1. STANDARDS: Facility related

• 1.1. Each hospital department or section (cath lab, operating room, radiology suite, etc) performing carotid artery stenting (CAS) must document that they have the resources to perform the procedure in a safe manner.¹
• 1.2. Equipment
  • 1.2.1. Digital subtraction angiography (> 12-in image intensifier preferred) storage and retrieval capabilities.
  • 1.2.2. Advanced physiologic monitoring with real-time and archived physiologic, hemodynamic and rhythm monitoring equipment with support staff capable of interpreting results and responding appropriately.
  • 1.2.3. Large inventory of disposable supplies for vascular access management, cervico-cerebral angiography, carotid intervention with embolic protection, and intra-cranial thrombus retrieval devices.
  • 1.2.4. Emergency management equipment and systems must be readily available in the interventional location performing carotid stenting. This includes resuscitation and personel familiar with their indications and use.
  • 1.2.5. There must be a process documenting routine preventive maintenance and testing of laboratory equipment, including a comprehensive radiation safety program such as outlined by The Society for Cardiovascular Angiography and Interventions . Rather than an inclusive document, this is to serve as a topic summary with recommendations for best practice. This will provide a framework for evaluating current compliance with these recommendations. Over time, these standards may become requirements for accreditation.

2. STANDARDS: Personnel related

• 2.1. Each Department within the Institution (cath lab, radiology, and surgery) performing CAS must have:
  • 2.1.1. A licensed, ABMS board-certified physician in an appropriate specialty as a Medical Director . There may be a single Medical Director responsible for performance in all areas where CAS is performed.
  • 2.1.2. A Technical Director (licensed technologist or registered nurse) with a minimum of 5 years experience working in an invasive angiographic imaging laboratory.
  • 2.1.3. There needs to be a designated individual responsible for coordination of quality assurance activities. This may be the Medical Director or his/her designee
  • 2.1.4. A clearly delineated program for the initial granting of carotid stent privileges with physician operators meeting one of the peer-reviewed national societal training 2.1.5. A standard operating procedure for monitoring peri-procedural, in-hospital and 30-day outcomes.
  • 2.1.6. Peri-procedural, in-hospital and 30 day outcomes- monitoring should include an independent neurological stoke evaluation by an NIH certified provider not directly involved in care of the patient and not a member of the interventional team.
    • 2.1.6.1. Follow up monitoring compliance for stroke, MI, Death should be reported at >90% for periprocedural and in-hospital period. Failure to achieve a minimum of 80% compliance with follow up will result in remedial action less than 80% follow up may result in denial of accreditation.
    • 2.1.6.2. 30 day outcomes for stroke, MI, Death monitoring should be no less than 50 % compliance and corrective action will result if follow up is between 30-50%.
    • 2.1.6.3. Patient follow up that includes independent neurologic evaluation that occurs less than 30% of the time not acceptable and may result in denial of accreditation.
• 2.2. Maintenance of physician privileges
  • 2.2.1. Physicians must obtain 20 hours of Category 1 continuing medical education credits over a 3-year period in the field of endovascular therapy of peripheral or cerebrovascular diseases (i.e. non-coronary, non-cardiac vascular diseases). At least 10 of these hours must be in the field of cervico-cerebral vascular disease management including carotid, vertebral, and intracranial endovascular therapy.
  • 2.2.2. The institution must have a defined process for recredentialing which should be based on volume, outcomes, fulfillment of CME requirements and other quality parameters. There are currently no accepted standards for recredentialing. These may develop over time and be implemented in a later version of these standards.
  • 2.2.3. Recertification criteria for individual practitioners should be decided by each institution but guidelines should include documentation for fulfillment of CME requirements as outlined in 2.2.1 and participation in at least 75 % of M and M and/or case review meetings.
  • 2.2.4. The operator’s complications should not exceed delineated thresholds.
  • 2.2.5. Hospital privileges and state licensing should be maintained throughout the period of certification for all operators. Any loss of either hospital privileges or state license shall be reported to ACE with an explanation from the Medical Director.
• 2.3. Other Health Care Professionals
  • 2.3.1. Skilled allied health professionals in the laboratory (nurses and technicians) must be trained and experienced in evaluating patients before and after catheter-based interventional procedure. State requirements for performance and roles of personnel must be supplied and facilities will be reviewed for compliance based on these standards.
  • 2.3.2. Documentation of training of nursing personnel in the recognition and management of acute neurological syndromes is required.
  • 2.3.3. Documentation of training of support staff to interpret results from physiologic, hemodynamic and rhythm monitoring equipment.
• 2.4. There must be a process in place for providing acute neuro-rescue or stroke intervention in the event of a complication. Documentation of this policy must be provided.

