GUIDELINES FOR CREDENTIALLING FOR
INTERVENTIONAL RADIOLOGY

Introduction
Traditionally, interventional radiology has been regarded as an integral part of
radiological practice, with any doctor gaining the F.R.A.N.Z.C.R. or equivalent
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 registrars have
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 those wishing
to perform the more complex interventional procedures.
The radiology community is ready and able to train medical graduates who are
willing to make a 5-year commitment to learning the skills required. However
we refuse outright to offer superficial or limited training to those who wish to
indulge in invasive radiology procedures. Unless one understands all aspects of
radiologic practice, it is not acceptable or responsible to try and perform one
small aspect of it in a vacuum.

Credentialling
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 physicians are
best qualified to perform which procedures.
Patients place their trust in the hospital to screen physicians based on training
and competency, not on their ability to refer patients to the hospital.

Training
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 in this
sub-specialty. This will consist of one year of approved full-time instruction in
interventional radiology at an approved site. Logbook documentation of which
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 (I.R.S.A.)
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
interventional radiology.

In brief the following requirements must be met:

1. Sufficient workload to provide the necessary hands-on experience for
   each trainee. As a guide a caseload of 20 procedures per week per trainee
   is considered a minimum.
2. Access to the other imaging modalities essential to proper performance of interventional radiology, namely CT, Ultrasound and M.R.I. The supervisor
   must be able to demonstrate competence in these modalities or be
   accredited by the R.A.N.Z.C.R
3. In-room supervision by an individual accredited for this purpose by
   IRSA /RANZCR.
4. Proof of an existing and active Quality Assurance or EQUiP program
5. Written record of the fluoroscopy time for each procedure.
6. Adherence to the established principles preventing self-referral for
   radiology procedures.
7. Consistent billing and facility fees for all groups using equipment owned
   by third parties.

It has been determined by I.R.S.A. that there are two tiers of interventional radiology.

TIER A
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.

TIER B

1. All neuro-interventional procedures intracranial and extracranial
2. All vascular interventional procedures other than basic diagnostic
   angiography, i.e. stents, angioplasty, thrombolysis, thrombectomy,
   atherectomy, embolisation, retrieval of foreign bodies and laser and
   mechanical angioplasty
3. Venous and arterio-venous graft interventions other than basic diagnostic
   venography or fistulography, i.e. thrombolysis, angioplasty, stents,
   atherectomy, pulmonary embolectomy/thrombolysis and caval filter insertion
4. Biliary intervention including T.I.P.S.
5. Thoracic intervention, i.e. embolisation of AVMs, bronchial stents,
   occlusion of broncho-pleural fistulae and bronchial artery embolisation
6. Gastro-intestinal intervention, i.e. oesophageal and duodenal stents,
   percutaneous gastrostomy, gastrointestinal vascular procedures other than
   diagnostic angiography, i.e. embolisation, chemo-embolisation and transplant intervention.
   
7. Urological intervention, i.e. renal artery embolisation, angioplasty or
   stenting, percutaneous nephrolithotomy
8. Gynaecological - fallopian tube recanalisation, embolisation of fibroids,
   temporary aortic occlusion
9. 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 number of
procedures performed as follows:

Minimum Training
The American Heart Association and S.C.V.I,R. have similar requirements for the
performance of percutaneous angioplasty. Based on these figures and Australian
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 operator,
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 aspiration
(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 equivalent
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 accredited
site open to peer review and audit with indications, primary success and complications
documented. Combined procedures are to be counted as one procedure with the
exception of ultrasound guided punctures.
(Angiogram + angioplasty + stent + aspiration + thrombolysis = one procedure)

Proof of Quality
I.R.S.A. in conjunction with the R.A.N.Z.C.R. has produced minimum standards of
practice for interventional radiology (Appendix 1). These include threshold for
complication rates and expectations of success of the procedures performed. The
indicators are based on an "intention to treat".

Appropriate clinical indicators	95%
Failure to obtain percutaneous access (required open procedure)	<1%
Success of diagnostic accuracy	95%
Success in crossing stenosis	95%
Success in crossing occlusion <6cm	85%
Success in renal stent placement	80%
Puncture site haematoma (requiring transfusion, surgery or delayed discharge)	<3%
Contrast extravasation	<1%
Distal embolisation	<0.5%
Dissection / occlusion of vessels	<2%
All neurologic deficits	<4%
Permanent neurologic deficit	<1%
Radiation dose to patient and staff "ALARA"	100%

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 procedures.

Equipment
Equipment standards are outlined in I.R.S.A. Standards documented on page 10.
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.