Article

Vascular surgery training trends from 2001-2007: A substantial increase in total procedure volume is driven by escalating endovascular procedure volume and stable open procedure volume

March 2009
Journal of Vascular Surgery 49(5):1339-44

DOI:10.1016/j.jvs.2008.12.019

Source
PubMed

Authors:

Endovascular procedure volume has increased rapidly, and endovascular procedures have become the initial treatment option for many vascular diseases. Consequently, training in endovascular procedures has become an essential component of vascular surgery training. We hypothesized that, due to this paradigm shift, open surgical case volume may have declined, thereby jeopardizing training and technical skill acquisition in open procedures. Vascular surgery trainees are required to log both open and endovascular procedures with the Accreditation Council for Graduate Medical Education (ACGME). We analyzed the ACGME database (2001-2007), which records all cases (by Current Procedural Terminology [CPT] code) performed by graduating vascular trainees. Case volume was evaluated according to the mean number of cases performed per graduating trainee. The mean number of total major vascular procedures performed per trainee increased by 174% between 2001 and 2007 (from 298.3 to 519.2). Endovascular diagnostic and therapeutic procedures increased by 422% (from 63.7 to 269.1) and accounted for 93.0% of the increase in total procedures. The number of open aortic procedures (aneurysm, occlusive, mesenteric, renal) decreased by 17.1% (from 49.7 to 41.2), while the number of endovascular aortic aneurysm repair procedures increased by 298.8% (from 16.9 to 50.5). Specifically, open aortic aneurysm procedures decreased by 21.8%, aortobifemoral bypass increased by 3.2%, and open mesenteric or renal procedures decreased by 13%. Infrainguinal bypass procedures remained relatively constant (from 37.6 to 36.5, 2.9% decrease), and the number of carotid endarterectomy procedures performed did not change significantly (from 43.6 to 42.2, 3.2% decrease). Vascular surgery trainees are performing a vastly increased total number of procedures. This increase in total procedure volume is almost entirely attributable to the recent increase in endovascular procedures. Aside from a small decline in open aortic procedures, the volume of open surgical procedures has largely remained stable. It is essential that vascular surgery training programs continue to focus on both endovascular and open surgical skills in order for vascular surgeons to remain the premier specialists to care for patients with vascular disease.

National survey to Portuguese Angiology and Vascular Surgery residents - Insights into the satisfaction and limitations of the residency program

Article

Full-text available

Jun 2023

Introduction: Vascular Surgery is a demanding specialty with vast technological and research advances in the last decades. This has led to an increasing complexity of providing adequate training programs for the modern Vascular Surgeon. Our aim was to understand the current satisfaction rates and perceived limitations of the Vascular Surgery residency program in Portugal by performing an online survey to residents. Methods: A survey study was conducted between April and June 2021 targeting Angiology and Vascular Surgery Residents in Portugal. Residents were contacted by e-mail from the National Portuguese Society of Angiology and Vascular Surgery to answer the survey. The survey was anonymized, and all residents from the 1st to 6th year were invited to participate. The survey was carried out using the Google® Forms platform and using Portuguese language. Questions were developed with two main objectives, the first being to analyze the satisfaction rates with the current residency program and the second to understand current limitations and possible areas of improvement. Results: Overall, 33 (65%) out of 51 invited residents participated in the survey, with equally distributions regarding the year of residency. Nineteen residents were male (57.6%). Most residents considered that the current one-year General Surgery rotation should be reduced and replaced by other specialties such as Radiology. Main surgical limitations were found with open aortic surgery. However, when compared to other European countries, residents considered that the main current limitation was scientific/academic training. Most residents were satisfied with their residency and felt professional fulfillment, however, most also reported having an unhealthy work-life balance and lack of time for academic and scientific research. When comparing the survey answers between younger and older residents, older residents reported more often having considered quitting and having experienced bullying or harassment. Conclusion: The findings from this study provide insight into the perceptions of the trainees regarding current training limitations and satisfaction rates with the residency program and may provide a base for improvement and development strategies in the residency programs in Portugal.

