GUIDELINES FOR CREDENTIALLING FOR
Traditionally, interventional radiology has been regarded as an integral
radiological practice, with any doctor gaining the F.R.A.N.Z.C.R. or
qualification considered competent to practice the full gamut of
interventional procedures. The last 10 years have seen an almost exponential
increase in the number and complexity of minimal invasive therapeutic
or biopsy procedures that require radiological guidance. All trainee
considerable exposure to interventional radiology in addition to College
requirements for angiography, nephrostomy, abscess drainage and biopsy.
However while they may have performed many complex procedures as first
operator, there is no doubt that additional training is required for
to perform the more complex interventional procedures.
The radiology community is ready and able to train medical graduates
willing to make a 5-year commitment to learning the skills required.
we refuse outright to offer superficial or limited training to those
who wish to
indulge in invasive radiology procedures. Unless one understands all
radiologic practice, it is not acceptable or responsible to try and
small aspect of it in a vacuum.
Credentialling is the process by which physicians are determined by
hospitals to be competent and are permitted to perform procedures.
The granting of credentials is
designed to protect patients from persons with superficial training
in imaging and
maintain quality of care. Patients are not in a position to know which
best qualified to perform which procedures.
Patients place their trust in the hospital to screen physicians based
and competency, not on their ability to refer patients to the hospital.
The primary requisite for an interventional or endovascular radiologist
is that they
must be fully trained in all aspects of imaging.
Specialist interventional radiologists will require additional training
sub-specialty. This will consist of one year of approved full-time
interventional radiology at an approved site. Logbook documentation
procedures have been performed is required. The documentation must
allow for independent verification of the work done and indicate for
which procedures the
trainee was the primary operator. The Interventional Society of Australia
and the Royal Australian and New Zealand College of Radiologists (R.A.N.Z.C.R)
has draft documents indicating accreditation requirements for training
In brief the following requirements must be met:
- Sufficient workload to provide the necessary hands-on experience
each trainee. As a guide a caseload of 20 procedures per week per
is considered a minimum.
- Access to the other imaging modalities essential to proper performance
of interventional radiology, namely CT, Ultrasound and M.R.I. The
must be able to demonstrate competence in these modalities or be
accredited by the R.A.N.Z.C.R
- In-room supervision by an individual accredited for this purpose
- Proof of an existing and active Quality Assurance or EQUiP program
- Written record of the fluoroscopy time for each procedure.
- Adherence to the established principles preventing self-referral
- Consistent billing and facility fees for all groups using equipment
by third parties.
It has been determined by I.R.S.A. that there are two tiers of interventional
Basic diagnostic angiography and interventional techniques -
angiography, nephrostomy, abscess drainage and biopsy.
This is in keeping with the training requirements of the R.A.N.Z.C.R.
and any individual with R.A.N.Z.C.R. or equivalent qualifications may
perform these procedures.
- All neuro-interventional procedures intracranial and extracranial
- All vascular interventional procedures other than basic diagnostic
angiography, i.e. stents, angioplasty, thrombolysis, thrombectomy,
atherectomy, embolisation, retrieval of foreign bodies and laser
- Venous and arterio-venous graft interventions other than basic
venography or fistulography, i.e. thrombolysis, angioplasty, stents,
atherectomy, pulmonary embolectomy/thrombolysis and caval filter
- Biliary intervention including T.I.P.S.
- Thoracic intervention, i.e. embolisation of AVMs, bronchial stents,
occlusion of broncho-pleural fistulae and bronchial artery embolisation
- Gastro-intestinal intervention, i.e. oesophageal and duodenal stents,
percutaneous gastrostomy, gastrointestinal vascular procedures other
diagnostic angiography, i.e. embolisation, chemo-embolisation and
- Urological intervention, i.e. renal artery embolisation, angioplasty
stenting, percutaneous nephrolithotomy
- Gynaecological - fallopian tube recanalisation, embolisation of
temporary aortic occlusion
- Orthopaedic - percutaneous vertebroplasty, percutaneous discectomy
In view of the small number of formal training sites so far established,
accreditation for these procedures should be based on proof of a certain
procedures performed as follows:
The American Heart Association and S.C.V.I,R. have similar requirements
performance of percutaneous angioplasty. Based on these figures and
experience, the following minimum training is proposed:
(i) Performance of 300 peripheral angiograms under accredited supervision
(ii) Performance of 50 peripheral/renal angioplasties with 25 as primary
with at least 10 using an antegrade femoral approach
(iii) Performance of 30 vascular stents (15 as primary operator)
(iv) Performance of 20 cases of peripheral vascular thrombolysis
(10 as primary operator)
(v) Performance of 10 cases of peripheral catheter guided thrombus
(5 as primary operator)
(vi) Ultrasound guided vessel puncture (20 cases as primary operator)
(vii) Completion of an approved course in radiation biology and protection
to that provided to F.R.A.N.Z.C.R. candidates
These procedures should have been performed in an I.R.S.A./ R.A.N.Z.C.R
site open to peer review and audit with indications, primary success
documented. Combined procedures are to be counted as one procedure
exception of ultrasound guided punctures.
(Angiogram + angioplasty + stent + aspiration + thrombolysis = one
Proof of Quality
I.R.S.A. in conjunction with the R.A.N.Z.C.R. has produced minimum
practice for interventional radiology (Appendix 1). These include threshold
complication rates and expectations of success of the procedures performed.
indicators are based on an "intention to treat".
Appropriate clinical indicators
Failure to obtain percutaneous access (required
Success of diagnostic accuracy
Success in crossing stenosis
Success in crossing occlusion <6cm
Success in renal stent placement
Puncture site haematoma (requiring transfusion,
surgery or delayed discharge)
Dissection / occlusion of vessels
All neurologic deficits
Permanent neurologic deficit
Radiation dose to patient and staff "ALARA"
On Call and cover for annual leave
Credentialling must allow for continuity of service to cover leave
and provide a
24-hour on-call service. Any additional accredited interventionist
would need to
take a full share of the after-hours procedures including all angiography
Equipment standards are outlined in I.R.S.A. Standards documented on
Over 75% of the procedures required for training must be performed
in a dedicated
angiography suite. Mobile image intensifiers are not considered in
the interests of the
patient or the operator.