Cardiovascular and Interventional Radiology Curriculum Outline | Renaissance School of Medicine at Stony Brook University

Developed by the Education Committee of the Society of Cardiovascular and Interventional Radiology

OVERVIEW

SECTION I: GENERAL TOPICS IN CARDIOVASCULAR AND INTERVENTIONAL RADIOLOGY
Included in this section are the historical aspects of the subspecialty as well as various General practice considerations: legal, political, economic, training, and workplace issues.

SECTION II: PATIENT CARE
This section includes general aspects of patient care; its topics are in turn included, as Appropriate, as they relate to more specific sections of the outline which follows.

SECTION III: VASCULAR DIAGNOSIS
This section starts with a list of "common" topics -radiological and non-radiological aspects of vascular diagnosis--which, in turn, are included as they relate to more specific sections. The specific sections are divided primarily by anatomic regions, and then by organs or organ systems. Although most of the section relates to the circulatory system, the lymphatic system is also included as a special topic.

SECTION IV: VASCULAR INTERVENTION
This section starts with a broad overview of major categories of vascular intervention which, in turn, are included as they relate to more specific sections. The specific sections are then divided primarily by anatomic regions and then by organs or organ systems.

SECTION V: NONVASCULAR INTERVENTION
This section starts with a list of "common" topics—radiological and non-radiological aspects of non vascular intervention--which, in turn, are included as they relate to more specific sections. The specific sections are divided into traditional subsections which relate primarily to organs or organ systems.

SECTION I:
GENERAL TOPICS IN CARDIOVASCULAR AND INTERVENTIONAL RADIOLOGY

History of Cardiovascular and Interventional Radiology
Educational Issues
Training and credentialing
Continuing education
Research in Vascular and Interventional Radiology
- Guidelines for research projects
- Biostatistics
- Grants/funding options
Legal and Political Aspects of Cardiovascular and Interventional Radiology
- Informed consent
- Malpractice
Regulatory agencies
- Investigational devices and procedures
Organized medicine
Business/Economic Aspects
- CPT coding and related issues
- Equipment purchase
- Inventory management
- Capitation
Quality Assurance Issues
- Outcomes analysis
- Practice guidelines
- Complications: classification, documentation
Workplace considerations
- The vascular/interventional radiology suite
  - Equipment
  - Fluoroscopy
  - Standard angiography
  - Digital angiography
  - Image processing and recording
  - Other equipment (e.g. interventional ultrasound units)
  - Layout
- Recovery room
- Noninvasive vascular laboratory
  - Equipment
  - Management
- Occupational Safety Issues
- Radiation safety and hygiene
- Infection control
- Other
Personnel Considerations
- The vascular/interventional radiology "team": role and relationship of nurses, technologists, trainees, other physicians
- Inservice/continuing education

SECTION II:
PATIENT ARE IN VASCULAR AND INTERVENTIONAL RADIOLOGY
* These topics stand alone as general subjects, but are also assumed to be included as appropriate under subheadings of Sections Ill-V of the outline.

Pre-procedural assessment and care
Intraprocedural monitoring
Post-procedural followup and care
General pharmacologic considerations
- Analgesia/anesthesia
- Conscious sedation
- Antibiotic therapy
- Anticoagulation
- Other