Variation in the choice of elective surgical procedure for abdominal aortic aneurysm in Spain

Article

Full-text available

Apr 2019

Objective: The two main surgical treatments for abdominal aortic aneurysm (AAA) are open surgical repair (OSR) and endovascular aneurysm repair (EVAR). The aim of this study was to analyze variation among Spanish hospitals in the use of OSR or EVAR for AAA. A secondary aim was to assess changes in preferences for these two procedures over time. Methods: This was a retrospective longitudinal study based on discharge data from public hospitals in Spain during 2002-2012. Patient inclusion criteria were: age >18 years, elective admission, primary diagnosis of unruptured AAA, and surgical treatment with OSR or EVAR. The characteristics of the treating center, patients, and in-hospital mortality were recorded. Results: We included 16,737 patients from 114 hospitals; 6,809 (40.7%) underwent EVAR and 9,928 (59.3%) underwent OSR. The total volume of surgeries increased throughout the period, and the probability that any given procedure was EVAR increased by 20% per year (OR 1.20, P<0.001). The volume and distribution of the two procedures varied highly across the participating hospitals. Overall, in-hospital mortality rate was 3.6% and it decreased during the study period (5.3% in 2002 and 3.2% in 2012), mainly due to a decrease in OSR-related mortality, despite a slight increase in EVAR-related mortality. Hospitals with higher surgical volumes were more likely to use EVAR and have lower in-hospital mortality rates. Conclusion: This study reveals high variability in the surgical treatment of unruptured AAA across Spanish hospitals. The number of interventions has increased in recent years, with EVAR accounting for a growing percentage of these surgical procedures. Overall in-hospital mortality rates decreased significantly during this period, mainly due to lower mortality among patients undergoing OSR. In-hospital mortality rates were lower in higher-volume centers, regardless of the surgical approach used. Further research on variability and appropriateness of surgical management of AAA is required to assess the suitability of concentrating elective AAA repair in more experienced centers to potentially achieve better outcomes.

Objective Evaluation of Clock Face Suture Using the Objective Structured Assessment of Technical Skill (OSATS) Checklist

Article

Full-text available

Oct 2022

Objective Assessment of the quality of the final product (QFP) is critical in simulation training, such as the clock face suture exercise that is used to assess trainees’ needle handling and accuracy in suture. Objective Structured Assessment of Technical Skill (OSATS) scores are the gold standard for the evaluation of trainees. The aim was to investigate variability in the use of OSATS checklists and to evaluate a semi-automatic method of suture analysis vs. OSATS scores. Methods Details of 287 CFS performed by trainees during Fundamentals in Vascular Surgery examinations were collected. All were rated according to a seven item OSATS checklist, including QFP score and an overall score by one or two expert surgeons immediately after completion. Intervariability was assessed for the CFS that were assessed by two assessors. In order to assess intravariability and intervariability, 50 CFS pictures were randomly chosen and submitted to three expert surgeons to rate the QFP twice and to carry out a semi-automatic image analysis of each CFS and the estimated cumulated error (CE; mm) recorded. It was hypothesised that the CE correlates to OSATS checklist items or overall score. Variables were compared for correlation with OSATS results using a linear regression. A Pearson’s test was used to confirm the proposed hypothesis. Results Mean ± standard deviation overall score for the OSATS checklist was 20.61 ± 6.33. Interassessor and intra-assessor correlation were statistically significant regarding OSATS checklist items. Both correlations presented a low coefficient of determination, indicating variability. The mean CE was 16.07 ± 4.84 mm, and the correlation between the QFP and CE was statistically significant, proving that CE is an objective metric by which to assess the QFP. Conclusion OSATS score demonstrated intra-assessor and interassessor variability, although there was a significant correlation between scores. CE is an objective metric that is not subject to assessor subjectivity or interassessor variability, and is correlated with the gold standard of evaluation.

Targeted muscle reinnervation: A narrative review of a novel tool for the management of neuropathic pathology in major lower extremity amputations

Article

Sep 2022

Objective The purpose of this narrative review is to provide the vascular surgery community with updated recommendations and information regarding the use of Targeted Muscle Reinnervation (TMR) for both the prevention and treatment of chronic pain and phantom limb pain occurring in patients after undergoing lower extremity amputation for peripheral artery disease. Methods Current available literature discussing TMR is reviewed and included in the article in order to provide a succinct overview on the indications, clinical applications, and surgical technique for TMR. Additionally, early studies showing favorable long-term results after TMR are discussed. Patient consent for publication was obtained for this investigation. Results TMR has been demonstrated to be an effective means of both treating and preventing neuroma-related symptoms including chronic pain and phantom limb pain. It has been proven to be technically feasible, and can help patients to have improved utilization of prostheses for ambulation, which can conceivably lead to a reduction in mortality. Conclusions TMR is an important tool to consider for any patient undergoing lower extremity amputation for a vascular-related indication. A vascular-plastic surgeon dual team approach is an effective means to prevent and reduce neuromas and associated chronic pain in this patient population.

