Not very long ago, the idea of directly injecting the coronary vasculature with a contrast agent was thought to be fatal, for surely, the patient would suffer a fatal arrhythmia or infarction. In the late 1950s, Dr. F. Mason Sones proved that coronary angiography could be done safely. About 20 years later, the idea of treating coronary artery disease with a catheter was met with the same doubts and fears, but Dr. Andreas Gruentzig believed otherwise. At first, percutaneous transluminal balloon angioplasty (PTCA) was a fairly risky procedure, with cardiac arrhythmias, vessel dissections, and emergent bypass surgery not uncommon.

       Now let’s jump to the latter half of the 1990s: percutaneous coronary interventions are routine and with the development of stenting, become safer, more effective therapy. The availability of hundreds of guide catheter curves, steerable guidewires, low-profile balloons, stents, GP IIb/IIIa agents and other adjunctive pharmacologic therapies not only have made coronary interventions easier to perform, but relatively benign as well (with the exception of hemodynamically unstable MI or cardiogenic shock). If this procedure is so effective in treating coronary artery disease, can we apply this to other parts of the vasculature as safely? What about patients with atherosclerotic carotid disease? But surely, the patient will suffer a stroke…
       As of this writing, carotid artery stenting (CAS) is still considered an investigational technique in the United States. It is expected that a combination self-expanding stent and distal embolic protection system (Precise Stent and Angioguard, Cordis Endovascular, Warren, NJ) will soon receive approval for clinical use. Although the FDA may limit indications, the general thought is that over the next five years, CAS will become a very common procedure. But just how safe is the procedure? Who should be doing it? How should nurses and technologists be trained?

       At the Cleveland Clinic, we currently perform about 10 CAS procedures weekly. The medical team is primarily comprised of an experienced group of interventional cardiologists and neurologists. With various clinical trials, vascular surgeons and neuroradiologists have also been part of the team. This multi-disciplinary structure is essential to a successful carotid intervention program.

       The birth of CAS is highly anticipated, although I expect it not to be entirely painfree. The hemodynamic response and instability of carotid stenting procedures can be challenging at times, especially if you are unprepared.

       In his interview, Dr. Yadav mentions that you should go through some didactic training in cerobrovascular disease and angiographic anatomy. As companies are competing to develop and market CAS products, they are developing training programs and working with medical simulators for training. A good knowledge base of carotid and cerebral vascular anatomy is a must.

       But what of the nurses and technologists who make up the support team during and after the procedure? Often times, when a new device or procedure comes along, they are just expected to know it. Like the early days of PTCA, the physicians performing CAS need to help educate their non-physician team members about patient assessment, anatomy, and equipment, as well as potential complications. It is my plea to interventionalists and the various companies developing CAS devices that they do not forget the nurses and technologists in the catheterization laboratory.

       There is a very exciting new era opening up in the catheterization laboratory, one I eagerly look forward to witnessing. Many of the technical necessities were developed based on knowledge and experienced gained from 25 years of coronary intervention. However, the brain is not the heart — there are important differences. Developing a proper orientation and training module for nurses and technologists, as well as physicians, will not only make the procedure go smoother, it will make it safer for the patient as well.