SECTION III:
VASCULAR DIAGNOSIS

PART I: Common topics

Although many of these topics can be discussed in a general sense, they are also applicable to the more specific subjects of Section III, Part II and can be assumed to be subheadings of these specific subjects, where appropriate.
Patient Care ( see Section II)
Clinical and Laboratory Considerations
- Symptomatology and staging of vascular disease
- Laboratory data (including non-imaging aspects of noninvasive vascular testing; for example, ankle-brachial indices for lower extremity arterial disease, impedance plethysmography for lower extremity venous disease)
Epidemiology of vascular disease
Natural history of vascular disorders
Vascular anatomy: arterial and venous
- Embryology
- Normal anatomy
- Variant anatomy
- Anatomy of collateral pathways
Vascular physiology, pathology and pathophysiology: arterial system
- Normal histology/physiology/morphology
- Hemodynamics: normal and abnormal flow
- Vasoactive extrinsic/pharmacologic agents
- Normal response
- Disorders related to pharmacologic/extrinsic agent exposure
Atherosclerosis
Medial sclerosis
Pathophysiology of arterial ischemia
Aneurysms
Thromboembolic disorders
Dissection
Congenital vascular disorders
- Vascular malformations
- Other congenital disorders (for example, popliteal artery entrapment in the case of lower extremity vascular disorders)
Arterial effects of adjacent tissues/disorders
Arterial infection
Vascular alterations in neoplasia: vascular supply of neoplasms, primary vascular neoplasms, vascular invasion by neoplasms
Vascular alterations in inflammatory diseases
Systemic vascular disorders
- Primary systemic vascular disorders: vasculitides and others (polyarteritis nodosa, TakayasuÍs arteritis, giant cell arteritis, BuergerÍs disease)
- Altered vascular pathology in systemic disease states (for example, in diabetes mellitus, collagen vascular disease, BehetÍs disease, etc.)
Vascular trauma: injuries and vascular response to injury
- Mechanical injury: acute and chronic
- Thermal injury
Arterial endothelium
Alterations in coagulation status
- Hypercoagulable states
- Impaired coagulation
Post-operative or post-interventional disorders
- Synthetic and endogenous grafts
- Myointimal hyperplasia
Other/unclassified
Vascular physiology, pathology and pathophysiology: venous/pulmonary arterial system
- Normal histology/physiology/morphology
- Hemodynamics: normal and abnormal flow
- Vasoactive extrinsic/pharmacologic agents
  - Normal response
  - Disorders related to pharmacologic/extrinsic agent exposure
- Thromboembolic disorders: acute and chronic
- Venous aneurysms
- Venous effects of adjacent tissues/disorders
- Congenital vascular disorders
  - Vascular malformations
  - Other congenital disorders
- Venous infection
- Vascular alterations in neoplasia: vascular drainage of neoplasms, primary vascular neoplasms, vascular invasion by neoplasms
- Vascular alterations in inflammatory diseases
- Systemic vascular disorders
  - Primary systemic vascular disorders
- Altered vascular pathology in systemic disease states
- Vascular trauma: injuries and vascular response to injury
  - Mechanical injury—acute and chronic
  - Thermal injury
- Venous endothelium
- Alterations in coagulation status
  - Hypercoagulable states
  - Impaired coagulation
- Post-operative or post-interventional disorders
  - Synthetic and endogenous grafts
  - Intimal hyperplasia
- Other/unclassified

Imaging of the vascular system: general principles

Plain film
Angiography: arteriography and venography
- Standard angiography
- Digital subtraction angiography
- Contrast agents
  - Iodinated agents
  - Carbon dioxide
- Vascular catheterization
  - Equipment: needles, guidewires, catheters, etc.
  - Vascular access
  - Selective and subselective catheterization
- Risks and complications
  - Contrast reactions, iodinated agents
    - Anaphylactoid reactions
    - Classification
    - Prevention
      - Ionic vs. nonionic agents
      - Premedication
    - Treatment
  - Dose dependent reactions
    - Classification
      - Acute and chronic renal effects
      - Other
    - Prevention
    - Treatment
- Procedural complications
  - Puncture site complications
  - Catheterization-related complications (apart from puncture site)
  - Systemic/generalized complications
- Pharmacoangiography: agents and uses
  - Vasodilatation
  - Vasoconstriction
  - Other
- Ultrasonography
  - Gray scale
  - Duplex Doppler
  - Color flow
  - Intravascular ultrasound
- Computed Tomography
  - General
  - Spiral and Cine CT
  - CT angiography
- Magnetic Resonance Imaging
  - General
  - Blood flow evaluation and MR angiography
- Nuclear medicine
- Angioscopy

PART II: Specific Topics
* The topics listed in Part I should be considered subheadings of the following. However, areas of particular importance are listed specifically.

