Working Together in the Treatment of Carotid Artery Disease

When I think about the way we treat carotid disease, I see a great example of multiple specialties that are not working together. Everybody has something to offer the specialty of carotid stenting, and everybody, in my view, needs to possess the following: catheter skills, general clinical skills, an understanding of the end-organ (which is probably more important in the brain than any other organ in the body because it’s so unforgiving), a referral base, which is critically important (it’s why vascular surgery has a virtual lock on carotid endarterectomy), and a bailout strategy (what do you do if you get in trouble?). These are all important for either of surgery or catheter-based intervention to treat stroke. There are different specialties involved in the treatment of carotid disease. Radiologists, for example, from my vantage point, possess catheter skills as their major skill set. Cardiologists have major catheter skills, good clinical skills, and a huge referral base. Vascular surgeons have a huge referral base as well, and they have clinical skills. Neurosurgeons have clinical skills and end-organ skills, but they don’t have the catheter skills, although they are rapidly beginning to acquire them. So rather than pontificate, let me throw this question out to the audience: How can we get these specialties to work together better? What can we do to make the different specialists join forces to treat carotid disease? Because, as Gary Roubin put it so nicely, we have targets to shoot for — the 3% rule, the 1% rule — however you want see it. I think that collaboration is essential to reach these targets. So how do we do that?