The Department of Radiology at the University of New Mexico sponsors a one year fellowship in Vascular / Interventional Radiology. The program is accredited by the Accreditation Council for Graduate Medical Education (ACGME). The Vascular / Interventional Radiology section consists of three full-time interventional attendings, one part-time attending, and one fellow. The fellowship offers experience in all aspects of this radiology subspecialty. The emphasis will be determined by the specific needs of the fellow in cooperation with the radiology staff. A broad range of vascular/interventional radiology procedures are performed.
Applicants to the Vascular/Interventional fellowship must have completed an accredited Radiology Residency Program, must be certified by the American Board of Radiology at the time of starting the fellowship, and be eligible for licensure by the State of New Mexico Board of Medical Examiners.
The fellowship program at UNMHSC is one year in duration. Trainees rotate one week at a time on the interventional service, alternating weeks between University Hospital and the VAMC. Trainees are supervised directly by Interventional and/or Neuro Radiologists. This includes pre-procedure clinical evaluation of patients with documentation of allergies, medical history, laboratory data, and pulses if appropriate, obtaining informed consent to include risks, benefits, complications and alternatives, review of pertinent preliminary diagnostic studies, discuss what questions are to be answered and which studies are most appropriate to answer these questions with the referring physician. Understanding and interpretation of physiologic monitoring, including EKG, non-invasive and arterial blood pressure and pulse oximetry, post-procedure note to include any intra- or post-procedure complications, findings, follow-up studies as required, recommendations, review of procedure images in order to generate procedural reports which are accurate, grammatically correct, and reflect an appropriate level of confidence, review of reports with corrections prior to signature and timely distribution, provide follow-up within 24 hours as well as long term care in patients with drainage tubes of all types, complications of any kind, and interventional procedures of any kind, discharge outpatients from the observation unit with appropriate written instruction signed by the patient, radiologist and companion/driver. Faculty is always available for supervision, assistance and consultation. If there are no neuroradiology trainees, diagnostic and interventional neurological procedures are performed by the interventional trainees with neuroradiology faculty supervision.
All procedures must be scheduled by the trainee or faculty, thus affording the opportunity for the trainee to consult directly with referring physicians. Pertinent studies, CT, US or plain films, must be reviewed with the clinician prior to scheduling a biopsy or drainage to confirm a lesion. If special cytologic or histologic studies are required, the pathologist is consulted prior to biopsy for guidance in appropriate handling of samples. Biopsy material is taken to pathology with complete clinical history and pertinent radiologic studies for review with the pathologist.
Trainees are responsible for both vascular and nonvascular interventional procedures. Vascular procedures include diagnostic angiography, venography, interventional vascular procedures such as thrombolysis, angioplasty, stent placement, atherectomy, foreign body removal, dialysis access management with therapy, embolotherapy including trauma, transcatheter chemoembolization, transcatheter infusion therapy, percutaneous central line placement, and inferior vena cava filters. Diagnostic neuorradiological studies including myelograms, fluoroscopic guided LP’s, cervical and intracranial carotid and vertebral angiography, spinal arteriograms, vertebral biopsies. Non-vascular procedures include CT, US and fluoroscopic guidance for biopsy including diagnostic or therapeutic procedures, percutaneous gastrostomy, percutaneous transhepatic and transcholecystic bilary procedures, percutaneous cholecystotomy combined biliary studies with GI service, TIPS, percutaneous drainage for diagnosis and treatment of infections and other fluid collections and percutaneous transcatheter abalation of neoplasms cysts and lymphocoeles. The only interventional procedure not performed by trainees are breast localizations, lymphangiography, and prostate biopsies.
The Vascular Surgery service is very active with many diagnostic arteriograms requested following abnormal non-invasive testing. Review of the non-invasive tests, examination of the patient and discussion with the referring physician is done to define the study which will provide the most information and therapy to be done at the time of arteriogram. The surgeons are readily available for consultation and backup for emergencies, should they arise. The semi-monthly conferences provide an avenue for discussion of techniques, workups, follow-ups, and interesting cases not only from UNMHSC and VAMC but also Lovelace Medical Center and promote confidence and trust between services. Stent placement is shared by IR and VS.
