; and performance of the tional radiology, the physician will technical aspects of the procedure. have a thorough understanding of procedures include the following: vascular anatomy including congeni- 1. Knowledge of the natural history PHYSICIAN QUALIFICATIONS tal and developmental variants and of the disease; common collateral pathways, angio- 2. Understanding of the risks of the Embolization is a complex and de- graphic equipment, radiation safety procedure given the patient’s spe- manding endovascular image-guided considerations, and physiologic moni- cific presentation and findings; intervention requiring all of the skills toring equipment. Moreover, it is an- 3. Review of all available diagnostic of the interventional radiologist. Inter- ticipated that, before the performance imaging tests; pretation of diagnostic imaging tests is of any embolization procedure, the 4. Knowledge of the acute tumor ly- integral to performance of emboliza- operator will have received specific sis syndrome; tion procedures. The interventional ra- training, including didactic training as 5. Treatment of the postembolization diologist who performs embolization well as hands-on training with a suffi- syndrome; must be competent in diagnostic im- cient number of procedures in each of 6. Use of
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