UNIVERSITY HOSPITAL



UNIVERSITY HOSPITAL

DEPARTMENT OF SURGERY

VASCULAR SURGERY

REQUEST FOR PRIVILEGES

To be eligible to request clinical privileges, the following threshold criteria must be met.

EDUCATION: MD or DO

TRAINING:

Successful completion of an approved residency/fellowship training program in Vascular Surgery.

Applicant must meet the requirements for board certification outlined in the Medical Staff Bylaws.

EXPERIENCE:

The initial applicant must be able to demonstrate training and/or experience on a level commensurate with

specialty training from an accredited vascular surgery residency/fellowship program or current

competency in providing medical/surgical management and/or treatment to patients within the scope of

core privileges for Vascular Surgery. Adequate documentation of this performance requires

submission of a case list and a reference letter. All initial applicants at completion of residency and/or

fellowship must provide an official case list and letter of recommendation assessing performance from

the Residency and/or Fellowship Program Director. All initial applicants beyond 12 months of residency/

fellowship completion must provide a case list from the hospital where the applicant has been actively

practicing for the last year and a letter of recommendation assessing performance from the hospital’s

Chief of Staff or Department Chair.

The reappointment applicant must demonstrate continuing competence and meet requirements for C.M.E.

according to the Medical Staff Bylaws. Reappointment is based upon unbiased, objective review of result

of care according to the hospital’s existing quality mechanisms.

CORE PRIVILEGES:

(This list is a sampling of privileges included in the core but is not intended to be an all-encompassing list

but rather reflective of the categories/types of privileges included in the core.)

REQUESTED GRANTED

|Admission of patients | | |

|Evaluation, diagnosis, consultation, pre/post-operative care of patients with underlying surgical conditions in| | |

|all areas of the hospital, including the emergency department and intensive care units. | | |

|Core Endovascular Procedure Privilege | | |

|Percutaneous peripheral diagnostic and interventional procedures, excluding cerebrovascular | | |

|Must have 100 diagnostic peripheral angiograms with at least 75 arterial and 50 interventions | | |

|Must be primary interventionalist in at least 25 interventions | | |

|Reappointment 25 diagnostic interventions and 50 during the two year reappointment cycle | | |

|Percutaneous cervico-cerebral diagnostic and interventional procedures (carotid stenting) | | |

|Must have 100 diagnostic peripheral angiograms with at least 75 arterial and 50 interventions. | | |

|Must be primary interventionalist in at least 25 interventions and 50 selective four vessel diagnostic | | |

|cervico-cerebral angiograms as primary operator in at least 50% | | |

|25 carotid stent procedures as primary or secondary operator in at least half | | |

|Non-Invasive Vascular Testing: Must meet ICAVL standards, Need RPVI certificate | | |

|Peripheral venous | | |

|Peripheral arterial | | |

|Extracranial cerebrovascular (carotid) | | |

|Intracranial cerebrovascular (transcranial Doppler) | | |

|Visceral vascular | | |

|Screening (CIMT, ABI, AAA) | | |

|Aortic Procedures | | |

|Aortic to aortic, femoral, iliac, mesenteric, renal bypass procedures | | |

|Infrarenal and suprarenal aortic aneurysm/dissection repair, open | | |

|Thoracic aortic aneurysm/dissection repair, open | | |

|Thoracoabdominal aortic aneurysm/dissection repair, open | | |

|Aortic aneurysm/dissection repair, endovascular | | |

|Need privilege in open repair. | | |

|25 EVAR cases and Core Endovascular Procedure Privilege (Non cervico-cerebral) | | |

|Aortic aneurysm/dissection repair, fenestrated endovascular | | |

|Need privilege in open repair | | |

|25 EVAR cases and Core Endovascular Procedure Privilege (Non cervico-cerebral) | | |

|Medical Director or Proctor letter of approval | | |

|Thoracic aortic aneurysm/dissection repair, endovascular | | |

|Need privilege in open repair | | |

|25 EVAR cases and Core Endovascular Procedure Privilege (Non cervico-cerebral) | | |

