The Miriam and Rhode Island Hospitals each have 4 catheterization laboratories, with two of four capable of performing endovascular procedures. These labs are fully equipped with digital subtraction angiography and hemodynamic monitoring. At the Miriam Hospital, the 2 rooms are Philip Integra FD-20s, and at the Rhode Island Hospital there is one Philip Integra FD-20 and one new Toshiba lab.

The Non-Invasive Vascular Laboratories at both hospitals are ICAVL accredited, and the outpatient non-invasive vascular laboratory is also ICAVL accredited. The vascular technologists are RVT certified. The outpatient vascular clinics are located at the University faculty offices.

Fellows will be exposed to adult patients from both the Miriam and Rhode Island Hospitals. These are the principal academic teaching hospitals of The Warren Alpert School of Medicine of Brown University. Both facilities support multiple residency and fellowship programs, including accredited general cardiovascular, electrophysiology, and interventional cardiology fellowship programs. Fellows will also see patients in the outpatient vascular clinics of the faculty.

The fellowship will be a dedicated one-year program. Upon completion of their year of training, fellows are eligible to sit for and take the Vascular Medicine and Endovascular Medicine Board Certifications Exams, as well as the Registered Physician Vascular Interpretation Exam.

• Multi-Disciplinary Vascular & Endovascular Medicine Conference – weekly
• Cath Conference – weekly
• Vascular Didactic Conference – weekly
• Journal Club – monthly
• Interventional Research Conference – monthly
• Non-Invasive Lab Conference – monthly
• Morbidity & Mortality Conference – monthly

• PAD: Pathophysiology, Clinical Manifestations, Natural History, Evaluation and Management
• VTE: Pathophysiology, Clinical Manifestations, Natural History, Evaluation and Management
• CVI: Pathophysiology, Clinical Manifestations, Natural History, Evaluation and Management
• Hypercoagulable Disorders
• Vasculitis
• Vasospastic Disorders
• Unusual Vascular Conditions
• Lymphatic Disorders
• Thoracic Outlet Syndrome: Pathophysiology, Clinical Manifestations, Natural History, Evaluation and Management

• Carotid Artery Disease: Pathophysiology, Clinical Manifestations, Natural History, Evaluation and Management
• Subclavian/Vertebral Disease: Pathophysiology, Clinical Manifestations, Natural History, Evaluation and Management
• Renal Artery Disease: Pathophysiology, Clinical Manifestations, Natural History, Evaluation and Management
• Aorto-iliac Disease: Pathophysiology, Clinical Manifestations, Natural History, Evaluation and Management
• SFA Stenting Data
• Atherectomy Devices
• Interventional Treatment of VTE
• Vascular Access/Vascular Closure Devices
• CTO Devices
• IVC Filters
• EVAR/TEVAR
• Dialysis Graft Angiography/Intervention
• Arterial Thrombosis: Pharmaco-mechanical thrombolysis
• Varicose Vein Treatment: EVLT, RF Ablation, Phlebectomy, Sclerotherapy

Arterial

• Carotid Artery Stenting with Distal and Proximal Embolic Protection
• Vertebral Artery Stenting with Distal Embolic Protection Devices
• Subclavian Artery PTA/Stenting
• Renal Artery PTA/Stenting with EPDs using BMS/covered stents
• Aorto-iliac PTA/Stenting with BMS/covered stents
• PFA/SFA/Pop PTA/Stenting with nitinol/covered stents
• CFA orbital/plaque excision/laser atherectomy/ CB PTA
• Atherectomy Devices: Orbital/Laser/Plaque Excision/Pathway Devices
• CTO Devices: Frontrunner/Outback/Pioneer/Wildcat/Crosser Devices
• Femoral/Brachial/Radial/Popliteal/Pedal Access/Antegrade Access
• Vascular Closure Devices: Perclose, AngioSeal, Mynx, StarClose Devices
• Embolization: Amplatzer Plug/Coils/Particles
• EVAR/TEVAR Implants
• Pharmaco-Mechanical Thrombolysis: Trellis/EKOS/AngioJet Devices
• Catheter Directed Thrombolysis with tPA
• Thrombin Injection of Pseudoaneurysms

Venous

• Subclavian/Central Vein PTA/Stenting
• Iliac vein PTA/Stenting
• Popliteal/Brachial/Tibial Vein Access
• Varicose Vein Ablation with EVLT/RF
• Ambulatory Phlebectomy
• Sclerotherapy
• IVC Filter Implantation/Retrieval
• Pharmaco-Mechanical Thrombolysis: Trellis/EKOS/AngioJet Devices
• Hemodialysis Angiography/PTA/Stenting/Declots

Fellows planning a career in vascular medicine require a distinct and comprehensive training program. In addition to fulfillment for board eligibility in cardiovascular medicine, the fellow will need to pursue an additional year of dedicated training in vascular medicine and endovascular medicine. This includes participation on the inpatient vascular medicine consult service, (aggregate 2-3 months); at least one-half to one full day a week of outpatient vascular medicine clinic; at least 3 months aggregate time in the non-invasive laboratory, preferably one-half day a week each in the hospital and outpatient non-invasive laboratories; one-half day research. The fellow would also spend 4-5 months aggregate time in the interventional laboratory. Elective rotations may be allocated to vascular surgery, MR/CT imaging, and hematology.