Lower extremity vascular disease
- Arterial
  - Peripheral atherosclerotic arterial disease
  - Lower extremity aneurysms (iliac, femoral, popliteal, other)
  - Nonatherosclerotic peripheral vascular disease (popliteal entrapment, adventitial cystic disease
  - Iatrogenic disorders: puncture site complications
  - Trauma
- Venous
  - Acute deep venous thrombosis
  - Chronic deep venous thrombosis/venous insufficiency
- Combined: vascular malformations
Upper extremity vascular disease
- Arterial
  - Thoracic outlet syndrome
  - Atherosclerosis
  - Vasculitis, RaynaudÍs disease and phenomenon
  - Trauma
- Venous
  - Acute upper extremity venous thrombosis
  - Chronic upper extremity venous thrombosis
- Combined: vascular malformations
Thoracic vascular disease
- Hemoptysis and its evaluation
- Pulmonary arteries and veins
  - Pulmonary artery hemodynamics (as related to pulmonary angiography)
  - Pulmonary thromboembolic disease
  - Pulmonary arteriovenous malformations
  - Pulmonary venous disorders
Aortic disorders
- Aortic aneurysm
- Aortic dissection
- Aortic trauma
- Congenital disorders
- Vasculitides affecting the aorta
- Post-operative aorta
Central venous disorders (SVC, IVC)
- Central venous occlusive disorders
Vascular diagnosis, abdominal and pelvic viscera
- Genitourinary system
  - Kidney
    - Renovascular hypertension: causes, workup, including noninvasive imaging, renin-angiotensin system and renin sampling, arteriography
    - Renal trauma
    - Renal neoplasms
  - Ureters/bladder
  - Prostate
  - Testes/scrotum
  - Vasogenic impotence in men
  - Uterus
    - Gynecologic hemorrhagic disorders
  - Ovaries
- Gastrointestinal Tract
  - Gastrointestinal hemorrhage
    - Workup considerations: angiography vs. endoscopy vs. nuclear medicine
    - Specific causes
      - Gastritis
      - Peptic ulcer disease
      - Mallory-Weiss tear
      - Hepatobiliary: hemobilia
      - Neoplasms
      - Angiodysplasia
      - Diverticulitis
      - Vascular malformations
      - Venous bleeding (see also section on portal hypertension)
      - Other
    - Angiographic evaluation
  - Mesenteric ischemia
    - Acute mesenteric ischemia
      - Embolic
      - Thrombotic
      - Nonocclusive
      - Mesenteric venous ischemia
      - Other
    - Chronic mesenteric ischemia/mesenteric atherosclerosis
  - Mesenteric aneurysms
- Portal/hepatic vascular disorders
  - Portal hypertension
    - General imaging evaluation
    - Angiographic evaluation: arterial portography, splenoportography, direct portography, hepatic venography, wedge (or balloon occlusion) hepatic venography and pressure measurements
    - Classification
  - Budd-Chiari syndrome and other forms of hepatic venous outflow obstruction
  - Hepatic neoplasms: primary and secondary
- Pancreas
  - Vascular manifestations of pancreatic inflammatory disease
  - Pancreatic neoplasms
    - Evaluation for resectability
    - Detection of islet cell tumors
      - Arteriography
      - Venous sampling
- Spleen
  - Splenic trauma
- Adrenal glands
  - Arteriographic and venographic evaluation of neoplasms (including risks in setting of pheochromocytoma)
- Cardiac/coronary vasculature
  - Congenital heart and great vessel disease
  - Coronary artery disease
  - Acquired non coronary heart disease
    - Valvular
    - Endocardial
    - Myocardial
    - Pericardial
Neuroangiography
- Atherosclerotic cerebral vascular disease
- Aneurysms
- Vascular malformations
Vascular aspects of endocrine disorders
- Clinical aspects
- Venous sampling
  - Indications
  - Techniques
- Specific sites
  - Thyroid/parathyroid
  - Adrenal
  - Pancreas
  - Ovarian
- Postsurgical conditions
  - Arterial and venous bypass procedures
  - Grafts for aneurysms
  - Grafts for dissection
  - Dialysis access procedures and disorders
- Vascular aspects of organ transplantation
  - Liver
  - Kidney
  - Pancreas
  - Small bowel
  - Heart
  - Lung
- Lymphatic system
  - Anatomy
  - Lymphangiography
    - Performance
    - Interpretation
    - Indications and contraindications
    - Risks
  - Other methods of evaluation
  - Physiology, pathology, pathophysiology
Pediatric vascular diagnosis (see the general topics parts I and II of this section; although clear differences exist in vascular diagnostic considerations between pediatric and adult age groups, a detailed outline is not provided here)

