Jan 19, 2016 | Grant W. Reed, MD and Heather L. Gornik, MD, FACC
Career Development

Peripheral artery disease affects 8.5 million U.S. individuals ≥ 40 years of age (approximately 12 percent of the U.S. adult population), and its prevalence is growing in developed nations. Other peripheral vascular diseases (PVD) that lead to major health events and quality of life impairment include venous thromboembolism (deep vein thrombosis and pulmonary embolism), chronic venous insufficiency and abdominal aortic aneurysm. As the population ages, the prevalence of PVD is expected to grow, and the demand for vascular services is expected to expand by approximately 20 – 30 percent in upcoming years.

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FITs interested in PVD stand to be rewarded with a diverse patient population, exposure to cutting-edge diagnostic imaging and treatments, and job security in the future. There are several different training options for cardiology fellows interested in PVD (see Table 1 below). It is the goal of this article to provide a concise overview of these available training pathways. A comprehensive overview of the training pathways is provided in the ACC Core Cardiovascular Training Statement (COCATS) 4 document.

Every cardiology fellowship must provide COCATS 4 Level I training in vascular medicine, which imparts the essential knowledge to provide care for patients with PVD. This includes at least two months of vascular training in dedicated rotations or in aggregate. Additional knowledge and skill in vascular medicine and the non-invasive vascular laboratory can be obtained through elective time. This can lead to Level II vascular medicine training (Table), which provides the trainee with exposure to interpretation of vascular ultrasound and peripheral vascular resistance testing.

Completion of either Level II or III training will allow the trainee to be eligible for the Physicians' Vascular Interpretation Examination, which is necessary to obtain the Registered Physician in Vascular Interpretation (RPVI) credential. RPVI certification is required by most institutions to bill for reading diagnostic vascular studies. Supervised interpretation of at least 500 diagnostic vascular studies distributed across vascular modalities is needed to sit for the RPVI examination. Additional criteria for obtaining RPVI certification are provided at www.ardms.org.

Level III training provides the knowledge and skill necessary to sit for the American Board of Vascular Medicine (AVM) examination as a vascular medicine specialist (Table). Level III training is typically satisfied in a fully dedicated additional year of training (i.e. 4th year) beyond general cardiology fellowship. Many vascular medicine fellowships also allow for the trainee to gain additional expertise in performing vascular studies with the Registered Vascular Technician credential (criteria for this can also be found at www.ardms.org).

Training in peripheral vascular intervention can be obtained through an interventional cardiology fellowship. This typically incorporates arterial intervention, involving the lower and upper extremities, renal, mesenteric and carotid vasculature; expertise in venous intervention may be acquired as well. It is usually necessary to dedicate a 2nd interventional year to peripheral vascular training if this skill set is desired. Interventional fellowship by itself may not meet prerequisites for RPVI certification.

However, at least Level II certification is recommended for individuals interested in peripheral vascular intervention. Depending on the program, it is often possible to satisfy these requirements for RPVI certification during interventional training. Certain hybrid programs may allow trainees to quality for the AVM endovascular examination as well.

With careful planning, cardiology fellows can take full advantage of the several different training pathways in PVD. There has never been a more exciting time to become a vascular specialist. The flexibility offered by current training pathways allows FITs to trailor their curriculum to their individual needs, and in turn, the needs of their patients in the future.

Table 1: Summary and Comparison of Training Pathways in PVD For FITs.
Pathway	Key Skills Acquired	Time Requirement / Notes
COCATS Level I	Required of all cardiology fellows Able to provide care for most patients with PVD as a consultant	None beyond standard 3-year fellowship Does not provide ability to bill for interpretation of PVD diagnostic testing
COCATS Level II	Provide specialized PVD care Able to interpret vascular tests Recommended prior to or during peripheral vascular intervention training	Able to complete within 3-year cardiology fellowship with careful planning Meets criteria to sit for RPVI exam
COCATS Level III / Vascular Medicine Certified	Knowledge and skill to become a vascular medicine expert Required for subspecialty boarding in vascular medicine	Requires a dedicated additional 1 year Meets criteria to sit for RPVI exam Meets criteria to sit for the ABVM general vascular medicine board examination
Peripheral Vascular Intervention	Knowledge and technical ability to perform peripheral arterial and venous endovascular interventions	Dedicated 1 additional year (in addition to 1 year of coronary interventional training) Does not provide RPVI or RVT certification May meet criteria to sit for the ABVM endovascular examination
RPVI Certification	Tests ability to interpret non-invasive vascular diagnostic studies (i.e. arterial and venous ultrasound, etc)	Supervised interpretation of at least 500 diagnostic studies COCATS II and III satisfy criteria to sit for the RPVI exam Specific requirements at http://ardms.org/
RVT Certification	Ability to perform vascular diagnostic studies (i.e. arterial and venous ultrasound, etc)	May require additional time or planning to obtain during training

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This article was authored by Grant W. Reed, MD, a fellow in training (FIT) in the department of cardiovascular medicine at Cleveland Clinic, and Heather L. Gornik, MD, FACC, medical director of the non-invasive vascular laboratory at Cleveland Clinic.