Clinical Core Curriculum

Exercise testing for assessment of lower extremity arterial circulation

Overview

A successful graduate of our program will be eligible for an additional 2 years clinical cardiology training that will allow the trainee to sit for the cardiology board examination. A one-year peripheral vascular interventional training program also is available after successful completion of the vascular medicine training program.

The clinical component of the Vascular Medicine-Clinical Research Training Program is based on the existing vascular medicine training program. Dr. Roger Shepherd is the director of the Vascular Medicine clinical training. Both required and elective clinical rotations are described below. Following completion of the clinical training, the trainee will be required to take the Vascular Medicine Board Examination and strongly recommended to pursue the Registered Vascular Technician (RVT) diploma.

Clinical Rotations in Vascular Diseases

Required clinical rotations will include: Vascular consults (outpatient and inpatient), Vascular Laboratory, Vascular Surgery, Vascular Radiology, Wound Care Clinic, and Thrombophilia Clinic. In addition, a series of elective rotations will be available for trainees to choose from including the Vasculitis Clinic, Early Atherosclerosis Clinic, Vein Clinic, Neurovascular Clinic, Lymphedema Clinic, A-V Malformation Clinic, Coagulation Laboratory and Clinic and Vascular Pathology. Each rotation is allotted a one month block, however this duration is flexible based on the needs of the trainee.

Required Clinical Rotations

  • Outpatient Vascular Consults (1 month) This rotation will expose the trainee to a broad range of vascular diseases in the outpatient setting. The trainee will be required to evaluate and treat patients with various vascular diseases under the direct supervision of a senior vascular consultant. The outpatient vascular medicine practice is primarily based within the Gonda Vascular Center. There are currently 10 fully trained vascular consultants staffing this practice. On a rotating basis, two vascular medicine consultants are assigned to participate in this busy practice which accommodates between 10 and 14 new patients for vascular evaluation and treatment each day. The vascular diseases seen within this practice span the full spectrum of arterial, venous and lymphatic disorders in patients spanning pediatric to geriatric age range. In 2004, there were 6,651 unique patient visits with vascular diseases requiring a vascular medicine consultation. These patients were nearly equally divided between arterial and venous disorders. Approximately 10% of patients referred for a Vascular Medicine consultation had a lymphatic disease. This busy clinical vascular practice provides a rich source of patients and vascular diseases for educational purposes and translational research opportunities.
  • Inpatient Vascular Consults (1 month) The objective of this rotation will be to expose the trainee to patients with more acute vascular diseases in the hospital setting. The trainee will be required to evaluate hospitalized patients with a broad spectrum of vascular diseases. During this month, the trainee will take responsibility for the hospital consult service including night call coverage under the direct supervision of a senior vascular medicine consultant. Vascular consultants assigned to the inpatient vascular practice are exposed to a fascinating mix of patients with severe and complex vascular diseases in Mayo Clinic Hosptial – Rochester. As in the outpatient practice the trainee will be exposed to a broad range of arterial, venous, and lymphatic disorders in patients ranging pediatric to geriatric ages. On a rotating basis, one vascular medicine consultant and one mid-level provider are assigned to the inpatient practice. On average, three - four new consultations are requested each day which maintains the census of active patients followed daily of between 15 and 20. The inpatient practice provides a rich source of patients and vascular diseases for educational purposes at a pace which is very conducive to didactic teaching. In 2004, there were 3,378 unique patients with vascular diseases that required an inpatient vascular medicine consultation.
  • Vascular Laboratory/Vascular Duplex Ultrasound (3 month) includes didactic and "hands-on" training in peripheral duplex ultrasonography which will qualify the trainee to sit for the RVT certification examination (as well as the other board exam for physicians). Such training/certification will allow the program graduate to act as a Director of Vascular Laboratory. During this rotation, the trainee will learn to perform and interpret non-invasive diagnostic tests for arterial and venous disorders that are performed in the Vascular Laboratory. It will be expected that following this rotation, the trainee will become proficient in the routine vascular testing performed in this laboratory. Located within the Gonda Vascular Center, the vascular laboratory provides a full range of vascular physiologic testing for patients with suspected venous and arterial diseases. There are five fully equipped rooms (1,695 square feet) devoted for lower extremity arterial evaluation (three rooms), venous evaluation (two rooms), and upper extremity arterial evaluation (one room). One vascular medicine physician is assigned to the vascular laboratory each day and is responsible for overseeing the testing including exercise protocols and test interpretation. The testing is performed by six fully trained vascular technicians (RVT certified). In 2004, there were 5,943 patients undergoing vascular test performed in this laboratory. These volumes included: 1,435 venous, 3,858 lower extremity arterial, and 650 upper extremity arterial studies. All patient data is recorded into a computerized vascular laboratory database employing an in-house software package for data archiving and retrieval. This busy clinical vascular laboratory feeds a rich database that provides better educational purposes and translational research opportunities. Dr. Paul Wennberg, Vascular Medicine consultant, is the director of this laboratory.

