CNS – Endovascular Surgery Fellowship

Introduction

The program in Endovascular Surgery is focused on the subspecialty that uses minimally invasive catheter-based technology along with radiologic imaging and clinical acumen to diagnose diseases of the central nervous system, head, neck and spine. At the University of Cincinnati College of Medicine (UCCOM), this CAST approved program is focused upon educating the next generation of Neurointerventionalists by providing a comprehensive program that will ensure proficiency and expertise in the skills and judgment required to care for patients with this complex series of diseases.

Goals and Objectives

• Achieve advanced proficiency in the recognition and endovascular treatment of patients with vascular diseases of the nervous system, head, neck and spine
• Achieve proficiency in the analysis of issues revolving around patient safety and hospital-based quality improvement in endovascular therapy
• Contribute meaningfully in facets of education and scholarship in the field of cerebrovascular disease and endovascular therapy

Length of the Educational Program

This fellowship offers one year of graduate medical education in Endovascular Surgery to those candidates who have fulfilled preliminary criteria as defined below. Should the candidate not meet this criteria, a supplementary program shall be offered and require successful completion to a minimum level of COMPETENCY.

Neurosurgeons:

• Satisfactory completion of a 7-year ACGME approved residency or be enfolded in the post Chief Residency year.
• Satisfactory participation in all ABNS CC/MOC requirements
• Neurologists:
• Satisfactory completion of an ACGME-accredited neurology residency
• Satisfactory completion of an ACGME-accredited Vascular Neurology fellowship with at least 3 months in the neurointensive care unit or satisfactory
• Completion of an ACGME, CAST, or UCNS approved Neurocritical Care fellowship
• Satisfactory participation in all ABNS CC/MOC requirements

Radiologists:

• Satisfactory completion of an ACGME accredited residency in radiology and completion of Neuroradiology fellowship
• Satisfactory completion of at least 6 months of clinical service in a neurological surgery, vascular neurology or neurocritical care program prior to entering the final advanced year of ES fellowship
  
• Satisfactory participation in all ABR CC/MOC requirements
• Preliminary endovascular training for Neurosurgeons, Neurologists, and Radiologists
• Performance of at least 200 catheter-based diagnostic and/or interventional cerebral angiographic procedures as primary operator completed during residency, preliminary subspecialty fellowship, or as a separate experience after completion of residency or during the CNS endovascular fellowship
• Demonstrated competency in catheter techniques, as validated by the CNS-ES Fellowship Program Director, and
• Expected knowledge of cerebrovascular diseases completed and approved by both the residency and fellowship program directors.

The preliminary training curriculum includes the following:

• Proper use of needles, catheters, guidewires, and contrast material,
• Fundamental understanding of radiation physics, biology and safety,
• Interpretation of cerebral angiography, neurovascular and neuroradiological studies
• Pathophysiology of cerebrovascular diseases,
• Coagulation pathways, testing and manipulation
• Evaluation and management of patients with cerebrovascular diseases
• Critical care management of the acute vascular patient, including placement of invasive monitoring devices
• Clinical indications, risks, and limitations of endovascular neurosurgical procedures,
• Understanding alternatives to NES including medical and surgical options,
• Generating procedural reports that include and adhere to CPT coding

Advanced CNS endovascular training year requirements:

• A minimum of 12 to 24 months (of which the final 12 months need to be continuous) of a dedicated CNS-ES fellowship experience during which the fellow performs a broad spectrum of endovascular procedures as defined by core-competency requirements. The final 12 months of fellowship will be performed after completion of ACGME primary residency and subspecialty requirements for neurologists and radiologists. Neurosurgeons have the option of completing the final 12 months of training after completion of the Chief Resident year during ACGME residency or after completion of the residency.
• Requisite knowledge and competency in the diagnosis and treatment of cerebrovascular diseases including extracranial and intracranial occlusive atherosclerotic disease and dissection in CNS-ES approved by the CNS-ES Fellowship Director, and

The advanced training curriculum includes the following:

• Arterial and venous angiographic anatomy of the brain, spinal cord, head, neck and spine including:
  • collateral anastomoses, anatomic variants and modifications induced by disease processes.
  • Bony and soft tissue anatomy and physiology of brain, head and neck and spine
  • Cerebral blood flow and its physiology and pharmacology.

Sponsoring Institution

The Sponsoring Institution is the University of Cincinnati College of Medicine in the city of Cincinnati, OH and shall serve as the PRIMARY CLINICAL SITE.
The UC Office of Graduate Medical Education, and the Departments of Neurological Surgery, Neurology and Radiology have supported and continue to support this fellowship.

Programs within the aforementioned departments integrate in the education of fellows in Endovascular Surgery.