|Peripheral Endovascular Procedures: Core endovascular procedure privilege (non-cervico-cerebral) required. | | |

|Percutaneous transluminal peripheral angioplasty | | |

|Percutaneous transluminal peripheral stenting | | |

|Percutaneous transluminal peripheral atherectomy, laser | | |

|Percutaneous transluminal peripheral atherectomy, rotational | | |

|Thrombolytic therapy, extracranial and non-coronary | | |

|Percutaneous thrombectomy, arterial and venous | | |

|Coil embolization and occlusive device, arterial | | |

|Coil embolization and occlusive device, venous | | |

|Intravascular ultrasound, arterial and venous | | |

|Venogram | | |

|Venous stenting | | |

|Venous angioplasty | | |

|IVC filter placement | | |

|IVC filter retrieval | | |

|Ultrasound guided repair of pseudoaneurysm | | |

|Peripheral Open Procedures | | |

|Exposure of artery | | |

|Bypass grafting lower extremity, vein (aortic, femoral, Popliteal and tibial) | | |

|Bypass grafting upper extremity, vein (subclavian, axiallary, brachial, radial, ulnar) | | |

|Bypass grafting mesenteric, vein (aortic, renal, mesenteric) | | |

|Bypass grafting cerivo-carotid (carotid, vertebral, innominate) | | |

|Bypass grafting lower extremity, prosthetic (aortic, femoral, Popliteal and tibial) | | |

|Bypass grafting upper extremity, prosthetic (subclavian, axiallary, brachial, radial, ulnar) | | |

|Bypass grafting mesenteric, prosthetic (aortic, renal, mesenteric) | | |

|Carotid endartectomy | | |

|Arterial endartectomy (non-carotid) | | |

|Carotid tumor, excision | | |

|Open Thrombectomy, embolectomy, arterial and venous | | |

|Peripheral aneurysm repair (iliac, femoral, popliteal) | | |

|Open repair of Psuedoaneurysm | | |

|Open repair of arterial venous fistula | | |

|Venous reconstruction, repair, bypass | | |

|Vascular trauma (Need to request to obtain other privileges) | | |

|Venous Treatment | | |

|Radiofrequency venous ablation (VNUS) | | |

|Laser venous ablation (EVLT) | | |

|Stab phlebectomy | | |

|Power phlebectomy (Trivex) | | |

|Sclerotherapy | | |

|Dialysis Access Procedures | | |

|AV fistula | | |

|AV graft | | |

|Percutaneous venous access non-tunneled and tunneled catheter placement | | |

|Declot procedures, Percutaneous and Open | | |

|Pulmonary artery procedures | | |

|Pulmonary artery angiogram | | |

|Pulmonary artery embolism, thrombectomy | | |

|Pulmonary artery embolism, thrombolysis | | |

|Swan-Ganz catheter placement and management | | |

|Miscellaneous | | |

|Chest tubes | | |

|Thoracentesis | | |

|Seroma treatment, drainage open or Percutaneous | | |

|Foreign body removal | | |

|Tumor excision of skin or soft tissue | | |

|Biopsy, open or core needle | | |

|Skin grafts | | |

|Debridement of skin, subcutaneous, muscle, ligament, tendon, bone | | |

|Burn Care | | |

|Thoracotomy | | |

|Exploration of abdomen | | |

|Endoscopic vein harvest | | |

|Lymphatic procedures | | |

|Arterial, venous, lymphatic ligation | | |

|Spine exposure | | |

|Arterial venous malformation repair | | |

Applicants requesting any other special privileges listed below must present documentation of training in

each privilege requested with a letter from the training director attesting to the applicant’s competence

and/or must meet any additional/other credentialing criteria which has been approved by the Medical Staff

and the Governing Board of University Hospital.

SPECIAL PRIVILEGES to include: REQUESTED GRANTED

|Moderate sedation | | |

|University Hospital Vein Center | | |

|Hyperbaric oxygen therapy | | |

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The applicant is required to submit a separate letter of request for any privilege not included on this form.

________________________________________ ___________________________

Applicant’s Signature Date

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