Neurosurgical Endovascular Credentialing in Europe and the United Kingdom for the “Complete” Neurovascular Surgeon: The Time has Come

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Since the birth of cerebral angiography in 1927,1,2 the field of endovascular neurosurgery has seen an exponential expansion for the treatment of neurovascular pathologies. Several technical landmark developments paved the way for endovascular practice as we know it today, including the introduction of intravascular balloon devices in 1964,3 particles for embolization in 1960,4 detachable coils in 1991,5 and flow diverters in 2011.6 The results of the International Subarachnoid Aneurysm Trial supported endovascular techniques over open surgery for the treatment of ruptured aneurysms.7 By extrapolation, unruptured aneurysms are also often managed with endovascular techniques. Today's neuroendovascular landscape includes a variety of techniques for the treatment of cerebrovascular diseases. Mechanical thrombectomy (MT) is increasingly replacing pharmacological thrombolysis for the treatment of acute large vessel occlusion (LVO) strokes and is considered a gold standard treatment that should be accessible to all stroke patients. The irrefutable future of neurological treatment will be dominated by neuroendovascular techniques. There is wide variation internationally of how clinicians obtain neuroendovascular training. In many European countries and the United Kingdom, endovascular training is accessible only through a radiology training route. Training of neurosurgeons and the retainment of endovascular skills in a “hybrid” practice situation is subject to limitations, which are variable by country. In North America, neuroendovascular training is easily accessible to neurosurgeons, and “hybrid” practice is common. This difference in workforce composition has resulted in differing patterns of practice among many other countries. In North America, several pathways were developed simultaneously that allowed for endovascular training of specialists from multiple disciplines. Endovascular program directors, as well as practicing endovascular neurosurgeons, first accepted neurosurgeons into fellowship training. The Committee on Advanced Subspecialty Training was created as a mechanism of maintaining training standards; these are applicable to trainees from different specialties and are reviewed regularly at multiple institutions. Fellowship accreditation for endovascular training for all specialties was initially provided through the NeuroEndovascular Surgery Advisory Committee, organized under the auspices of The Society of Neurological Surgeons.8 Later, the Credentialing Endovascular Surgery Advisory Committee was established with multispecialty representation on the board, which allowed for fellow credentialing with recognition of focused practice.9 In the nationalized health care systems of Europe and the UK, neuroendovascular services were largely developed by an expanding interventional neuroradiology (INR) workforce. Although inherent differences in health care structures exist, there are also numerous examples in Europe/UK of “dual”-trained neurosurgeons maintaining a hybrid practice. The European Board of Neuroradiology credentials endovascular training through the European Diploma in INR (EDiINR).10 Where candidates are not radiologists by background, alternative pathways to certification11 can be achieved through attendance at training courses and experience in diagnostic neuroradiology, as attested by local radiology departments. Despite this existing scaffold, many still encounter barriers to training and practice in Europe, where much of the resistance is encountered at national and regional levels. The issue of accessible training in endovascular neurosurgery and the barriers faced by many for credentialing and maintaining a practice are yet to be resolved. Recent progress was made in the UK to introduce neurosurgeons formally into endovascular practice. The General Medical Council approved a credential for MT that was published by the Royal College of Radiologists in June 2023.12 The intent of this credential is to train a workforce that can learn and deliver 24/7 MT services across England, through the recruitment of neurosurgeons and other specialists. The interest among neurosurgeons worldwide to train in neuroendovascular techniques is longstanding; in many places, this has been met with systemic hurdles and lack of collaboration with radiologists.13,14 A recently published, comprehensive summary of the landscape and obstacles to practice in Europe/UK is illustrated in Peschillo and Meling.14 The divergence in endovascular and open surgery training has created a knowledge gap for aspiring neurovascular surgeons through a lack of familiarity with endovascular imaging and techniques and a reduction in open surgical volume. Moreover, there is a need for the workforce to meet the increasing demand for “essential services” in neuroendovascular procedures, the definition of which is rapidly expanding. This is particularly pressing for acute LVO ischemic stroke. We acknowledge that endovascular licensing, legislature, and practice in Europe is heterogeneous and ever-shifting. We do not presume to describe all practices accurately nor do we wish to make generalizations when referring to “Europe and the UK.” The intent of this article is to highlight existing discrepancies and benefits of systems whereby “dual” training of neurosurgeons is accessible and “dual” practice is permitted. Referral to the “UK and wider Europe” will be used to describe practices of countries, or parts of countries, whereby hurdles exist in the training and practice of endovascular techniques by neurosurgeons. The field must evolve through expansion and further inclusion of neurosurgeons in Europe and the UK. This can only be achieved through multispecialty collaboration. We must break down the barriers to credentialing and make high-quality training accessible to those wishing to pursue a career in endovascular surgery. The time to act is now. CURRENT PRACTICE Currently, in much of wider Europe and the UK, coverage of endovascular services is provided by INR. The training for INR consists of core years of diagnostic training and further years of neurointervention training—across Europe, the median time is 5 years.15 In many countries, a dedicated fellowship program is necessary for neurosurgeons to obtain credentialing, whereas in others, a neurosurgeon must go through radiology training in addition to their own training. In a few countries, legislation does not permit neurosurgeons to practice endovascular treatments. In addition, in many countries, institutional barriers exist to neurosurgeons establishing a “hybrid” practice, despite successful completion of “dual” training.12 In recent years, the volume of endovascularly treated aneurysms has escalated, with a commensurate decrease in the volume of open microvascular procedures. Consequently, the number of trained “open” vascular neurosurgeons has decreased over time. This has had implications for the availability of neurovascular surgical expertise, particularly in the delivery of emergency on-call services. There exists variability in hospital admission privileges and follow-up patient care by radiologists. In addition, many institutions do not provide 24/7 endovascular service, and out-of-hours management of neurovascular emergencies does not include a full spectrum of treatment options. For wider Europe and the UK, neuroendovascular experience is not mandated in the neurosurgical curriculum; many trainees will have observation experience only in the angiography suite. Currently, 8 countries in Europe (Bulgaria, Denmark, Finland, France, Germany, Greece, Hungary, and Ukraine) provide training fellowships for neurosurgeons11 in comparison with 116 established endovascular fellowship programs in the United States.16 A lack of familiarity with vascular imaging among trainees is in contrast to the ethos for which neuroangiography was initially developed as an adjunct for the evaluation of surgical anatomy to aid the

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