3. STANDARDS: Quality assurance

• 3.1. A quality monitoring program must include a peer-review conference with randomly selected CAS procedures reviewed for their indications and complications
  • 3.1.1. All major complications should be reviewed
• 3.2. The regularly scheduled quality monitoring conference occurs at least once per month. Attendance at a super-majority (75%) of the meetings is a requirement for CAS privileges for individual practitioners.
• 3.3. The oversight committee for this program should be representative of the individual specialties involved, and the Chair of the committee should not be a member of any of the carotid interventional teams.
• 3.4. Procedure in place to document radiation exposure of the patients and staff
  • 3.4.1. The radiation safety program should be considered a component of the overall carotid artery stenting facility quality assurance (QA) process with the Carotid Artery Stenting program QA individual(s) actively involved with this process .
  • 3.4.2. Each carotid stent facility must establish a radiation safety education program either in conjunction with the hospital Health Physics Department/ Medical Physicist and/or an outside consultant and/or assistance from a web-based tutorial. Documentation of this training must be provided. This program should have the following mandated components: a) initial training or verification of prior training for all physicians and staff using fluoroscopy in the carotid stent facility; b) annual updates on radiation safety; c). hands on training for new operators in a facility and existing operators on newly purchased equipment.
• 3.5. The oversight committee should be empowered to identify the minimum case volume for primary operators to maintain privileges, as well as a threshold complication rate to trigger suspension of privileges or activation of measures for remediation
• 3.6. Major events such as Death &, Major Stroke rate should not exceed 3% for asymptomatic and should not exceed 6% for symptomatic patients.

4. STANDARDS Patient: Indications

• 4.1. The indication for carotid artery stenting (CAS) must be documented.
• 4.2. Symptomatic vs. asymptomatic
  • 4.2.1. Symptomatic Defined as: focal neurologic findings such as TIA persisting < 24 hours, Non-Disabling stroke: Modified Rankin Scale, Transient monocular blindness: amaurosis fuax occurring within the previous 180 days (Services, 2010)
• 4.3. Severity of carotid artery stenosis
  • 4.3.1. By ultrasound
  • 4.3.2. By MRA/CTA
  • 4.3.3. By Digital Subtraction Angiography (DSA)
    • 4.3.3.1. The degree of CAS stenosis shall be measured by duplex Doppler ultrasound or carotid artery angiography and recorded in the patient’s medical record. If the degree of stenosis is measured by the ultrasound prior to the procedure, then the degree of stenosis must be confirmed by angiography at the start of the procedure. Angiography using the NASCET criteria for measurment, is the gold standard for determination of the severity of stenosis,. If the stenosis is determined to be <70% by angiography in a symptomatic patient, then CAS should not proceed. If the stenosis is <80% in an asymptomatic patient, CAS should not proceed. (Services, 2010)
• 4.4. All patients shall have an angiogram clearly documenting pre and post lesion assessment.
  • 4.4.1. NASCET Criteria shall be used to calculate % stenosis
    • 4.4.1.1. The North American Symptomatic Carotid Endarterectomy Trial (NASCET) is a method of quantifying internal carotid artery stenosis. The diameter of the stenotic segment is divided by the diameter of a normal, distal segment of internal carotid artery (where walls are parallel) and subtracted from 1 and expressed as a percentage of the distal segment diameter.
• 4.5. >90% of determinations should meet these criteria for stenosis depending on symptomatic status. Failure to achieve a minimum of 75% compliance with stenosis severity will result in remedial action less than 75% compliance with stenosis severity may result in denial of accreditation.
• 4.6. All treated patients shall have a post procedure cerebral angiogram to evaluate flow and evaluate for distal embolization
  • 4.6.1. Pre treatment cerebral anatomy may be evaluated by DSA but if so documentation of these findings should be included as part of the pre procedure evaluation. Otherwise, pre stenting cerebral angiography should be performed as part of the initial angiographic lesion and anatomic assessment.
• 4.7. High surgical risk (CMS criteria) vs. average surgical risk
  • 4.7.1. Patients at high risk for CEA are defined as having significant comorbidities and/or anatomic risk factors(i.e.,recurrent stenosis and/or previous radical neck dissection), and would be poor candidates for CEA. Significant comorbid conditiona include but are not limited to: (Services, 2010)
    • Congestive Heart Failure (CHF) class III/IV
    • Left ventricular ejection fraction (LVEF)<30%
    • Unstable Angina
    • Contralateral caroted occlusion
    • Recent myocardial infarction (MI)
    • Prior radiation treatment to the neck
    • Other conditions that were used to determine patients at high risk for CEA in the prior carotid artery stenting trials and studies such as ARCHER, CABERNET, SAPPHIRE, BEACH, MAVERIC II
• 4.8. Lesion location: common carotid vs. internal carotid artery