• The University of Cincinnati’s ACGME-accredited Neurological Surgery residency training program will expose fellows through conferences, education and clinical care to patients requiring surgical treatment and radiosurgical treatment for all forms of cerebrovascular disease. Patients present for bypass surgery, aneurysm clipping, AVM resection and radiosurgery, carotid endarterectomy, cavernous malformation surgery (including seizure surgery), surgery of the head and neck for vascular lesions (e.g. glomus tumors) and blunt and penetrating cerebrovascular injury. A pituitary surgery service has allowed for the growth of our inferior petrosal sinus sampling program. Our complex spine surgery service works with our cerebrovascular team in managing and operating on vascular diseases of the spine. Such exposure increases the understanding the role of endovascular therapy as well as the limitations of some of the operative procedures. Such interactions provide the candidate with an advanced approach to assessing the role of endovascular in caring for these patients.
• The Department of Neurology has an active ACGME-accredited residency training program, an ACGME-accredited stroke/vascular neurology fellowship program and an ACGME-accredited neurocritical care program. It has a stroke program that forms one of the three major pillars of our Joint Commission-certified Comprehensive Stroke Center. With national and international expertise in intracerebral hemorrhage and ischemic stroke, the program cares for all stroke patients in the Greater Cincinnati/Northern Kentucky region. Multiple interactive opportunities through web-based weekly conferences have actually increased the opportunity for fellows to attend these important educational sessions.
• The Department of Radiology has an active ACGME-accredited Neuroradiology Fellowship Training Program that continues to be instrumental in educating our fellows in the nuances of neuroimaging. More importantly, the opportunity to discuss complex presentations through case-based learning and weekly imaging conferences enhances the bandwidth of our fellows in recognizing rare disease entities.
• All three departments have active nationally and/or regionally funded research programs that range from benchtop basic science, and advanced anatomical analyses, to bedside translational clinical research to computer-based imaging analysis and modeling.

Participating Sites

At present, with the anticipated complement of ONE fellow per year to be accepted to this program, the fellow is dedicated to the primary site alone for all clinical, educational and research activities.

Equipment and Facilities –

The University of Cincinnati Medical Center continues to improve its state-of-the-art imaging facilities and endovascular facilities. UCMC has 3 high-speed 1.5 and 3 Tesla MRI for inpatient and outpatient use with DWI and PWI capabilities. Two emergency CT scanners (256-slice) with CT perfusion and CT angiography and two additional in-patient CT scanners (256-slice) with CTA and CTP capabilities are available 24/7. Ultrasound and transcranial Doppler is available for patients in an in-patient, out-patient and emergent settings. In addition, UCMC has two newly-installed biplane angiography machines with rotational imaging, advanced 3-D road-mapping, and Dyna-CT capabilities.

The fellows enjoy the opportunity to participate in the care of patients treated with the most current devices for thrombectomy, AVM embolization and aneurysm treatment. Five HDE protocols and three endovascular clinical trials are currently active at UCMC, with several others undergoing an approval process.

Of note, fellows have the unique opportunity to participate in cerebrovascular anatomical research in the Department of Neurological Surgery’s Goodyear Microsurgery Lab, which consists of 5 fully-equipped, microscope-based stations for cadaveric dissections of latex injected heads and spine. Neuronavigation, advanced imaging and endoscopy supplement the facilities for advanced projects and technology innovation. Additionally, we host various workshops throughout the year in this lab with participating industry sponsors, where fellows and residents trial the latest endovascular equipment on various cerebrovascular model systems.

Clinical Resources

The combined Endovascular surgery program and the stroke program at UC provide a plethora of diverse and complex illnesses. The endovascular service receives, on average 3 in-patient consults daily while also evaluating 2-3 patients daily for out-patient procedures. Though ischemic stroke and subarachnoid hemorrhage comprise the majority of our in-patient consultations, as a level I trauma center focused on better understanding blunt cerebrovascular injury (BCVI), the fellow is exposed to extensive BCVI evaluation and management. The fellow will also be exposed to management of hemorrhagic head and neck pathology, such as epistaxis or extracranial bleeding secondary to blunt trauma.

Learning and Teaching Environment

Fellows in this program are part of a team of educators. It is expected (and evaluated) that fellows provide education to nurses, technologists, students and residents from the neurosciences and radiology. They are also expected to integrate education through presenting and participating in quality assurance and performance improvement programs.

In addition to the one-on-one education offered during the day-to-day patient care interactions, fellows are exposed to a radiation physics lecture program, divided into twelve one-hour lectures, to cover fundamental and advanced principles of radiation physics, biology and safety to include an understanding of CT, ancillary vascular imaging modalities and the effects of radiation to patients and personnel. This course in radiation physics will supplement the fundamental principles learned in the preparatory years such that all trainees on the Endovascular service will have a standardized curriculum of training and fund of knowledge at the time of successful completion of the fellowship program.

Personnel

With four primary teaching/core faculty (Drs. Charles Prestigiacomo, Aaron Grossman, Peyman Shirani, and Matthew Smith) dedicated to performing procedures exclusively at UCMC, the fellow has unfettered access to didactic and research opportunities. Daily rounds of the endovascular service with image-based reviews, weekly imaging-based endovascular conferences and journal clubs are mandatory for faculty as much as they are mandatory for fellows. Fellows will undergo closely supervised training (direct supervision) over the course of the 12 months by all core faculty members with immediate, post-procedure team-based feedback (the “Debrief”).