SECTION IV:
VASCULAR INTERVENTION

PART I: Common Topics and Major Categories, Vascular Intervention
* Although many of these topics can be discussed in a general sense, they are also applicable to the more specific subjects of Section IV, Part II and can be assumed to be subheadings of these specific subjects., where appropriate.

Patient Care (see Section II)
Common Topics: vascular interventional procedures
- Anatomic considerations
- Indications and contraindications
- Techniques, devices, materials
- Results, efficacy
- Risks and complications
- Alternate techniques (surgical and medical therapeutic options)
Vascular canalization/recanalization: re-establishment of flow
- Thrombolytic therapy
  - Pharmacologic thrombolysis
    - General principles
    - Specific agents: urokinase, streptokinase, tissue plasminogen activator, others
  - Mechanical techniques
    - Fogarty balloon
    - Suction thromboembolectomy
    - Other/newer devices
- Balloon angioplasty
- Atherectomy
- Laser recanalization
- Mechanical recanalization
- Vascular stents
- Endovascular grafts
- Other
Vascular blockade: obliteration of flow
- Embolization
  - Techniques
    - Transcatheter
    - Direct injection
  - Agents
- Other methods
  - Ultrasound guided compression repair
Infusional therapy
- Flow diminution
- Flow enhancement
Re-routing of flow
- Endovascular repair of aneurysms
- Creation of new vascular channels (e.g. TIPS, fenestration of aortic dissection)
Vascular filters
Vascular foreign body removal
Intravascular/transvascular biopsy
- Transvenous liver biopsy
- Other

PART II: Specific Topics
* The topics listed in Part I should be considered subheadings of the following. However, areas of particular importance are listed specifically.

Lower extremity vascular disease
- Arterial
  - Occlusive atherosclerotic disease: recanalization
    - Aortoiliac
    - Femoropopliteal
    - Tibioperoneal
  - Intervention for peripheral arterial trauma
  - Thromboembolic disorders: recanalization
  - Peripheral arterial graft failure: recanalization
  - Iatrogenic disorders: therapy for puncture site complications
- Venous
- Combined: vascular malformations: obliteration
Upper extremity vascular disease
- Arterial
  - Thromboembolic disorders: recanalization
  - Trauma
- Venous
  - Acute upper extremity venous thrombosis: recanalization
  - Chronic upper extremity venous thrombosis: recanalization
- Combined: vascular malformations: obliteration
Thoracic vascular disease
- Hemoptysis
  - Bronchial embolization
  - Other techniques
- Pulmonary arteries and veins
  - Pulmonary thromboembolic disease: thrombolytic therapy, thromboembolectomy
  - Pulmonary arteriovenous malformations: embolization
Aortic disorders
- Aortic aneurysm: embolization, endovascular grafting
- Aortic dissection: endovascular grafting, fenestration
- Aortic trauma
Central venous intervention (SVC, IVC)
- Central venous occlusive disorders
  - Thromboembolic disorders
  - Congenital webs
- Indwelling central venous access
- Caval filtration and related techniques for thromboembolic disease
Vascular diagnosis, abdominal and pelvic viscera
- Genitourinary system
  - Kidney
    - Renovascular hypertension: recanalization techniques
    - Renal trauma
    - Renal neoplasms
    - Renal ablation
  - Uterus: Treatment of gynecologic hemorrhage
  - Interventional techniques in treatment of vasogenic impotence
  - Varicoceles
- Gastrointestinal Tract
  - Gastrointestinal hemorrhage
    - Embolization vs. infusional therapy (vasopressin)
    - Specific sites
      - Upper GI (esophago-gastro-duodenal)
      - Small bowel
      - Colonic
    - Mesenteric ischemia
      - Acute mesenteric ischemia
        