Learning-based catheter and guidewire-driven autonomous vascular intervention robotic system for reduced repulsive force

Article

Full-text available

Aug 2022

Manual vascular intervention radiology (VIR) procedures have been performed under radiation exposure conditions, and many commercial master-slave VIR robot systems have recently been developed to overcome this issue. However, master-slave VIR robot systems still have limitations. The operator must reside near the master device and control the slave robot using only the master device. In addition, the operator must simultaneously process the recognition of the surgical tool from the X-ray image while operating the master device. To overcome the limitations of master-slave VIR robot systems, we propose an autonomous VIR robot system with a deep learning algorithm that excludes the master device. The proposed autonomous VIR robot with a deep learning algorithm drives surgical tools to the target blood vessel location while simultaneously performing surgical tool recognition. The proposed autonomous VIR robot system detects the location of the surgical tool based on a supervised learning algorithm, and controls the surgical tools based on a reinforcement-learning algorithm. Experiments are conducted using two types of vascular phantoms to verify the effectiveness of the proposed autonomous VIR robot system. The experimental results of the vascular phantom show a comparison between the master-slave VIR robot system and the proposed autonomous VIR robot system in terms of the repulsive force, task completion time, and success rate during the operation. The proposed autonomous VIR robot system is shown to exhibit a significant reduction in repulsive force and a 96% success ratio based on a vascular phantom.

Educational Impact of a Pulsatile Human Cadaver Circulation Model for Endovascular Training

Article

Sep 2019
EUR J VASC ENDOVASC

Objectives: The face and construct validity of a novel pulsatile human cadaver model (PHCM) was recently demonstrated for endovascular training. This study aimed to assess the model's educational impact. Methods: Twenty-four endovascular novices were recruited and split into two equal training groups: PHCM and virtual reality simulator (VRS). Each candidate performed eight consecutive training attempts of endovascular renal artery catheterisation on their designated model, and a final crossover attempt on the alternate model. Performances were video recorded and scored using a validated scoring tool by two independent endovascular experts, blinded to the candidate's identity and attempt number. Each participant was given a task specific checklist score (TSC), global rating score (GRS), and overall procedure score (OPS). Results: In the PHCM group average OPS improved gradually from 19.42 (TSC 8.58, GRS 10.83) to 39.50 (TSC 15.00, GRS 24.5) over eight attempts (p < .0005). In the VRS group OPS improved from 20.54 (TSC 10.29, GRS 10.25) to 36.04 (TSC 14.21, GRS 21.88) between the first and eighth attempts (p < .0005), with limited improvement after the second attempt. PHCM training significantly improved OPS on their VRS crossover attempt (p ≤ .0001), achieving a similar OPS to candidates who had completed VRS training (p = .398). VRS training significantly improved OPS on PHCM (p < 0.05); however, OPS was significantly worse than candidates who had completed PHCM training (p ≤ .001). Conclusions: PHCM training has a longer learning curve, with gradual improvement, reflecting the enhanced difficulty of a more realistic model. These results support the use of PHCM preceded by VRS training, prior to performing endovascular surgery on patients.

Fundamentals of radiation safety: Focus on reducing short-term and long-term harmful exposures

Chapter

Full-text available

Apr 2019

This chapter provides an overview of key topics in the area of radiation safety. Three clinical vignettes will serve to frame the review of the literature around both diagnostic radiation exposure and the risk of radioisotope contamination. Advancement in medical technology is rarely innocuous, and the use of radiation as both means to diagnose and treat certain conditions is not an exception. It is very important for clinicians to review the basics of harmful medical radiation exposure since, although seldom encountered, treatment, and outcomes are time sensitive. The advent of newer technology and the widespread availability of equipment will only serve to increase the prevalence of potentially harmful medical radiation exposure. Moreover, this chapter aims to explore current multidisciplinary endeavors to provide safe and efficient use of radiation in medicine. Solely relying on the medical profession for development of safeguards against harmful medical radiation exposure would be an impossible task. This is why it is crucial for professionals such as health physicists, radiation safety enforcement officers, and policy-makers at the state, national, and international level to reach consensus guidelines aimed toward safe, reliable utilization of radiation in medicine. Part of this interdisciplinary approach needs to focus on accurate education of patients. A thorough assessment of acute radiation syndrome, including diagnosis, treatment, and prognostic indicators is also part of this chapter. Furthermore, principles of screening for, and protection from, radiation contamination are outlined. Finally, areas for further research are identified throughout the chapter. The discussion takes into account both US-based and International research and practice guidelines.

