In an effort to improve outcomes in individuals with chronic limb-threatening ischemia (CLTI), a multispecialty societal group convened to develop a position statement outlining competencies for endovascular specialists providing CLTI care. The document, which was released Monday and published online in the Journal of the Society for Cardiovascular Angiography and Interventions, details key skills that all endovascular specialists should have to provide successful outcomes for CLTI patients, according to a Society for Cardiovascular Angiography and Interventions (SCAI) news release. The skill sets are classified into six core competencies based on the Accreditation Council for Graduate Medical Education framework: medical knowledge, patient care and procedural skills, systems-based practice, practice-based learning and improvement, professionalism, and interpersonal and communication skills. To account for a range of complexity across the competencies, the document also gives examples stratified into “fundamental” and “advanced” categories. An estimated 2 million Americans have CLTI. As the population ages, and atherosclerotic risk factors such as diabetes and renal disease rise, CLTI is expected to become more prevalent. CLTI is associated with an increased risk of amputation, myocardial infarction and death. CLTI often requires complex and multilayered care compared to milder forms of PAD and those with cardiovascular disease. The document is a collaboration of SCAI, the American College of Radiology, American Podiatric Medical Association, Society for Interventional Radiology, Society for Vascular Medicine, Society for Vascular Surgery, Society for Clinical Vascular Surgery and Vascular and Endovascular Surgical Society. The statement was developed in accordance with SCAI Publications Committee policies, and each society nominated one representative to participate in the writing group. “Care for patients with CLTI is typically complex, multifaceted, and multidisciplinary. Standardizing expected competencies for endovascular specialists is an important step to ensure that patient-centric and evidence-based therapy is delivered,” said Beau M. Hawkins, MD, the chair of the writing group for the document. “This new framework is a starting point to enable training programs, professional medical societies, and other entities to develop curricula that address the needs of this unique patient population.” From an anatomic standpoint, lengthy occlusive tibial disease was the most commonly encountered lesion phenotype in CLTI patients. Infra-malleolar disease is a prevalent finding in CLTI and is a marker of poor wound healing, and the efficacy of pedal angioplasty to improve limb salvages remains uncertain. Additionally, the presence of vascular calcification challenges the approach and success of endovascular procedures and the need for alternate access and multi-staged procedures. Accordingly, severe multilevel disease CLTI patients may be better suited for bypass, particularly when there is evident tissue loss, which often takes more than 6 months of healing and needs patency durable enough for wound healing. Wound assessment and differentiating ischemic from non-ischemic wounds are also integral components of CLTI management. Noninvasive vascular testing entities such as the ankle-brachial index, toe pressures and toe-brachial index, Doppler waveforms, pulse volume recordings and photoplethysmography are essential components of patient care for initial referral in symptomatic patients and also help quantify the effects of revascularization, and for surveillance monitoring during short- and long-term follow up. Similarly, imaging using computed tomography angiography, magnetic resonance angiography and duplex ultrasonography helps localize disease and assist with procedural planning. The committee stressed that it is important that an endovascular proceduralist recognize the multidisciplinary nature of care provided to the CLTI patient to achieve optimal patient outcomes, which involves working closely with members of other specialties to ensure optimal medical, surgical, vascular and wound care. However, the committee did not suggest the minimal requisite procedural volume for the endovascular trainees but noted that technical proficiency for operators improves by procedural volumes and experience and a systematic approach for endovascular trainees to stratify procedure log by segment and complexity and submitting it to a central repository should be considered. To attain the skillset, the statement also discusses the institutional requirements and resources necessary for trainees to become competent in their specialty of interest. Recommendations for formal training and independent courses in a post-training practice are also provided. A CLTI certification process may be helpful in the future to objectively evaluate individual and institutional performance, the writing committee stated. The document emphasizes the need for common ground for all specialties involved in the care of CLTI patients to improve quality of life, lower cardiovascular morbidity and mortality, and eliminate preventable amputation. "This unprecedented collaborative effort among these eight multidisciplinary medical societies is another step forward towards advancing care for patients with CLTI,” said Mehdi Shishehbor, DO, MPH, PhD, the president of Harrington Heart and Vascular Institute, University Hospitals Cleveland, and co-chair of the writing group. “I hope that these efforts will evolve and translate into better care for these high-risk patients at risk of limb loss." Image Credit: Mindaugas – stock.adobe.com