        Infusional therapy: vasodilators
        
        Thromboembolic disease: thrombolytic therapy
      - Chronic mesenteric ischemia/mesenteric atherosclerosis
        
        Recanalization techniques: angioplasty, stents, etc.
    - Mesenteric aneurysms/pseudoaneurysms
  - Portal/hepatic vascular disorders
    - Portal hypertension
      - Variceal bleeding: embolization and infusional therapy
      - Transjugular intrahepatic portosystemic shunt-stent (TIPS)
    - Budd-Chiari syndrome and other forms of hepatic venous outflow obstruction
    - Hepatic neoplasms: infusional therapy and chemoembolization
  - Pancreas
    - Therapy for vascular manifestations of pancreatic inflammatory disease
  - Spleen
    - Vascular intervention for splenic trauma
    - Treatment of hypersplenism
Cardiac/coronary vasculature
- Congenital heart disease
- Coronary artery disease
- Valvular disease
Neurovascular intervention
- Chronic cerebrovascular occlusive disease
  - Atherosclerotic
  - Other
- Neurovascular intervention in stroke
- Aneurysms
- Vascular malformations
- Neoplasms
Intravascular tumor therapy
- Infusional therapy
- Chemoembolization
Vascular intervention in organ transplantation
- Liver
- Kidney
- Pancreas
- Small bowel
- Heart
- Lung
Dialysis access intervention: recanalization techniques
Congenital disorders: Principles and practice of interventional management of Arteriovenous malformations
Pediatric vascular intervention (see the general topics parts I and II of this Section; although clear differences exist in types and frequencies of procedures between pediatric and adult age groups, a detailed outline is not provided here)

SECTION V:
NON VASCULAR INTERVENTION

PART I: Common topics
* Although many of these topics can be discussed in a general sense, they are also applicable to the more specific subjects of Section V, Part II and can be assumed to be subheadings of these specific subjects, where appropriate.

Patient Care (see Section II): note that ñtube managementÍ plays a large role in many nonvascular interventions
Clinical and Laboratory Considerations
- Symptomatology and staging of nonvascular disorders
- Laboratory data
- Epidemiology
Natural history
Imaging
- Plain film
- Endoluminal contrast studies: gastrointestinal tract, cholangiographic techniques)
- Intravascular contrast studies (intravenous urography, cholangiographic techniques)
- Direct injection of contrast (percutaneous cholangiography, antegrade nephrostograms, retrograde ureteropyelography)
- Ultrasonography
- Computed tomography
- Magnetic resonance imaging
- Nuclear medicine
- Endoscopic techniques
  - Gastrointestinal endoscopy
  - ERCP
  - Biliary endoscopy
  - Genitourinary endoscopy: antegrade, retrograde
Anatomic considerations
- Embryology
- Normal anatomy
- Variant anatomy
Physiology, pathology and pathophysiology
- Normal histology/physiology/morphology
- Pathologic conditions
Procedural aspects
- Indications and contraindications
- Techniques, devices, materials
- Results, efficacy
- Risks and complications
- Alternate techniques (surgical and medical therapeutic options)

PART II: Specific Topics
* The topics listed in Part I should be considered subheadings of the following.