UNMHSC is the only level one trauma center for New Mexico, eastern Arizona and southern Colorado. Therefore, the Burn and Trauma service is extremely busy. Diagnostic, as well as therapeutic, procedures are performed and represent approximately 50% of on call cases. It is a policy to start emergency cases within 30 minutes of notification, if possible, to expedite surgical or therapeutic intervention if required.
CVIR has an excellent rapport with the Hematology/Oncology service. The Cancer Center is attached to UNMHSC with both chemotherapy, brachytherapy and radiation therapy services provided. CVIR performs biopsies of all types, including solid organs, lymph nodes, lung and mediastinal masses, bones and others, using CT, US and fluoroscopic guidance. Pathology is present during many FNA biopsies for confirmation of adequate tissue, assure proper handling of tissue in correlation with the radiographic findings. Comparison with previous biopsies or surgical specimens if a primary is present is helpful. There is tumor board weekly at UNMHSC and VAMC which trainee is welcome to attend and participate. We provide upper arm central access with a subcutaneous reservoir for patients with cancer, cystic fibrosis, HIV and other patients requiring long term access. We have taken over the placement and management of dialysis patients at both institutions.
The gastroenterologists have an extensive endoscopic service, however, CVIR does perform PTC and drainage, stent placement, transjugular hepatic biopsies, TIPS, angioplasty of biliary strictures, and other procedures. UNMHSC currently has a liver transplant service which has increased the number of cases diagnostic and therapeutic in this area. There is a Radiology/GI/Surgery Conference weekly during which problem cases are discussed with input from all services. Trainees are encouraged to attend, review studies and participate in discussion and percutaneous management as required.
The Urology service has a lithotripter at VAMC and the number of percutaneous nephrostomy tubes for stone removal has decreased. We continue to provide percutaneous drainage using nephrostomy tubes, universal stents and double J stents for obstructed and infected systems. Routine maintenance is performed by CVIR. Pre-operative ablation of kidneys using embolization with coils, permanent particles and ethanol is performed in highly vascular tumors. Biopsies of native kidneys and renal transplants are performed by the Nephrology service using US or CT guidance.
Miscellaneous procedures such as IVC filters, abscess drainages, cyst and lymphocoele drainage and ablation, percutaneous gastrostomy/jejunostomy and foreign body removal are requested by varying services.
Although Children's Hospital is located in UNMHSC, the number of CVIR pediatric cases is limited. We have performed diagnostic and therapeutic procedures for extremity AVMs and trauma cases, removed foreign bodies, performed biopsies and drained abscesses, placed IVC filters, and percuteneous arm ports. A protocol for percutaneous embolization of lymphangiomas is in progress in children.
The didactic curriculum includes review of basic tools including guidewires, catheters, needles, embolization materials, stents, angioplasty balloons, and snares during the first week of training and repeated prior to use of each tool for a specific procedure. There is also a review of basic techniques for all types of procedures which is reinforced prior to each procedure. There are weekly fellow tutorials discussing basic and advance techniques, review of current literature, morbidity and mortality in the past week, practice manipulation of catheters with plastic aorta, review new techniques and devices, review tutorial classes in the SCVIR syllabus. There is a one month Interventional Radiology teaching block for the residents every year, although the teaching level is appropriate for trainees. Visiting radiologists provide lectures of experience from other institutions. Faculty and fellows give lectures in basic concepts as well as topics "on the cutting edge". A lecture is given by the head technologist from the vascular lab regarding non-invasive diagnostic imaging and physiologic studies including transcutaneous oximetry, segmental pressures and waveforms and/or ankle/brachial indices are often included. Other topics include contrast agents, analgesics, antibiotics and other drugs commonly used during interventional procedures. There are also teaching blocks in CT, US, GI, GU, Chest, Pediatrics, Nuclear Medicine, Neuroradiology and Skeletal which incorporate interventional lectures. The majority of these lectures are given during the noon hour and trainees are encouraged to attend if there are no procedures in progress. There is a year long physics course given once a week to the first year residents which includes x-ray generators, image intensifiers, film, film/screen combinations, film changers, processing, US, CT, MRI, etc. which is available to trainees for reinforcement of knowledge obtained in residency. Trainee is guided in accurate and appropriate coding for billing purposes.