    Duplex ultrasound has become a cornerstone in the evaluation of many if not all vascular disease processes. Hence it is mandatory that the trainee get adequate exposure to this modality of vascular testing. It is expected that the trainee will develop an appreciation for the types of ultrasound imaging studies currently available as well as the strengths and potential pitfalls of this type of imaging modality. Vascular Ultrasound is also located within the Gonda Vascular Center distinct from but adjacent to the Vascular Laboratory. This laboratory encompasses 2,850 square feet with 14 examination rooms fully equipped with the latest Acuson Sequoia ultrasound machines. This laboratory is staffed by five vascular radiologists and 40 sonographers all extensively trained in vascular ultrasound (RVT certified). In 1994, Mayo Clinic began its own sonographer school to train the many sonographers needed to staff the busy ultrasound practice. The majority of studies performed in this area include aneurysm screening, carotid ultrasound, venous ultrasound for deep venous thrombosis and venous incompetence, vascular bypass graft surveillance, and renal ultrasound. In 2004, 13,689 procedures were performed in the Vascular Ultrasound laboratory.

  • Peripheral vascular angiography/interventional rotation (analogous to the cardiac cath lab experience for a cardiology fellow, 6-weeks). Endovascular interventions are increasing exponentially for patients with both arterial and venous diseases. New techniques and devices are ever-expanding the indications for such procedures. It is therefore necessary for trainees in Vascular Medicine to have an appreciation for these procedures including their indications and feasibility. Furthermore, the trainee must have first hand knowledge regarding the interpretation of diagnostic arteriography and venography. Within the Gonda Vascular Center, there exists a strong and vibrant multidisciplinary interventional vascular practice including eight interventional radiologists, one interventional Vascular Medicine consultant, and two cardiologists trained in peripheral vascular interventions. Furthermore, all six vascular surgeons have received training in vascular interventions. The vascular interventional practice is located at two sites within the Rochester Mayo Campus including Mayo Clinic Hospital, Saint Marys Campus and the second floor of the Gonda Building. In 2004, 5,724 diagnostic/interventional procedures were performed. Dr Haraldur Bjarnason (proposed clinical adjunct mentor) chairs this multidisciplinary practice.
  • Vascular Surgery (1 month) Although many patients seen in both the Gonda Vascular Center and in the hospital are seen conjointly by Vascular Medicine and Vascular Surgery, our Vascular Surgery colleagues are asked to see many patients which do not require vascular medicine input. A prime example is patients with acute arterial occlusion. In order to get a complete training in vascular diseases, the trainee will therefore be required to spend one month training with consultants in Vascular Surgery. An additional objective of this rotation is to provide the trainee with an in depth appreciation of surgical interventions on patients previously assessed by a vascular medicine consultant. The division of Vascular Surgery is staffed by six vascular surgeons, six physician assistants and four vascular surgery fellows. Outpatient vascular surgery consultations are performed within the Gonda Vascular Center. Each surgeon has their own unique hospital service and hospital consultative service supported by rotating surgery residents and fellows. In 2004, the Vascular Surgical division performed 4,872 vascular surgical procedures. Dr. Peter Gloviczki (proposed clinical adjunct mentor) is the chair of Vascular Surgery as well as the chair of the Gonda Vascular Center.
