VASCULAR SURGERY

Clinical Rotation Goals for IR Trainees

Written by: Shantanu Warhadpande MD
Edited by: Geogy Vatakencherry MD and Kyle Cooper MD

Today, more than ever, Interventional Radiologists need a solid foundation in vascular disease. To provide
patients with optimal care to treat patients with vascular disease. It is imperative that new-generation, clinical
interventional radiology trainees learn in the ins-and-outs of diagnosing, managing, and treating peripheral
vascular disease. The following document was put together to provide a list of goals that an IR trainee should
meet while rotating through their vascular surgery rotation. This can also be viewed as a compendium of goals
that a young IR physician should have mastery of before even considering entering the vascular disease playing-
field. Anything less than mastery will only lead to suboptimal patient care and poor patient outcomes. We hope
this will provide you a starting point.

GENERAL GOALS
o Vascular anatomy
Know arterial and venous vessels and major branches in the upper extremity, lower extremity,
thorax, abdomen, neck and cranium including:
Thoracic/abdominal aorta
Vena Cava
Subclavian vessels
Brachial vessels
Femoral vessels
Popliteal and infra-popliteal vessels
Cerebral vessels
Vertebral vessels
Interpret and identify vessels and associated pathology during fluoroscopic angiography and in
CT angiography studies
o For all peripheral vascular diseases (arterial occlusive disease, TAA, AAA, peripheral aneurysmal disease,
venous disease), know pathogenesis, risk factors, usual disease course, and complications

IN-PATIENT CARE OF VASCULAR PATIENTS

*Please see ICU Clinical Goals for more detailed information on in-patient care

Ensure competency in the following:

o How to use a Doppler probe to assess pulses/waveforms
o Managing electrolyte abnormalities (K, Ca, Mg, Na, Phosphate)
o Assessing and managing patients fluid status using renal function/creatinine, urine output, vitals,
physical exam findings, CVP, and ultrasound
o Managing a febrile patient by determining source of infection and using appropriate antibiotics and
stabilizing vitals
o Managing a patient with hypotension
o Know the etiologies of and management of shock
o Managing an in-patient with:
sudden-onset neurological changes or altered mental status
sudden-onset chest pain
sudden-onset dyspnea
abdominal pain
constipation/diarrhea
urinary retention
o Know commonly used pain medications, including formulations, dosages, potency, and side-effects
(NSAIDs, opiates, etc.)
o Know indications for the following:
Foley catheter
PICC
Central line
NG tube
G-tube

OUT-PATIENT GOALS
o Peripheral vascular occlusive disease
For the following goals, ensure you know how to do each for the following disease entities:
Aorto-iliac occlusions
Femoral-popliteal occlusive disease
Tibial/pedal occlusion
Carotid occlusion
Renal artery stenosis
Mesenteric ischemia
Pathogenesis, risk factors, usual disease course, and complications
Initial workup of a patient with peripheral vascular occlusive disease
Obtain a complete history/review-of-systems
Perform an accurate physical exam, including a vascular exam
Recognize signs/symptoms of:
aorto-iliac disease
femoral-popliteal disease
tibial/pedal disease

carotid disease
renal artery stenosis
mesenteric ischemia
Diagnosing a patient with peripheral vascular occlusive disease
Non-invasive exams/physiologic exams
Ankle-brachial index/Toe-brachial index
Segmental pressures/PVRs
Arterial duplex with waveforms
Non-invasive/anatomic exams
CT/MR angiography
Analyzing and interpreting the results from above
Familiarity with the TASC classification scheme for arterial occlusions
Familiarity with the Rutherford classification for acute limb ischemia and critical limb ischemia
Medical management of patient with peripheral vascular occlusive disease
Know when medical management is appropriate and when surgical/endovascular
intervention is indicated
Know indications of the following medications commonly used in vascular medicine
Beta blockers
ACE Inhibitors
Statins
Cilostazol
Anticoagulants
o Heparin, Warfarin, Enoxaparin, Lepirudin, Argatroban, Bivalirudin,
Dagibatran
Antiplatelets
o Aspirin, Clopidogrel, Prasugrel
Diabetes medications
o Metformin, Sulfonylureas, glitazones, Insulin
Surgical/Interventional management of patient with peripheral vascular occlusive disease
Identify when operative management is indicated in patients with peripheral vascular
disease for following entities: aorto-iliac, ilio-femoral, femoral and lower-extremities,
carotid disease, mesenteric ischemia, renal artery stenosis
Be comfortable with the indications for the different bypasses (femoral-femoral
bypass, axillary-bi-femoral bypass, fem-pop, fem-tib, etc.)
Identify when endovascular interventions are indicated in patients with peripheral
vascular disease for following entities: aorto-iliac, femoral-popliteal, tibial/pedal, carotid
disease, mesenteric ischemia, renal artery stenosis
Know the pros and cons of open surgical interventions and endovascular interventions
Know when different types of amputations are indicated (BKA, AKA, TMA, etc)
Wound care
Differentiate different types of wounds (venous, arterial, neurogenic)
Identify signs and symptoms of gangrene/sepsis (wet vs dry gangrene)
Know the treatment options and the management options available

o Aneurysmal disease AAA

General knowledge (ensure you know the following)
Pathogenesis and risk factors for a AAA
Screening protocol for AAA
Imaging studies used to diagnose a AAA
Risk factor modifications for patients with AAA
AAA surveillance and when endovascular/surgical intervention is indicated
Indications for a surgical repair
Limitations of an endovascular repair of a AAA (EVAR)

o Dialysis AV grafts
General knowledge (ensure you know the following)
Indications for a dialysis fistula (GFR < 25 mL/min)
Different types of grafts (radio-cephalic, brachio-cephalic, transposition brachiobasilic,
etc.)
Complications associated with AV fistulas/grafts (SVC syndrome, Steal syndrome,
aneurysmal disease, threatened skin, infections)

o Venous Disease
Venous Thromboembolic Disease (VTE)
DVT:
Risk factors
Clinical examination (signs of phlegmasia, Homans test, other physical findings
of DVT, etc.)
Wells criteria
Lab tests to order
Imaging studies to order
Underlying etiology (malignancy, May-Thurner Syndrome, etc.)
Medical management options
Endovascular management options
Pulmonary Embolism:
Risk factors
Clinical findings
Imaging findings
Medical management options
Endovascular options

PROCEDURAL GOALS
o General
Skin closure / basic suturing
Know how to obtain venous/arterial access in femoral, brachial, popliteal, and radial vessels
Know the tools of the trade and terminology: catheter types, catheter sizes, sheaths, dilators,
balloons, guidewires, stent types
Know how to manipulate catheter through and past occlusive lesions
Demonstrate knowledge of which catheters to use, and when
Know the general principles of balloon angioplasty and vessel revascularization
o Procedure specific goals
Participate in open surgical procedures (bypasses, fistula creations, AAA repairs, etc.)
Participate in, demonstrate knowledge of, and recall the steps for each of the following
procedures:
Endovascular repair of a AAA (EVAR)
Fenestrated endovascular repair of a AAA (FEVAR)
Aorto-iliac occlusion revascularization
Ilio-femoral occlusion revascularization
Lower limb revascularization
De-clot of dialysis fistulas and grafts
Aneurysm coiling
Know the post-procedural complications most often seen following these procedures and what
steps can be taken to minimize these complications
Know how to manage these patients post-procedure and what red-flags to be aware of for
each procedure (i.e. ensure patient has bilateral distal LE pulses s/p an EVAR)
*Please see ICU Clinical Goals for more detailed information on in-patient care