Credentials for uterine artery embolization.

(1), Dr. BruceMcLucas advocated that gynecologistslearn the skills to perform the proce-dure of uterine artery embolization(UAE) as treatment for symptomaticleiomyomas. Although few gynecolo-gists currently have the advanced,specialized catheter and guide wireskills necessary to perform this proce-dure, McLucas describes a routethrough which he believes they mightattain these skills. His EndovascularCredentialing Standards are appar-ently his own and do not appear torepresent any gynecologic or otherprofessional society. In this commen-tary, we compare the training stan-dards of the SIR with those suggestedby McLucas and provide the stan-dards for outcomes for UAE that phy-sicians performing this procedureshould meet.The Society of Interventional Radi-ology (SIR) welcomes the acknowl-edgment by McLucas that UAE is avaluable therapeutic option in thetreatment of patients with symptom-atic leiomyomata, and we welcome hisinterest in having this procedure beeasily available. His suggestion that itbe performed by gynecologists is anadditional endorsement of the proce-dure. From his perspective, the issue isno longer whether this is a useful ther-apy, but rather who should perform it.Adoption of techniques from onespecialty to another is not a new con-cept. As noted by McLucas, endovas-cular procedures for the treatment ofperipheral arterial disease were devel-oped by interventional radiologistsand are now also performed by cardi-ologists and vascular surgeons. Proce-dures such as venous access and portplacement were previously offeredpredominantly by surgeons and arenow widely offered by interventionalradiologists. The important issue isnot which specialist performs the pro-cedure but that the procedure is donewell and that patients receive high-quality care.However, UAE differs from other,more routine endovascular proce-dures mentioned by McLucas in waysthat warrant specific mention.• First, the pelvic arterial anatomyis among the most complex inthe body. Identifying and cathe-terizing the correct artery forUAE can be extraordinarily diffi-cult even for a physician whoroutinely does so. Although thegynecologist has the advantageof knowing the vessel from theoutside in, as noted by McLucas,this perspective bears little re-semblance to angiographic anat-omy and, in reality, conveys lit-tle advantage to the performanceof UAE. If a physician per-formed a catheterization of thevena cava for the initiation ofUAE, as is described by McLu-cas, the procedure would failbecause of a fundamental misun-derstanding of vascularanatomy.• Second, the uterus and ovariesare in the direct radiation beamthroughout a UAE procedureand cannot be shielded. The go-nads are among the most radia-tion-sensitive organs in any indi-vidual, regardless of age, gender,or fertility, and the potential forgenetic injury and malignant de-generation increase directly withexposure.• Third, UAE often requires a co-axial approach with microcath-eters, which requires a muchhigher level of skill than otherselective catheterizations and theuse of the highest-quality fluoro-scopic equipment.For all these reasons, adequatetraining is essential for the physicianperforming UAE.The SIR is committed to the conceptof clinical competence: proceduresmust be done safely and effectivelyand for appropriate indications. As apart of this commitment, the SIR hascreated standards of practice for mul-tiple procedures, including UAE.These standards include training, re-porting, quality assurance, and clinicalcare (2–5). The SIR training standardsfor UAE (2) were published in 2001and were created in a specialty-neutralway so that any physician might offerthis procedure after completing ap-propriate training. McLucas referencesthis standard in his article. Adherenceto these SIR standards by physicianswill help assure patients that they willreceive appropriate care in a safe en-vironment and will reassure institu-tions that their practicing physicians