IV Multidisciplinary Management

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Multidisciplinary vascular centers

The concept and its implementation
Fabrizio Benedetti-Valentini (Italy)
and The vascular medicine perspective
Adriana Visona (Italy)

Both speakers discussed two parts of the same subject. They introduced the problem of using a multidisciplinary treatment approach for vascular patients. According to the definition, a vascular center is a “dedicated center where patients with vascular disease can receive high-quality medical, endovascular, and open surgical treatment by appropriate experts working as a coordinated team.” A key component of a vascular center is the collaboration between vascular medicine, endovascular treatment, and vascular surgery; however, the center also provides training in vascular medicine, vascular surgery, and endovascular therapy and participates in vascular research. The idea for creating vascular centers was presented in 2003, and, in 2009, it was published in the guidelines (Int Angiol. 2009;28:347-352).

The majority of patients referred to a vascular center do not require surgical treatment. Vascular centers should have a minimum number of inpatients for conservative treatment: peripheral arterial occlusive disease >100; diabetic foot >80; deep vein thrombosis >100; chronic venous insufficiency >70; others ≈20. Patients should be cared for by a team who understands their condition completely and who can organize appropriate investigations and treatment. The minimum number of endovascular and open surgical procedures per year for vascular centers are as follows: carotid >50; abdominal aortic aneurysm >50; occlusive disease >100; combined procedures >20; trauma ≈20; varicose veins >100. For accreditation, vascular centers should have an endovascular unit, vascular surgical theater, C-arm radiolucent table, and a cell-saver that are all available 24 hours a day for emergencies and a hybrid radiosurgical unit, if possible. Therefore, only large articulated hospitals can host a vascular center.

The Commission for Accreditation of Vascular Centers was created in Buenos Aires, Argentina on April 21, 2010. After completing all requirements for visiting commissioners, any vascular center around the world can obtain the Diploma of Accreditation. Accreditation means that patients will know where to find the best vascular care and they can find these accredited vascular centers via the internet, even in an emergency. In addition, valuable supranational accreditation is crucial when dealing with the health authorities for funding and personnel equipment. Additional information can be obtained by sending an email to secretariat@angiology.org.

The vascular surgery perspective
Stephan Acosta (Sweden)

Acosta shared his experience working in the vascular center at the Skåne University Hospital (Malmö, Sweden). The center includes vascular surgeons, vascular physicians, and radiologists, and it focuses on transient ischemic attacks, ischemic stroke, angina pectoris, angina abdominals, pulmonary artery disease, and critical limb ischemia. Acosta is focused on the impact of preoperative evaluation by vascular physicians on mortality in patients undergoing surgical or endovascular procedures.

The best care to the vascular patient, every day: the benefit of a multidisciplinary vascular center
Peter Gloviczki (USA)

Peter Gloviczki from the Mayo Clinic (USA) started by quoting Dr William W. Mayo “No one is big enough to be independent of others,” which is now a principle of the Mayo clinic. The Mayo Clinic’s Gonda Vascular Center was founded in 1991. The center treats more than 30 000 people annually. The structure of the center includes units, such as peripheral vascular laboratories, an interventional radiology clinic, a thrombophilia clinic, a vascular surgery clinic, ultrasound laboratories, a wound care center, a vascular medical clinic, an early atherosclerosis and vascular rehabilitation clinic, a vein clinic, a vascular access clinic, a vascular malformation clinic, a lymphedema clinic, and an aortic center. Now, many multidisciplinary vascular forums are available, such as the Vascular Annual Meeting (VAM) of the Society for Vascular Surgery (SVS), the VEITH symposium, VIVA meetings, the American Venous Forum, European Venous Forum, Latin American Venous Forum, and Central European Vascular Forum, and the International Union of Angiology congress. The objective of these multidisciplinary forums and vascular clinics is to unite forces and include large scale medicine, surgery, and endovascular interventions to treat vascular diseases at an international level.

Other experiences in Europe?
Karel Roztocil (Czech Republic)

The Czech Republic has created an original two-level system to care for vascular patients. In the first level, vascular care is performed in an outpatient vascular center, where the number of centers is expected to be around 2 to 3 per 100 000 inhabitants. The primary settings include essential diagnosis, outpatient therapeutic and prophylactic care for vascular patients with arterial, venous, lymphatic, and microvascular disorders, and the centers should have one or more physicians and one or more vascular nurses. First-level centers usually have the equipment to noninvasively evaluate pulmonary artery disease, diagnose venous thrombosis, evaluate chronic venous disease, lymphatic disorders, and vascular functional disturbances, and collaborate with the vascular centers. The vascular centers (angiology and vascular medicine centers) have highly specialized facilities that should provide all traditional and newer innovative approved surgical, nonsurgical, interventional, and medical treatment. The vascular center philosophy involves a multidisciplinary cooperation of vascular medicine with vascular surgery, cardiovascular surgery, cardiology, noninterventional and interventional radiology, podiatry, diabetology, wound care, hematology, etc. Per year, each vascular center must have a minimum number of patients, including 1000 noncoronary diagnostic or interventional cases; 100 open vascular surgeries; 25 stent grafts, and they must have accreditation for angiology. Today, the density of vascular centers is 1.8 centers per million inhabitants. Highly specialized care for selected vascular cases is available by intermediacy of vascular centers covering the territory of the country. Patients are benefiting from a comprehensive approach, concentrated technologies, devices, and treatment strategies provided by a multidisciplinary team. As a result, according to the registry data on open vascular surgery and endovascular interventions in the Czech Republic, there are around 250 per 100 000 inhabitants (one-quarter are open surgery and three-quarters are endovascular interventions).