  • Thrombophilia Clinic (1 month) A considerable proportion of vascular patients have thrombotic manifestations of their disease, a good example being venous thromboembolism. The objective of this rotation will be to educate the trainee on the proper evaluation and treatment of patients with thrombotic disorders. Founded by Dr. John A. Heit (PI) in 1997, the Thrombophilia Center is currently directed by Dr. Robert D. McBane (Co-Director). A multidisciplinary group of nine consultants staffs the Thrombophilia Center (specialties represented include Cardiovascular Diseases, Hematology/Oncology, Cerebrovascular Neurology, and General Internal Medicine). Goals for this group are to provide comprehensive care for patients with thrombophilia as well as an academic nucleus for education and research in thrombotic disorders. A nurse practitioner supervisor, five Thrombophilia Center Nurses and two physician's assistants provide direct patient care for acute and chronic anticoagulation management services. Over 5,000 unique patients have been seen since the inception of the Thrombophilia Center, including over 1,500 patients with a familial or acquired thrombophilia. Other services include recommendations for thromboprophylaxis in high risk patients, chronic anticoagulation clinic services (point-of-care testing), peri-procedural management of outpatient low molecular weight heparin therapy for the chronically anticoagulated patient and outpatient management of newly diagnosed cases of venous thromboembolism. In 2004, personnel in this clinic attended 10,936 unique clinic visits. The Center for Disease Control recently funded the Thrombophilia Center as one of eight National Demonstration Projects, providing funding for completion of the Thrombophilia Center Registry for every patient episode of care. This will provide a rich research opportunity vascular medicine trainees interested in clinical research in thrombosis. The close proximity of Vascular Ultrasound facilitates enrollment of eligible patients into clinical trials of novel antithrombotic therapies. Finally, patients with venous thromboembolism are enrolled into epidemiological and laboratory (including molecular) studies of thrombophilia.
  • Wound Care Clinic (1 month) Acquisition of skills to be able to care for vascular wounds which are quite prevalent in this patient population. The objective of this rotation will be to expose the trainee to a variety of patients with vascular wounds and instill the clinical skills required for the proper evaluation and treatment of these patients. Founded in 1994 by Dr. Thom Rooke (proposed clinical adjunct mentor), this clinic comprises 1695 square feet within the Gonda Vascular Center. This multidisciplinary clinic is staffed by Vascular Medicine, Dermatology, General Internal Medicine, Podiatry and Physiatry. Since inception, this clinic has cared for over 15,000 unique patients with arterial, venous, traumatic and neurotrophic wounds with a healing success rate of 88%. Novel therapeutic modalities within this clinic include application of cultured skin grafts, in-house growth factor, ultrasonic dermal debridement, and intermittent pneumatic compression. Within the next year, a hyperbaric oxygen chamber will be added to this wound healing armamentarium. The average time to heal a would in this clinic is 18 weeks. In 2004, this clinic had 7,367 unique patient visits. Cindy Felty CNP, is the current director of this clinic.