The Pathway to a National Vascular Skills Examination and the Role of Simulation-Based Training in An Increasingly Complex Specialty

Article

Mar 2019
SEMIN VASC SURG

The evolving demands of surgical training have led to the successful implementation of skills examinations in the areas of laparoscopic and endoscopic surgery. Currently, there is no similar formal skills assessment in vascular surgery, despite endovascular intervention replacing open surgery in treatment of many vascular conditions. The adoption of less invasive techniques to treat aneurysm and occlusive disease has resulted in new training paradigms and technical challenges for trainees. The duty hour restriction for trainees and declining numbers of complex open vascular interventions have added to the challenges of vascular surgery training. Simulation is a promising avenue for both skills training and assessment. The ability to evaluate the fundamental skills of trainees would be an important step to ensure a degree of uniformity in trainees' technical abilities. The role of simulation-based training in acquiring, testing, and refining these skills is still in its infancy in the vascular surgery training paradigm. This article aims to impart a deeper understanding of the conditions for developing and implementing the fundamentals of vascular and endovascular surgery, and to provide guidance regarding the role of simulation-based training in a rapidly evolving specialty. There are various forms of simulation available, including benchtop models, high-fidelity simulators, and virtual-reality simulators, and each requires a different method of proficiency assessment. Both open surgery and endovascular skills can be assessed and the application of successful implementation in academic vascular surgery training program is presented.

Vascular fellow and resident experience performing infrapopliteal revascularization with endovascular procedures and vein bypass during training

Article

Nov 2018
J VASC SURG

Objective Endovascular aneurysm repair has led to a significant reduction in vascular trainee experience in the surgical treatment of aortic aneurysms. We sought to evaluate whether the vascular training paradigm or the “endovascular first” approach to lower extremity vascular disease has had a similar effect on trainee experience with infrapopliteal endovascular therapy and vein bypass. Methods Deidentified data were provided by the Vascular Surgery Board on the number of procedures performed by each 2014 fellowship and residency (0 + 5) graduate during training. Data were analyzed using parametric and nonparametric methods, where appropriate. Results Of 125 trainees (109 fellows, 16 residents), 33 (27%) performed 10 or fewer infrapopliteal vein bypasses and 37 (29%) performed 10 or fewer infrapopliteal endovascular procedures during their training. Eleven trainees (9%) performed 10 or fewer of both procedures. There was a positive correlation between number of infrapopliteal vein bypass and endovascular procedures performed (r = 0.19; P = .03). There was no difference between fellows and residents in the mean number of bypass operations performed during training (17.3 vs 19.1; P = .50; range, 0-53). However, residents performed more infrapopliteal endovascular procedures than fellows did (median, 29 vs 16; P = .03; range, 0-128). Conclusions More than one in four graduates of both training paradigms finish with a low number of infrapopliteal bypasses and endovascular interventions. The number of these procedures needed for proficiency is not known. Vascular surgery training programs should critically evaluate the number of infrapopliteal procedures required to achieve proficiency.

Temporal trends in the management and clinical outcomes of lower extremity arterial thromboembolism within a national Veteran population

Article

Aug 2018

Lower extremity arterial thromboembolism is associated with significant morbidity and mortality. We sought to establish temporal trends in the incidence, management and outcomes of lower extremity arterial thromboembolism within the Veterans Affairs Healthcare System (VAHS). We identified patients admitted to VAHS between 2003 and 2014 with a primary diagnosis of lower extremity arterial thromboembolism. Medical and procedural management were ascertained from pharmaceutical and administrative data. Subsequent rates of major adverse limb events (MALE), major adverse cardiovascular events (MACE), and mortality were calculated using Cox proportional hazards models. From 2003 to 2014, there were 10,636 patients hospitalized for lower extremity thromboembolism across 140 facilities, of which 8474 patients had adequate comorbid information for analysis. Age-adjusted incidence decreased from 7.98 per 100,000 patients (95% CI: 7.28–8.75) in 2003 to 3.54 (95% CI: 3.14–3.99) in 2014. On average, the likelihood of receiving anti-platelet or anti-thrombotic therapy increased 2.3% (95% CI: 1.2–3.4%) per year during this time period and the likelihood of undergoing endovascular revascularization increased 4.0% (95% CI: 2.7–5.4%) per year. Clinical outcomes remained constant over time, with similar rates of MALE, MACE and mortality at 1 year after adjustment. In conclusion, the incidence of lower extremity arterial thromboembolism is decreasing, with increasing utilization of anti-thrombotic therapies and endovascular revascularization among those with this condition. Despite this evolution in management, patients with lower extremity thromboembolism continue to experience high rates of amputation and death within a year of the index event.

Toward training surgeons with motion-based feedback: Initial validation of smoothness as a measure of motor learning

Article

Full-text available

Sep 2017

Surgery is a challenging domain for motor skill acquisition. A critical contributing factor in this difficulty is that feedback is often delayed from performance and qualitative in nature. Collection of highdensity motion information may offer a solution. Metrics derived from this motion capture, in particular indices of movement smoothness, have been shown to correlate with task outcomes in multiple domains, including endovascular surgery. The open question is whether providing feedback based on these metrics can be used to accelerate learning. In pursuit of that goal, we examined the relationship between a motion metric that is computationally simple to compute—spectral arc length—and performance on a simple but challenging motor task, mirror tracing. We were able to replicate previous results showing that movement smoothness measures are linked to overall performance, and now have performance thresholds to use in subsequent work on using these metrics for training.

