Such requirements for additional training and experience in performing CAS have been recognized by the Accreditation Council for Graduate Medical Education (ACGME) as part of the specialty training requirements for endovascular surgical neuroradiology (5). At a minimum, performance of CAS requires extensive prior experience and demonstrated competence with diagnostic cervicocerebral angiography, as well as experience with angioplasty and stent placement. Far more experience and training and fewer complications during diagnostic cerebral angiography are expected of those who perform neurovascular interventions, similar to what is expected of those who perform coronary interventions. The published standard of practice for cervicocerebral angiography describes the minimum acceptable requirements for performance of the much less difficult and lower risk procedure of diagnostic cervicocerebral angiography (4) it is the purpose of this standard to describe the minimum prerequisite for the performance of the far more difficult and higher risk procedure of carotid artery angioplasty and stent placement (CAS). Furthermore, due to the implications concerning stroke prevention, the ASITN, ASNR, and SIR wish to encourage the careful and scientific study of the safety and efficacy of brachiocephalic revascularization as well as appropriate utilization of these techniques (3). There is a critical need to encourage the development of procedures that may improve outcomes for patients with brachiocephalic and intracranial atherosclerotic stenoses. The ASITN, the ASNR, and the SIR recognize that brachiocephalic revascularization is undergoing rapid change in technology even as it is being increasingly adopted in clinical practice for the treatment of cerebrovascular pathologies (3). Thresholds for quality assurance were difficult to set due to the relative paucity of data and lack of uniform reporting of clinical outcomes and complications. A thorough review of the literature was performed. This Quality Improvement Guideline for the Performance of Cervical Carotid Angioplasty and Stent Placement was developed by a writing group consisting of members from interventional neuroradiology, neurosurgery, neuroradiology, and interventional radiology. Before its publication, the document was endorsed by the ASITN Executive Committee, ASNR Executive Committee, and the SIR Executive Council. These comments are discussed by the Standards of Practice Committee, and appropriate revisions made to create the finished standards document. The finalized draft from the Committee is sent to the ASITN, ASNR, and SIR membership for further input/criticism during a 30-day comment period. The draft document is critically reviewed by the Standards of Practice Committee members, either by telephone conference calling or face-to-face meeting. For purposes of these documents, consensus is defined as 80% Delphi participant agreement on a value or parameter. When the evidence of literature is weak, conflicting, or contradictory, consensus for the parameter is reached by a minimum of 12 Standards of Practice Committee members with a Modified Delphi Consensus Method (1,2). Data compiled from selected articles meeting evidence thresholds are used to develop content and to set standards. Then a critical review and selection of peer-reviewed articles are performed based on study methodology, results, and conclusions. Additional authors may be assigned depending on the magnitude of the project.Īn in-depth literature search is performed with electronic medical literature data bases. A recognized expert is identified to serve as the principal author for the standard.
Standards documents of relevance and timeliness are conceptualized by the Standards of Practice Committee members. ASITN, ASNR, and SIR Standards of Practice documents are produced using the following process.
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