Biopsy and diagnostic fluid aspiration
- Specific sites
  - Thoracic (see also thoracic nonvascular intervention, below)
    - Lung
    - Mediastinum
    - Pleura
  - Cervical
    - Thyroid/parathyroid
    - Salivary
    - Other neck
  - Breast (including biopsy and tumor localization)
  - Superficial tissues
  - Abdominal
    - Liver
    - Pancreas
    - Biliary system
    - Spleen
    - Adrenals
    - Genitourinary
      - Kidneys
      - Ureters/bladder
      - Prostate
      - Uterus/ovaries
      - Testes
    - Gastrointestinal tract
    - Retroperitoneum
    - Peritoneum
      - Paracentesis
      - Peritoneal masses
    - Bone
- Tissue sampling considerations
Fluid/abscess drainage
- Sites
  - Chest: see chest intervention, below
  - Abdomen/Pelvis
    - Peritoneal
    - Retroperitoneal
    - Genitourinary
      - Renal abscess
      - Renal cyst
    - Liver
      - Hepatic abscess
      - Bilomas
      - Hepatic cysts
    - Pancreas
      - Types of collections, pancreatic inflammatory disease (abscess, pseudocyst, etc.)
      - Drainage in pancreatic inflammatory disease
    - Spleen
    - Gastrointestinal tract: see gastrointestinal intervention, below
  - Musculoskeletal
- Categories
  - Cysts
    - Cyst sclerosis
  - Hematomas
    - Use of thrombolytic therapy
  - Lymphoceles
  - Lymphocele sclerosis
  - Abscesses
Biliary intervention
- Percutaneous transhepatic cholangiography
- Biliary obstruction: percutaneous biliary drainage and stenting
  - Malignant obstruction and strictures
  - Primary biliary tumors: cholangiocellular carcinoma, etc.
  - Ampullary and periampullary tumors
  - Metastatic disease (intraductal, extrinsic)
- Benign obstruction and strictures
  - Primary disorders
    - Inflammatory (including sclerosing cholangitis)
    - Neoplastic
  - Post-surgical
- Percutaneous cholecystostomy
  - Acalculous cholecystitis
  - Calculous cholecystitis
  - As an adjunct to cholangiography and biliary drainage
- Treatment of biliary calculi
  - In the gallbladder
  - In the biliary ducts
Gastrointestinal intervention
- Gastrointestinal intubation
- Percutaneous gastrostomy and gastrojejunostomy
- Percutaneous jejunostomy
- Percutaneous cecostomy
- Abscesses resulting from enteric leaks
- Gastrointestinal fistulas: interventional management
- Gastrointestinal strictures
- Gastrointestinal obstruction
- Gastrointestinal foreign body retrieval
- Interventional radiology in specific disorders
  - Appendicitis
  - Diverticulitis
  - Inflammatory bowel disease
Genitourinary intervention
- Renal obstruction
  - Antegrade pyelography and percutaneous nephrostomy
  - Whitaker test
  - Nephroureteral stenting
  - Upper urinary tract strictures
  - Upper urinary tract calculi
- Urinary leaks/fistulas
- Urinary diversions
- Bladder
- Urethra
  - Strictures
- Male specific
  - Benign prostatic hyperplasia
- Female specific
  - Fallopian tube recanalization
Thoracic nonvascular intervention
- Chest tube placement and management
  - Pleural collections
    - Pneumothorax
    - Empyema
      - Natural history
      - Principles of therapy
      - Use of fibrinolytic agents
    - Malignant pleural effusions
      - Sclerotherapy
    - Hemothorax
      - Principles of therapy
      - Use of fibrinolytic agents
- Infected parenchymal collections
- Tracheobronchial tree
  - Stricture dilatation and stenting
- Transthoracic needle biopsy
- Mediastinal disorders
Foreign body retrieval: nonvascular
Nonvascular interventional aspects of organ transplantation
- Liver
- Kidney
- Pancreas
- Small bowel
Nonvascular interventional methods of tumor therapy
Direct injection techniques: ethanol, chemotherapeutic agents, cryotherapy
Nonvascular interventional methods of organ ablation
Pediatric Nonvascular Intervention (see the general topics parts I and II of this section; although clear differences exist in types and frequencies of procedures between pediatric and adult age groups, a detailed outline is not provided here)
Other nonvascular intervention