Elective Clinical Rotations

  • Integrated Coagulation Clinical and Laboratory Services (1 month) Thrombotic complications of arterial and venous disorders are by far the leading causes of morbidity and mortality in the United States. The objective of this rotation is to provide the trainee with an understanding of thrombophilia testing and test interpretation. The Coagulation Laboratory is broadly comprised of an integrated clinical and laboratory enterprise and the Section of Hematology Research. In 2004, 4,460 Mayo Clinic patients underwent Special Coagulation testing. An additional 13,750 patients were tested through Mayo Medical Laboratories (our diagnostic reference laboratory); 1,953 of these were for thrombophilia and 9,428 were for lupus anticoagulant/anticardiolipin antibody, and tests for bleeding disorders. About 165,000 individual Special Coagulation laboratory tests (including about 50 esoteric assays) were performed for Mayo Medical Center patients and for clients around the world through Mayo Medical Laboratories. The Laboratory has supported 40 clinical correlative studies over the past several years through developmental testing. It also supports national Clinical Trials for factor concentrates by serving as a central reference laboratory. The General Coagulation Laboratory, is integrated with the Special Coagulation Laboratory and offers 24 hour testing for six tests, and in 2002 performed 272,000 assays. The Special Coagulation DNA-Diagnostic Laboratory, founded in 1996 by John A. Heit, in 2002, performed 24,371 individual genetic tests for patients with either bleeding or prothrombotic disorders: Factor V R506Q (Leiden), Prothrombin G20210A, N5,10-Methylenetetrahydrofolate reductase (MTHFR) C677T, type 2N (Normandy) von Willebrand disease. Dr. John A. Heit (PI) is the Director of the Coagulation Laboratory.
  • Coagulation Clinic (1 month) A multidisciplinary group of eight consultants (specialties represented include Hematology/Oncology, Cardiovascular Diseases, and Pediatrics) staff the Coagulation Clinic. The goal of this rotation is to educate the trainee regarding the diagnostic and therapeutic recommendations for patients with suspected or known thrombotic or bleeding disorders. In 2002, 438 patients were seen in the Coagulation Clinic, of which 75% were referred for an acquired or familial thrombophilia, while the remainder were seen for bleeding disorders. Data on all Mayo Clinic patients who have had Special Coagulation testing is entered onto an electronic database thus providing a rich educational and clinical resource. Dr. John A. Heit (PI) is the Director of the Coagulation Clinic.
  • Vasculitis Clinic (1 month) Patients with large, medium, and small vessel vasculitis receive primary care through a multi-disciplinary vasculitis clinic located within the Gonda Vascular Center. This clinic is a primary unit within the Department of Medicine (DOM) Immunology and Immunotherapeutics program. Dr. Cooper (proposed mentor) is a core faculty member of the Department of Medicine (DOM) Immunology and Immunotherapeutics program. The vasculitis clinic was established in 2002 and is currently staffed by a rheumatologist and a vascular medicine physician two mornings per week. These two staff consultants see new vasculitis patients together to efficiently address immunologic, wound care, and revascularization issues. Noninvasive vascular testing, vascular surgical and interventional radiological consults are obtained expediently in this setting. From 1980 to 2000, 4,168 unique patients were seen at Mayo with diagnoses of temporal arteritis or giant cell arteritis, an average of 208 new patients per year. Over the same time period 203 new patients with Takayasu's arteritis were seen. In 2004, 230 new patients were seen in the Vasculitis Clinic.
  • Vein Clinic (1 month) The evaluation and treatment of varicose veins is rapidly evolving. Varicose veins represents the most common vascular disorder in the United States. The vascular physician therefore needs to gain an appreciation for the evaluation and treatment options available for patients with venous varicosities. The newly incepted Vein Clinic (2004) was developed to provide prompt treatment of these patients with varicose veins. This clinic, staffed by physicians from Vascular Medicine, Vascular Surgery and Dermatology, offers patients the latest techniques for varicose vein management. In 2004, 379 new patients were seen in the Vein Clinic. Dr. Thom Rooke (proposed clinical adjunct mentor) is the current director of this clinic.
  • Lymphedema Clinic (1 month) The goal of this rotation is to educate the trainee in the diagnosis of lymphedema and in the proper evaluation and treatment of these patients. World-wide, lymphedema is the most prevalent of all vascular disorders largely due to filariasis. In United States, cancer is a major cause but many patients present with primary lymphedema (praecox or tarda). Lymphedema remains a major diagnostic concern for the patient being evaluated for limb edema. In the Gonda Vascular Center, evaluation of limb swelling represents one of the most common reasons for referral. In our experience, lymphoscintigraphy is a common test performed as part of this evaluation. The Mayo Lymphedema Clinic has been providing valuable service since its inception in 1988 and occupies 1,200 square feet. This clinic is staffed by six physicians and eight allied health personnel. In 2004, 2,822 patient visits were performed in this clinic. This included unique 674 patients with a new diagnosis of lymphedema.