The Role of Simulation in Boosting the Learning Curve in EVAR Procedures

Article

Sep 2017

Objective: Simulation may be a useful tool for training in endovascular procedures. The aim of this study was to evaluate the effect of endovascular repair of abdominal aortic aneurysms (EVAR) simulation in boosting trainees' learning curve. Design: Ten vascular surgery residents were recruited and divided in 2 groups (Trainee Group and Control group). At a first session (t0), each resident performed 2 simulated EVAR procedures using an endovascular simulator. After 2 weeks, each participant simulated other 2 EVAR procedures in a final session (t1). In the period between t0 and t1, each resident in the Trainee Group performed 6 simulated EVAR procedures, whereas the Control Group did not perform any other simulation. Both quantitative and qualitative performance evaluations were performed at t0 and t1. Quantitative evaluation from simulator metrics included total procedural time (TP), total fluoroscopy time (TF), time for contralateral gate cannulation (TG), and contrast medium volume (CM) injected. Qualitative evaluation was based on a Likert scale used to calculate a total performance score referred to skills involving major EVAR procedural steps. Results: All residents in the Trainee Group significantly reduced TP (48 ± 12 vs 32 ± 8 minutes, t0 vs t1, p < 0.05), TF (18 ± 7 vs 11 ± 6 minutes, p < 0.05), and CM used over time (121 ± 37 vs 85 ± 26ml, p < 0.05), but not TG (5 ± 5 vs 3 ± 4 minutes, p = 0.284). In the Control Group metrics did not change significantly in any field (TP = 55 ± 11 vs 46 ± 10 minutes; TF = 25 ± 9 vs 21 ± 4 minutes; CM = 132 ± 51 vs 102 ± 42ml; TG = 6 ± 4 vs 8 ± 5 minutes, all p > 0.05). The average Trainee Group qualitative total performance score improved significantly (p < 0.05) after rehearsal sessions when compared with the Control Group. Conclusion: Simulation is an effective method to improve competence of vascular surgery residents with EVAR procedures.

A national resident survey about the current state of venous education in vascular surgery training programs

Article

Full-text available

Aug 2017

Objective: The objective of this study was to characterize U.S. vascular surgery trainees' perceptions, case numbers, and attitudes toward venous disease education, as well as their intent to incorporate it into future practice. These data will provide us with a current snapshot of postgraduate venous education from a resident's perspective. Methods: Institutional Review Board approval was obtained. A 13-question survey was created and distributed to all vascular surgery residents in the United States by SurveyMonkey. Formal electronic distribution remained deidentified as the surveys were e-mailed to residents from the Association of Program Directors in Vascular Surgery. Results: Of 464 vascular surgery trainees queried, 104 (22%) responded to the survey. The majority of responders (80%) were between 25 and 34 years of age, 60% were male, and 72% were white; 91% reported that they were in an academic training program, and 57% were enrolled in an integrated vascular surgery residency program. Postgraduate years (PGYs) of training among respondents were well represented: PGY 1, 14%; PGY 2, 8%; PGY 3, 14%; PGY 4, 12%; PGY 5, 9%; PGY 6, 18%; and PGY 7, 25%. Vascular resident training experience with venous disease revealed the following: 63% performed <10 inferior vena cava stents, 64% performed <10 vein stripping/ligation procedures, and 50% performed <10 iliac stents; 92% of responders reported having performed <10 venous bypasses during their training. Experience with endothermal ablations was slightly better, with 74% of responders reporting having performed up to 20 cases. Case volumes for endothermal ablation, vein stripping/ligation, inferior vena cava stenting, and iliac stenting increased progressively by clinical training year among integrated vascular residents (P ≤ .02) but were relatively stable for classic 5 + 2 vascular fellows (P ≥ .67). Integrated residents reported having received more didactic venous education than the 5 + 2 vascular surgery fellows (P = .01). There were no differences in overall reported venous procedure volumes between groups (P ≥ .28). The majority of trainees (82%) acknowledged that treating venous disease is part of a standard vascular surgery practice, and many (75%) indicated a desire to have increased venous training. Despite this, 59% of responders reported plans to dedicate <25% of their future vascular surgery practice to venous disease. Conclusions: In this national survey-based study of vascular surgery trainees, we demonstrate a perceived weakness in venous disease case volumes and didactic education in residency. This training deficit is apparent in both integrated (0 + 5) and traditional (5 + 2) training pathways. Our data suggest that expansion of the venous disease curriculum with clear training standards is warranted and that trainees would welcome such a change.