The trainee is responsible for coordinating the Interventional Radiology service under the direct supervision of faculty. This responsibility is given gradually as the trainee exhibits clinical and technical skills, as well as judgment commensurate with such responsibility. The trainee schedules all cases, completes pre- and post-procedure evaluations. Performs all procedures within his/her capabilities. Supervises residents performing simple procedures, completes short and long term follow-up with written documentation, reviews studies with faculty, then dictates and corrects reports prior to distribution, prepares teaching files. Morning review of cases to be done each day and previous night on-call procedures by faculty, fellow and resident provides an opportunity to discuss techniques, emergency cases, and prioritization in scheduling, review evaluation and treatment of complications, discuss any special requirements with the technicians and nurses. Afternoon rounds are performed by faculty, trainee and resident. Patients with catheters in place are evaluated daily, with documentation of fever, vital signs, output, cultures, dressing, and review of pertinent follow-up studies such as CT or US. Post arteriogram patients are evaluated for puncture site hematoma, change in vital signs or pulse, fever, neurological changes, etc. and findings are charted. Patient’s scheduled for procedures the following day are evaluated, pre-procedure note and orders written, informed consent obtained, techniques discussed after review of pertinent studies. The referring physician is contacted to assure the appropriate study is performed. Any special arrangements such as specimen handling, blood products, etc. are made.
The trainee gives one or two lectures during the Interventional Radiology teaching block. They also teach residents informally on a daily basis during procedures, in morning and afternoon rounds, and during review and dictation of studies performed. Fourth year medical students rotate through radiology in month blocks and observe in Interventional Radiology during that time. Trainees or faculty must sign off on the procedures the students observe and are responsible for teaching them about the procedure they are observing and answering any questions they may have. There is no formal didactic teaching of medical students by the trainee.
The vascular/interventional fellow works a schedule similar to that of the interventional faculty. Trainees work an average of 50 hours a week. Trainees are on call every third week with faculty supervision during the entire year. The fellow is only in-house during the performance of emergency procedures. Residents assist on on-call procedures. Faculty is always present for on-call procedures.
The case is scheduled by the trainee following discussion with referring MD to obtain appropriate clinical information, including whether the study will be performed as an out patient or inpatient, questions to be answered, type of study to be performed, whether additional post-procedure studies, such as post-arteriogram CT, are required, special preparation of patient, such as prophylaxis for contrast allergy or blood products, will be necessary. Pre-procedure evaluation of patients are performed the evening prior to the procedure. Review of the history, allergies, laboratory findings, pertinent radiologic and non-radiologic studies, physical examination including palpation and marking of pulses if appropriate, is completed and documented in the chart. Informed written consent is obtained from the patient or guardian after discussion of risks, benefits and alternatives. Orders are written to include NPO, IV or heparin lock placement, any required pre-procedure medications, time of procedure, void on call, and any other specific orders.
Post-procedure note and orders are completed and placed on the chart. The patient is sent to the floor or observation unit. All patients are seen during afternoon rounds, including anyone with a percutaneous tube placed by CVIR. Evaluation of puncture site, pulses, neurological status, vital signs, chest x-ray for pneumothorax , and any other appropriate clinical indices is completed and documented in the chart. Arteriogram patients are checked at 24 hours if still in the hospital and called at home if an out-patient.. Patients with complications are followed to resolution in the hospital or as an outpatient with phone calls and clinic visits. Outpatients who do not live in town are discharged after 6 hours of observation, if there are no complications but are required to stay in town overnight, have someone drive them home and remain with them during the night. A written instruction sheet with phone numbers to call if complications occur or questions arise is reviewed with the patient and companion, signed by MD, patient and companion and sent home with the patient with instructions for follow-up, including clinic appointment. Patients who are sent home with indwelling catheters are seen in clinic, however, we currently do not have a clinic of our own.
At the VAMC facility, the vascular surgeons have placed a new angiography suite in the OR in preparation of performing stent grafts. As a result, very little diagnostic and therapeutic angiography is done at that facility by CVIR.
You will receive fringe benefits including health insurance, a dental plan, vision insurance, life insurance, disability insurance and moving expenses.