  • Early Atherosclerosis Clinic (1 month) The objective of this rotation in the Early Atherosclerosis Clinic is to educate the trainee in comprehensive risk profiling of patients with early-onset ASCVD or a family history of early-onset ASCVD. In these patient groups, conventional risk algorithms do not perform well in explaining or predicting ASCVD events, and other 'non-conventional' risk factors may play a role. Improved risk stratification will have a major impact on ASCVD by identifying patients that need aggressive preventive measures including lipid-lowering drugs. Based on the presence of conventional risk factors, one can broadly classify patients as being at low-, intermediate-, or high-risk for ASCVD. However, such an approach lacks precision. Although most patients who suffer ASCVD will have one or more of the conventional risk factors, so do many patients who are asymptomatic. Moreover, risk stratification based on conventional risk factors does not incorporate family history of ASCVD, obesity, elevated triglycerides, and fasting hyperglycemia. Each patient seen in the Early Atherosclerosis Clinic undergoes comprehensive risk profiling including estimation of the 10-year probability of coronary heart disease based on the Framingham risk equation, assessing whether metabolic syndrome is present, and evaluating the levels of the novel risk factors (homocysteine, fibrinogen, lipoprotein (a), C-reactive protein and LDL particle size and number). Additional testing in patients with family history of ASCVD includes non-invasive imaging of the coronary arteries with a coronary artery calcium scan. The trainee will develop an understanding of both conventional and novel risk factors for ASCVD and the ability to individualize treatment plans based on conventional risk factor profiling and the expanded testing. Dr. Iftikhar Kullo, Vascular Medicine (proposed mentor) is the current director of this clinic.
  • Vascular Malformation Clinic (1 month) The Vascular Malformation Clinic is a multidisciplinary clinic staffed with vascular, plastic, general, and orthopedic surgeons, radiologists, and medical specialists in Pediatrics and Internal Medicine. A particular focus of this clinic is Klippel-Trenaunay syndrome which has interested Mayo Clinic physicians and surgeons since the early 70's. In 1992 Dr. Driscoll published a description of 252 patients with Klippel-Trenaunay syndrome who had been evaluated at Mayo Clinic up until that time. Since then the number of patients with Klippel-Trenaunay syndrome seen at Mayo Clinic exceeds 400. The national support group for Klippel-Trenaunay syndrome meets in Rochester, Minnesota within the facilities of the Mayo Medical Center every other summer. At that time the physicians and surgeons of the Mayo Clinic provide a scientific symposium for the families and patients who attend this meeting. On average two-three patients with vascular malformations are evaluated per week in the Clinic and it is one of the two largest referral centers for patients with Klippel-Trenaunay syndrome and other related vascular malformations. For several years Dr. Driscoll has collaborated with Dr. Qing Wang's laboratory to determine the genetic factors responsible for Klippel-Trenaunay syndrome. Their collaboration lead to the discovery of a unique genetic mutation implicated in this disease (Nature. 2004;427:640-645).
  • Cerebrovascular Neurology (1 month) Each year, 700,000 Americans suffer from a new or recurrent stroke. Cerebrovascular neurologists at the Mayo Clinic have long been at the forefront of both the clinical evaluation and treatment of these patients as well as defining the epidemiology and natural history of these diseases. The objective of this rotation is to provide the trainee with an understanding of the proper evaluation and treatment of patients suffering or at risk of suffering TIA or stroke. The trainee will spend three of the four weeks working up patients in the outpatient cerebrovascular clinic. A one week rotation on the Stroke service (a busy inpatient Mayo Clinic Hospital, Saint Marys Campus service) will provide the trainee with first hand experience in the acute care of stroke patients.
  • Vascular Pathology (1 month) The goal of this rotation is to provide a broad overview of vascular pathology. This goal is accomplished with a structured review of the gross specimen archives and teaching files of microscopic slides of classic vascular cases. In addition, the trainee will participate in current in-house and referral cases of vascular disorders. During this rotation, the trainee will be encouraged to complete a small clinicopathologic research project. Dr. William Edwards, Department of Laboratory and Medical Pathology is the director of Cardiovascular Pathology.