SOM and LVQ Classification of Endovascular Surgeons Using Motion-Based Metrics

Conference Paper

Jan 2016

An increase in the prevalence of endovascular surgery requires a growing number of proficient surgeons. Current endovascular surgeon evaluation techniques are subjective and time-consuming; as a result, there is a demand for an objective and automated evaluation procedure. Leveraging reliable movement metrics and tool-tip data acquisition, we here use neural network techniques such as LVQs and SOMs to identify the mapping between surgeons’ motion data and imposed rating scales. Using LVQs, only 50 % testing accuracy was achieved. SOM visualization of this inadequate generalization, however, highlights limitations of the present rating scale and sheds light upon the differences between traditional skill groupings and neural network clusters. In particular, our SOM clustering both exhibits more truthful segmentation and demonstrates which metrics are most indicative of surgeon ability, providing an outline for more rigorous evaluation strategies.

Radiation hazards to vascular surgeon and scrub nurse in mobile fluoroscopy equipped hybrid vascular room

Article

Full-text available

Mar 2017

Purpose The aim of the present study was to identify the radiation hazards to vascular surgeons and scrub nurses working in mobile fluoroscopy equipped hybrid vascular operation rooms; additionally, to estimate cumulative cancer risk due to certain exposure dosages. Methods The study was conducted prospectively in 71 patients (53 men and 18 women) who had undergone vascular intervention at our hybrid vascular theater for 6 months. OEC 9900 fluoroscopy was used as mobile C-arm. Exposure dose (ED) was measured by attaching optically stimulated luminescence at in and outside of the radiation protectors. To measure X-ray scatter with the anthropomorphic phantom model, the dose was measured at 3 distances (20, 50, 100 cm) and 3 angles (horizontal, upward 45°, downward 45°) using a personal gamma radiation dosimeter, Ecotest CARD DKG-21, for 1, 3, 5, 10 minutes. Results Lifetime attributable risk of cancer was estimated using the approach of the Biological Effects of Ionizing Radiation report VII. The 6-month ED of vascular surgeons and scrub nurses were 3.85, 1.31 mSv, respectively. The attenuation rate of lead apron, neck protector and goggle were 74.6%, 60.6%, and 70.1%, respectively. All cancer incidences among surgeons and scrub nurses correspond to 2,355 and 795 per 100,000 persons. The 10-minute dose at 100-cm distance was 0.004 mSv at horizontal, 0.009 mSv at downward 45°, 0.003 mSv at upward 45°. Conclusion Although yearly radiation hazards for vascular surgeons and scrub nurses are still within safety guidelines, protection principles can never be too stringent when aiming to minimize the cumulative harmful effects.

The State of Venous Education in Vascular Residency Programs: a Resident Questionnaire

Article

Jan 2017

INTRA-OPERATIVE STAFF RADIATION EXPOSURE DURING AORTIC ENDOVASCULAR PROCEDURES

Article

Apr 2024
ANN VASC SURG

Impact of the Endovascular Revolution on Vascular Training Through Analysis of National Data Case Reports

Article

Feb 2024
J VASC SURG

Concerning Trends in Vascular Surgery Trainee Operative Experience in Venous Disease

Article

Dec 2023
ANN VASC SURG

Development, Feasibility, and Knowledge Impact of a Massive Open Online Course on Radiation Safety: A Multicentre Prospective Cohort Study

Article

Dec 2023
EUR J VASC ENDOVASC

Impact of Integrated Vascular Surgery Residency on General Surgery Resident and Vascular Fellow Operative Volume: A National Analysis

Article

Nov 2023

Background The impact of integrated vascular surgery (VS) residency (0 + 5) programs on general surgery (GS) resident and VS fellow (5 + 2) operative volume has not been investigated on a national scale. Methods Accreditation Council for Graduate Medical Education (ACGME) case logs were reviewed for GS resident, VS resident, and VS fellow operative volume from 2001-2021. Integrated VS resident data was available from 2012-2021, corresponding with the introduction of the 0 + 5 paradigm. Trends in operative volume were evaluated via linear regression analysis. Results The national cohort of chief GS resident graduates increased from 1005 to 1357 per year. Total operative volume also increased from 932 to 1039 cases (+7.4 cases/yr, R ² = .80, P < .0001) among GS residents. Major vascular cases decreased among GS residents from 138 to 101 cases (−2.4 cases/yr, R ² = .58, P < .0001) with a decrease in proportion of chief-level vascular cases from 30.4% to 11.9% (−1.0%/yr, R ² = .92, P < .0001). Palliative procedures (amputations and hemodialysis access) comprised a significant proportion of GS cases (median 44.7%). Concurrently, integrated VS graduates increased from 11 to 37 per year, with an increase in major vascular case volume from 506 to 658 cases (+18.4 cases/yr, R ² = .63, P = .01). Total VS fellow major case volume also increased from 369 to 444 cases (+3.5 cases/yr, R ² = .73, P < .0001). Conclusions The introduction of the 0 + 5 intgrated VS residency paradigm has correlated with a significant decrease in GS operative experience in major vascular procedures on a national level. Traditional VS fellow case volume does not appear to be impacted by 0 + 5 integrated residents. Further analysis with program-level data may help to explain the causative relationship of these findings.

