Societal Guidelines and Consensus Documents

This month I’d like to discuss an issue straying quite a bit from my usual blog covering clinical issues for the vascular specialist. Instead, I’d like to discuss societal guidelines, and specifically, a consensus document for carotid artery revascularization.

I was pleased to see the daunting task of bringing together a whole slew of societies including AHA, ACC, SCAI, SVS and neurologic groups including the AAN, in writing a new set of updated guidelines for the application of CAS and CEA standards to patients with high and now low risk who are asymptomatic this past year (including CREST). After their publication, later in 2011, the SVS came out with another guideline to further document for the surgical community their emphasis on surgical revascularization seems duplicative and frankly disingenuous to the process of societal collaboration. Both sides are crying foul regarding the unique step away from a collaborative guideline to a solitary guideline within the time-period as having the ink still drying for the signature period.

I think the next few months will be interesting with the SCAI president Dr. White and other thought leaders in CAS describing the ongoing issues with this breakdown in collaboration and the surgical rebuttals. I am clearly not in favor of this duplicative or isolated work when another was written to be an overall guideline, but also I am equally concerned about how to read one from the other. We are all well aware that these types of collaborative guidelines are compromises throughout. Single societal guidelines are easier to write as they conform to the nuances and practices of only one group in general. A great example was the dueling guidelines for carotid angiography that just a few years ago recommended as few 3 cases and a weekend course in one guideline to a complete fellowship with over 100-150 cases before you could safely provide this service for any patient. Somewhere between these two extremes is where a consensus was finally reached and now we have certain fundamental guides for credentialing physicians for this procedure. No one group won a clear victory with these guidelines but we all agreed to have them help with our process of credentialing physicians to perform these procedures. Clearly someone will have to blink during the current fiasco, but equally important is that the guidelines are published and not to be withdrawn. Unfortunately, the biggest losers to these issues will remain the patients. When they look to their physicians for guidance they will then be told that one set of guidelines suggests one thing and another set of guidelines suggests another. How are they to feel empowered to make an evidence-based decision regarding their healthcare or help loved ones make a difficult decision?


Dr. Garcia received his B.A. and M.D. degrees from the University of Arizona. He was an intern and resident at Parkland Memorial Hospital, University of Texas at Southwestern in Dallas, Texas. He received his training in cardiology at the University of Iowa Hospitals and Clinics in Iowa City, Iowa, and as an interventional cardiologist at the Beth Israel Deaconess Medical Center, Harvard Medical School. Further, he received his peripheral vascular training at St. Elizabeth’s Medical Center, Tuft’s University, Boston, Massachusetts. He then served as the Chief of Vascular Medicine and Peripheral Vascular Interventions for the Florida Heart Group in Orlando, Florida. Dr. Garcia returned to Harvard’s Beth Israel Hospital as a full-time interventional cardiologist and Director of the Peripheral Cardiovascular Program and Peripheral Interventions at the Beth Israel Deaconess Medical Center as well as the Director of the Interventional Fellowship Program. This program developed into one of the busiest in the city of Boston, performing over 600 peripheral procedures per year.

Dr. Garcia has now returned to St. Elizabeth’s Medical Center as Chief of the Section of Interventional Cardiology and as Associate Director of the Vascular Medicine Program. Dr. Garcia’s work has largely focused on arterial occlusion-reperfusion models and the efficacy of therapeutic modalities or interventions with regard to free radical generation or endovascular stenting outcomes. Dr. Garcia continues his research interests in a wide variety of studies including acute MI studies, unstable angina studies, interventional trials, peripheral interventional trials, angiogenesis trials, imaging modality studies, and numerous device trials for both the coronary and peripheral circulations. His work has been presented in numerous manuscripts, abstracts, textbooks and textbook chapters.

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