5. STANDARDS Patient: Outcomes:

• 5.1. Primary outcomes to 30 days (3 to 6 weeks post procedure)
  • 5.1.1. All stroke and all death for elective carotid artery stent cases.
    • 5.1.1.1. Stratify by symptom status (www.cms.hhs.gov/Transmittals/Downloads/R98NCD.pdf - 2009-08-19)
      • 5.1.1.1.1. Symptomatic benchmark = 6%
      • 5.1.1.1.2. Asymptomatic benchmark = 3%
    • 5.1.1.2. Stratify by CEA risk status (www.cms.hhs.gov/Transmittals/Downloads/R98NCD.pdf - 2009-08-19)
      • 5.1.1.2.1. Comorbid
      • 5.1.1.2.2. Anatomic
  • 5.1.2. >90% of all elective CAS patients must have a documented NIH stroke scale by an NIHSS certified examiner, who is not a member of the interventional team.
    • 5.1.2.1. Pre-procedure; within 4 weeks prior to the procedure.
    • 5.1.2.2. Post-procedure; within 72 hrs post procedure
    • 5.1.2.3. 1 month follow-up; 3 to 8 weeks post-procedure
• 5.2. Secondary outcomes for elective cases.
  • 5.2.1. Angiographic success rate >90%: <50% residual target lesion stenosis determined by NASCET methodology at the conclusion of the procedure.
  • 5.2.2. Procedural success rate . 90%: Angiographic success without a major complication at hospital discharge.
    • 5.2.2.1. Major Complications
      • 5.2.2.1.1. Death
      • 5.2.2.1.2. Stroke
      • 5.2.2.1.3. TIA
      • 5.2.2.1.4. Hyperperfusion syndrome
      • 5.2.2.1.5. Acute MI (STEMI and NSTEMI)
      • 5.2.2.1.6. Decompensated heart failure
      • 5.2.2.1.7. Severe contrast reaction.
      • 5.2.2.1.8. Respiratory arrest requiring intubation
      • 5.2.2.1.9. Cardiac arrest requiring defibrillator or pacemaker therapy
      • 5.2.2.1.10. CAS procedure failure requiring urgent/emergent surgery.
        • 5.2.2.1.10.1. Requires re-intervention or surgical correction.
        • 5.2.2.1.10.2. Thromboembolism
        • 5.2.2.1.10.3. Infection requiring antibiotics or drainage.
        • 5.2.2.1.10.4. Results in prolonged hospital stay
        • 5.2.2.1.10.5. Requires any transfusion of PRBC’s or platelets.
      • 5.2.2.1.11. Bleeding (any blood product transfusion).
      • 5.2.2.1.12. Renal failure (i.e. need for dialysis, doubling serum Cr)
    • 5.2.2.2. Minor Complications
      • 5.2.2.2.1. Access site complication not requiring intervention
        • 5.2.2.2.1.1. Hematoma
        • 5.2.2.2.1.2. Percutaneous repair (i.e. thrombin injection, ultrasound-guided compression) of pseudoaneurysm
        • 5.2.2.2.1.3. AV fistula not requiring further treatment
      • 5.2.2.2.2. Hypotension (periprocedural) requiring . 24 hours of intravenous pharmacologic support.
      • 5.2.2.2.3. Jaw claudication due to external carotid compression. Non MAE complication rates will be compared to benchmark data. If rates exceed 2 standard deviations from the mean value, corrective action will be required.
  • 5.2.3. Patient radiation dose needs to be monitored and recorded. This should include the Fluoroscopic Time (FT, min), and Total Air Kerma at the Interventional Reference Point (Ka,r, Gy) and/or Air Kerma Area Product (PKA , Gycm2) . Peak Skin Dose (PSD, Gy) should be included if technology permits its measurement.
    • 5.2.3.1. A program should be in place for patients whose recorded Total Air Kerma at the Interventional Reference Point (Ka,r,) is 5 Gy or greater and/or fluoroscopy doses that exceed 60 minutes. This should include what dose and a reason for this dose, patient notification, medical physicist/health physics involvement for Ka,r >10Gy, and a mechanism for patient follow up of potential adverse effects from radiation.
  • 5.2.4. One year outcomes:
    • 5.2.4.1. 30 day all stroke and death plus 31 days to 1 year ipsilateral stroke and neurologic death.
    • 5.2.4.2. Restenosis:
      • 5.2.4.2.1. Symptoms (hemispheric or retinal ischemia (TIA or Stroke)).
      • 5.2.4.2.2. Imaging study demonstrating . 70% in-stent restenosis.
      • 5.2.4.2.3. Target vessel revascularization:
      • 5.2.4.2.4. Target lesion revascularizaiton:

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