General Goals

  • 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 an din CT – angiography studies
  • For all peripheral vascular disease (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

  • How to use a Doppler probe to assess pulses/waveforms
  • Managing electrolyte abnormalities (K, Ca, Mg, Na, Phosphate)
  • Assessing and managing patient’s fluid status using renal function/creatinine, urine output, vitals, physical exam findings, CVP, and ultrasound
  • Managing a febrile patient by determining source of infection and using appropriate antibiotics and stabilizing vitals
  • Managing a patient with hypotension
  • Know the etiologies of and management of shock
  • 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
  • Know commonly used pain medications, including formulations, dosages, potency, and side-effects (NSAIDs, opiates, etc.)
  • Know indications for the following:
    • Foley catheter
    • PICC
    • Central Line
    • NG tube
    • G-tube

Out-Patient Goals

  • 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 classifications 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
          • Heparin, Warfarin, Enoxaparin, Lepirudin, Argatroban, Bivalirudin, Dagibatran
        • Antiplatelets
          • Aspirin, Clopidogrel, Prasugrel
        • Diabetes medications
          • 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
  • 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)
  • 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
  • Venous Disease
    • Venous Thromboembolic Disease (VTE)
      • DVT:
        • Risk factors
        • Clinical examination (signs of phlegmasia, Homan’s test, other physical findings of DVT, etc.)
        • Well’s 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

  • 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
  • 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)