Expertise in the non-invasive laboratory is a vital aspect of training for the vascular specialist. The fellow will receive instruction in the principles of ultrasound physics, Doppler characteristics, and be able to interpret both arterial and venous duplex ultrasound, as well as physiologic tests of the arteries and veins. The minimum required studies follow the guidelines recommended by the ICAVL, which include 100 venous, 100 carotid artery, 100 arterial duplex, and 100 physiologic arterial examinations. Visceral, (renal and mesenteric) artery and venous duplex ultrasonography will be included, as well as dialysis graft ultrasonography.

Physicians from various subspecialty backgrounds have the interest and expertise to perform invasive endovascular procedures, but there currently exist no common pathway certification process. Hospital credentialing committees have increasingly insisted on a year of formal training to bestow hospital privileges, relying on societal guidelines recommendations to help insure similar standards and to optimize quality outcomes. The most recent ACC/ACP/SCAI/SVMB/SVS Clinical Competence Statement (JACC 2004; 44; 941-957) also mandated a year of formal training upon the five-year anniversary of its publication, 08/18/2009. It is therefore essential that the cardiology community support programs such as the Brown fellowship program. The Graduate Medical Education office of the Warren Alpert School of Medicine of Brown University has approved the fellowship.

The fellow will acquire the following skills during the fellowship year:

• Mechanisms that regulate blood vessel function and hemostasis
• Pathophysiology, clinical manifestation, natural history, evaluation, and treatment of peripheral arterial disease, renal artery stenosis, mesenteric ischemia, extracranial cerebrovascular disease, aneurysmal disease, arterial dissection, and arterial and venous thromboembolism
• Noninvasive vascular tests such as segmental blood pressure measurements, arterial and venous duplex ultrasonography, and computed tomographic and magnetic resonance angiography
• Accuracy and limitations of diagnostic tests
• Radiation physics, safety, and radiographic imaging equipment
• Principles of image acquisition and display
• Advantages, disadvantages, and potential complications of iodinated and noniodinated contrast agents
• Advantages, disadvantages, potential outcomes, and complications of interventional procedures
• Indications, alternatives, and contraindications for catheter-based interventions The vascular interventionalist should have the following technical skills:
• Ability to safely gain vascular access from multiple sites (femoral, popliteal, and upper extremity arteries, as well as femoral, upper extremity, and neck veins)
• Ability to obtain hemostasis including application of compression and vascular closure devices
• Ability to manipulate guidewires and catheters
• Ability to place and deploy angioplasty equipment (e.g., balloons, atherectomy devices, stents, distal protection devices)
• Ability to recognize and treat procedure-related complications (e.g., dissection, pseudoaneurysms, embolism, vessel perforation or occlusion, stent thrombosis, adverse hemodynamic events)
• Ability to perform catheter-directed thrombolysis/thrombectomy
• Ability to perform vascular interventions in each of the following: aorta and lower extremity arteries, brachiocephalic and upper extremity arteries, mesenteric and renal arteries, central and peripheral veins, and pulmonary arteries

Training requirements for cardiovascular physicians

• Duration of training-12 months
• Diagnostic coronary angiograms-300 cases (200 as the primary operator)
• Diagnostic peripheral angiograms-100 cases (50 as primary operator)
• Peripheral interventional cases-50 cases (25 as primary operator) – No fewer than 20 diagnostic/10 interventional cases in each area, excluding extracranial cerebral arteries
• Aortic aneurysm endografts- 10 cases (5 as primary operator)
• Percutaneous thrombolysis/thrombectomy- 10 cases (5 as primary operator)
• Extracranial cerebral (carotid/vertebral) arteries-30 diagnostic – (15 as primary operator)/25 interventional (13 as primary operator)

This table is consistent with current Residency Review Committee requirements.
*After completing 24 months of core cardiovascular training and 8 months of cardiac catheterization.
*Coronary catheterization procedures should be completed prior to interventional training.
*The case mix should be evenly distributed among the different vascular beds. Supervised cases of thrombus management for limb ischemia and venous thrombosis, utilizing percutaneous thrombolysis or thrombectomy, should be included.
Vascular areas are: 1) aortoiliac and brachiocephalic arteries; 2) abdominal visceral and renal arteries; and 3) infrainguinal arteries