Naomi M. Hamburg, MD

As a cardiologist specializing in vascular medicine, I am excited by the increasing interest from medical students, residents, and cardiology fellows in vascular medicine training. Vascular diseases affect millions of patients each year, with increases expected as our population ages. Interventional approaches and improvements in secondary prevention have vastly altered the treatment landscape. Noninvasive vascular testing, including ultrasound, is essential to the management of many vascular diseases, including carotid artery disease, peripheral artery disease, abdominal aneurysms, and venous diseases. The creation of the Vascular Ultrasound Council highlights the commitment by ASE to excellence in comprehensive cardiovascular imaging. As is the case for echocardiography, vascular diagnostic testing is best performed by physicians with familiarity with all aspects of vascular care. Thus, education in vascular imaging should be provided in the context of training cardiovascular specialists with broad knowledge of diagnostic and therapeutic approaches to manage vascular diseases.

The most recent American College of Cardiology (ACC)/American Heart Association (AHA) Core Cardiology Training Symposium (COCATS) document published in 2008 (available at www.asefiles.org/COCATS.pdf ) reflects the importance of vascular training. Total vascular medicine time to satisfy Level 1 training requirements was increased from 1 to 2 months. Trainees should be exposed to management of arterial, venous, and lymphatic diseases and the perioperative assessment of vascular surgery patients. A key element of this training is instruction regarding the indications and interpretation of vascular ultrasound and physiologic testing. It is suggested that the primary training site include an Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL) accredited laboratory. As with echocardiography, Level 1 training serves to familiarize trainees with vascular testing, but is not sufficient to allow them to be independent readers or to run noninvasive vascular laboratories.

A career in noninvasive vascular medicine requires additional dedicated fellowship training time. Vascular medicine programs are pursued both by cardiology fellows and by internists. As outlined in the COCATS 3 document, the 12 month training period should include the following experiences: inpatient vascular medicine consultation (2-3 months); magnetic resonance imaging and computed tomography angiography (1-2 months); peripheral vascular catheterization (1-2 months); and additional electives such as vascular surgery, rheumatology, and hematology. An outpatient experience of at least a half day per week should be provided to facilitate training in the longitudinal care of vascular patients. Both case conferences and formal didactic lectures should be available and are encouraged to involve faculty from multiple disciplines including vascular surgery, radiology, neurology, and rheumatology.

Further training in vascular ultrasound is a critical element of a vascular medicine fellowship. While cardiology trainees will have exposure to the basics of ultrasound technology and physics through echocardiography rotations, there are elements specific to vascular duplex that should be covered. Fellows rotate for at least 3 months in the noninvasive laboratory, including performing tests with the guidance of trained sonographers and supervised reading. Trainees without prior echo knowledge require additional time in the vascular lab. A broad range of tests should be covered in training, including: duplex ultrasound evaluation of the carotid arteries; veins of upper and lower extremities; abdominal aorta; renal and mesenteric vessels; extremity bypass grafts; physiologic arterial testing; duplex to evaluate for complications of arterial access; and others. Requirements to sit for the American Registry of Diagnostic Medical Sonography (ARDMS) Registered Physician in Vascular Interpretation (RPVI) examination ( www.ardms.org ) include supervised interpretation of at least 500 studies, and it should be expected that all vascular medicine trainees complete this examination.

Expertise in vascular medicine is now formally recognized by board certification. Starting in 2005, the American Board of Vascular Medicine (ABVM) has offered an annual computer-based examination in general vascular medicine. Details are available at www.vascularboard.org . Eligibility requirements include internal medicine certification and completion of a 12 month vascular medicine fellowship that can be undertaken within cardiology training. A practice-based pathway is also available through 2015. Over 400 vascular medicine physicians are currently certified. The newly-established vascular physician pathway to FASE requires completion of both ABVM and RPVI certification.

Advancing vascular care and vascular imaging requires cutting edge clinical research. In response to the need for vascular medicine experts equipped with skills to become clinical research leaders, the National Institutes of Health funded seven K12 Research Career Development Programs in Vascular Medicine across the US. This unique program is a tremendous opportunity for fellows committed to an academic career in vascular medicine. Each three-year fellowship combines two years of mentored training in patient-oriented research with a 12-month clinical vascular medicine fellowship. A detailed description of training locations along with contact information is available online ( www.nhlbi.nih.gov/funding/training/redbook/k12-vasmed.htm ).

Vascular medicine is a rapidly expanding field. Through coordinated training in vascular imaging, vascular pathophysiology, and vascular therapies,we have the opportunity to insure the highest standards in vascular care.