A National Analysis of Vascular Surgery Resident Operative Experience in Peripheral Artery Disease

Article

Aug 2023
J VASC SURG

Introduction: Endovascular and hybrid interventions have played an increasingly prominent role in the treatment of peripheral arterial disease (PAD) in the past decade. This shift has prompted concerns about the adequacy of open surgical training for current surgical residents. Moreover, the recent BEST-CLI trial has further emphasized the importance of open surgical techniques in the treatment of PAD. The purpose of this study is to examine national temporal trends in peripheral operative volume among integrated vascular surgery residents. Methods: Data was obtained from the Accreditation Council for Graduate Medical Education national data reports for integrated vascular surgery residents. Case volumes for "surgeon chief" or "surgeon junior cases" were collected from academic years 2012-13 to 2021-22. Trends in case-mix and volume were evaluated using linear regression analysis. Results: The mean total vascular operative volume increased from 851.2 to 914.3 cases among graduating chief residents, with an annual growth of 8.5±1.7 cases/yr (R2=0.77, p<0.0001). Major vascular case volume also increased at a rate of 5.7±1.2 cases/yr (R2=0.74, p<0.001). Among operative categories, peripheral cases were the most frequent (n=232.2, 26.6%) and demonstrated the greatest annual growth (+8.0±0.8 cases/yr, R2=0.93, p<0.001). No changes were seen in volume of open peripheral cases, including suprainguinal bypass (+0.1±0.2 cases/yr, R2=0.08, p=0.40) or femoropopliteal bypass procedures (-0.1±0.2 cases/yr, R2=0.17, p=0.20). Infrapopliteal bypass (+0.4±0.1 cases/yr, R2=0.48, p=0.006), iliac/femoral endarterectomy (+1.3±0.2 cases/yr, R2=0.82, p<0.001), and leg thromboembolectomy (+0.4±0.1 cases/yr, R2=0.64, p<0.001) all demonstrated annual growth. For endovascular peripheral cases, aortoiliac revascularization (+3.4±0.3 cases/yr, R2=0.94, p<0.001), femoropopliteal revascularization (+5.4±0.2 cases/yr, R2=0.98, p<0.001), and tibioperoneal revascularization (+2.0±0.2 cases/yr, R2=0.92, p<0.001) all increased in volume. Lower extremity amputations, including above-knee amputation (+0.6±0.2 cases/yr, R2=0.65, p<0.001) and below-knee amputation (+0.9±0.2 cases/yr, R2=0.72, p<0.001) also demonstrated an increase in volume. Conclusions: Current graduating residents have higher open and endovascular case volumes for peripheral artery disease on a national level, despite the increasing popularity of endovascular techniques. Further studies are needed to identify how these trends may impact current vascular surgery milestones. These trends may also influence the rising interest in competency-based training programs.

A propensity score matching analysis: Impact of senior resident versus fellow participation on outcomes of complex surgical oncology

Article

Mar 2023
SURG ONCOL

Background: Teaching hospitals that train both general surgery residents and fellows in complex general surgical oncology have become more common. This study investigates whether participation of a senior resident versus a fellow has an impact on outcomes of patients undergoing complex cancer surgery. Methods: Patients who underwent esophagectomy, gastrectomy, hepatectomy, or pancreatectomy between 2007 and 2012 with assistance from a senior resident (post-graduate years 4-5) or a fellow (post-graduate years 6-8) were identified from the ACS NSQIP. Based on age, sex, body mass index, ASA classification, diagnosis of diabetes mellitus, and smoking status, propensity-scores were created for odds of undergoing the operation assisted by a fellow. Patients were matched 1:1 based on propensity score. Postoperative outcomes including risk of major complication were compared after matching. Results: In total, 6934 esophagectomies, 13,152 gastrectomies, 4927 hepatectomies, and 8040 pancreatectomies were performed with assistance of a senior resident or fellow. After matching, overall rates of major complications were equivalent across all four anatomic locations between cases performed with the participation of a senior resident versus a surgical fellow: esophagectomy (37.0%% vs 31.6%, p = 0.10), gastrectomy (22.6% vs 22.3%, p = 0.93), hepatectomy (15.8% v 16.0%, p = 0.91), and pancreatectomy (23.9% vs 25.2%, p = 0.48). Operative time was shorter for gastrectomy (212 vs. 232 min; p = 0.004) involving a resident compared to a fellow, but comparable for esophagectomy (330 vs. 336 min; p = 0.41), hepatectomy (217 vs. 219 min; p = 0.85), and pancreatectomy (320 vs. 330 min; p = 0.43). Conclusions: Senior resident participation in complex cancer operations does not appear to negatively impact operative time or postoperative outcomes. Future research is needed to further assess this domain of surgical practice and education, particularly with regard to case selection and operative complexity.

