P.L. Antignani Dept. of Angiology, S. Giovanni Hospital, Rome, Italy

1. Palermo 2009 VASCULAR CENTRES: THE MULTIDISCIPLINARY WAY TO VASCULAR CARES Who and how should manage the vascular laboratory P.L. Antignani Dept. of Angiology, S. Giovanni Hospital, Rome, Italy

2. Definition of Vascular Centre A Vascular Centre (VC) is defined as a “ Dedicated centre where patients with vascular disease can receive high quality medical, endovascular and open surgical treatment by appropriate experts working as a co-ordinated team”

3. Definition of Vascular Centre The VC will provide training in Vascular Medicine, Vascular Surgery and Endovascular Therapy and will be involved in research. Its functions are to give qualified angiological, radiological and surgical services, vascular consulting service including vascular laboratory, 24h-365d service for emergency and cooperation with primary care physicians.

4. Key components of VC - Expertise and facilities for Vascular Medicine, Endovascular Therapy and Open Vascular Surgery - Diagnostics and Therapy 24h – 7 days a week - Appropriate case load - Accredited vascular laboratory - Quality assessment

5. Competence of Vascular laboratory Core of competences to be present in a vascular laboratory of VC and they should be there for elective cases and for emergencies.

6. Number of patients • Minimum number of patients per year in a vascular laboratory of VC: • CFDS of supra aortic vessels: 150 • CFDS of abdominal arteries and veins 50 • CFDS of arteries of limbs 125 • CFDS of veins of limbs 125 Antignani P. L., Gossetti B. et al: Vascular diagnostics laboratory. Workloads and Indications. Minerva Cardioangiologica 2004 October;52(5):447-64

7. Diagnostic laboratory Diagnostic laboratories can be managed by several specialities with appropriate competence, alone or in collaboration, and can vary from hospital to hospital, from country to country. Anyhow it is considered important that the investigations be supervised by a clinician with established competence.

8. Non invasive vascular laboratory Advised investigations: Doppler CW Dupplex Scanning Transcranial Doppler Venous Pressure measurements Tcp 02 – TcpC02 measurements

9. Vascular laboratory • Non-invasive evaluation by ultrasound and radiological studies are the two cornerstones of the workup with the vascular patients. • Color coded duplex scanning is definitely the core instrument of a vascular laboratory: many forms of treatment, both endovascular and open surgical, are performed today based exclusively on evaluation with duplex scanning. • In a high level VC ideally all the advised investigation should be available. Creager MA, Hirsch AT, Cooke J et al: Postgraduate training in vascular medicine: proposed requirements and standards. Vascular Medicine 2003;8:47-52

10. Non invasive vascular laboratory and training The training requirement for interpretation of non invasive vascular tests: • Ultrasound physics, transducer technologies, ultrasound instrument characteristics • Ultrasound instrument settings, and transducer manipulation required to obtain an optimal image

11. Non invasive vascular laboratory and training A structured VL should be provided to expose each trainee to the following diagnostic modalities: • Physiological diagnostic studies of the upper and lower limbs at rest and after exercise (pulse volume recordoings, Doppler waveform analysis) • Duplex ultrasound examination for carotid, vertebral and intracranial arteries • Duplex ultrasound to evaluate venous thrombosis and insufficiency, obstructive disease of abdominal and peripheral arteries, aneurysms, arterovenous fistulas, preoperative venous and arterial mapping.

12. Non invasive vascular laboratory and training Training has some cornerstones: • Ability to perform standard vascular laboratory procedures with high accuracy • Interpretation of results under the supervision of a faculty expert • Application of knowledge gained from the literature concerning the limitations and indications of vascular diagnostic laboratory data. Antignani P. L., Gossetti B., Righi D et al: Accreditation process for the performance of ultrasound vascular diagnostics procedures. Minerva Cardioangiologica 2005 October;53(5):485-508

13. Vascular laboratory and quality Vascular Laboratory should be accredited following guidelines. Quality assessment should also be provided through internal and external audit.

14. Quality and vascular laboratory • A comprehensive programme for audit of outcomes should be active; record keeping, quality control and continuing education of the staff are essential components of a vascular laboratory of VC. • Vascular Laboratory should be accredited following guidelines. Quality assessment should also be provided through internal and external audit. • The programme includes the daily use of validated and standardized guidelines.

15. Radiology Investigations available 24h/day - CT - Angio – CT - MR - Angio – MR

16. Who manage the vascular investigation laboratory of VC ? • Non-invasive vascular investigations and vascular laboratories should be managed by either vascular physician or by vascular surgeon or by both. • In some countries ultrasound examinations and other non-invasive vascular studies are performed by technicians and at some places by medical specialists who are otherwise not involved in patient care.

17. Who manage the Vascular Centre ? • The vascular clinician with expertise in all vascular diseases (venous and arterial disorders), including functional forms, dysplasia and complementary diseases such as diabetes, hypertension, neurological disorders and so on.

18. Who manage the vascular Centre ? • A clinician with “charisma” • Obviously, the choice depends on the local situation and varies from country to country

19. Thank you for your attention !!