Trends in Comprehensive Thoracic Case Experience Among General Surgery Residents in the Modern Integrated Cardiothoracic Residency Era: Review of Twenty Years of Resident Case Logs

Article

Feb 2023
AM SURGEON

Background Thoracic surgery training among general surgery residents in the United States is regulated by the Accreditation Council for Graduate Medical Education (ACGME) to ensure exposure to subspecialty fields during residency. Thoracic surgery training has changed over time with the placement of work hour restrictions, the emphasis on minimally invasive surgery, and increased subspecialization of training like integrated six-year cardiothoracic surgery programs. We aim to investigate how these changes over the past twenty years have affected thoracic surgery training among general surgery residents. Methods ACGME general surgery resident case logs from 1999 to 2019 were reviewed. Data included exposure to the thorax via thoracic, cardiac, vascular, pediatric, trauma, and alimentary tract procedures. Cases from the above categories were consolidated to determine the comprehensive experience. Descriptive statistics were performed over four 5-year Eras (Era 1:1999-2004, Era 2: 2004-2009, Era 3: 2009-2014, Era 4: 2014-2019). Results Between Era 1 and Era 4, there was an increase in thoracic surgery experience (37.6 ± 1.03 vs 39.3 ± .64; P = .006). The mean total thoracic experience for thoracoscopic, open, and cardiac procedures was 12.89 ± 3.76, 20.09 ± 2.33, and 4.98 ± 1.28, respectively. There was a difference between Era 1 and Era 4 in thoracoscopic (8.78 ± .961 vs 17.18 ± .75; P < .001) and open thoracic experience (22 ± .97 vs 17.06 ± .88; P < .001), and a decrease in thoracic trauma procedures (3.7 ± .06 vs 3.2 ± .32; P = .03). Discussion Over twenty years there has been a similar, to slight increase in thoracic surgery exposure among general surgery residents. The changes seen in thoracic surgery training reflect the overall movement of surgery towards minimally invasive surgery.

The Impact of Endovascular Repair of Abdominal Aortic Aneurysms on Vascular Surgery Training in Open Aneurysm Repair

Article

Feb 2023
ANN VASC SURG

Introduction: Since the introduction of endovascular abdominal aortic aneurysm (AAA) repair (EVAR) in 1992, the number of open AAA repair (OAR) cases continue to decline. The consequence of reduced OAR cases raises valid concerns related to patient safety and future training of vascular surgeons that need to be appropriately addressed. Our objective is to analyze trends in open and endovascular AAA repair cases and to assess their implications on the quality of vascular surgery training. Methods: We analyzed the Accreditation Council for Graduate Medical Education (ACGME) case log database for total clinical experience in open and endovascular AAA repair for graduating vascular surgery fellows (VSF) finishing 5+2 programs between 2002-2019 and vascular surgery integrated residents (VSR) between 2013-2019. VSF case totals were calculated by combining average total cases of open and endovascular supra- and infra-renal AAA repair during fellowship years combined with total cases performed during their general surgery residency. VSR case totals included only the cases performed during the 5-year residency period. Isolated Iliac and thoracic aortic aneurysms were excluded from our analysis. Results: The average number of OAR cases per trainee has decreased by 60% (from 36.9 to 14.7) with a rate of 1.4 cases per year (P<0.001) for VSF. Meanwhile, EVAR average cases have increased by 102% (from 22 to 44.4). However, there were two different trends exhibited with EVAR over the study period. Between 2002 and 2007, EVAR cases tended to increase by 5.9 cases per year (P<0.001). Whereas, between 2007 and 2019, there was a slightly decreased trend in EVAR cases by 0.3 cases per year (P=0.01) (Figure 1). For VSR, while no significant trend was observed in the mean number of OAR cases (Coef. -0.3, P=0.2) due to limited time frame, the proportion of open cases was significantly lower compared to endovascular cases. Additionally, there were two different trends exhibited with EVAR over the study period. Between 2013 and 2015, EVAR cases tended to increase by 1.7 cases per year (P=0.1). Whereas, between 2015 and 2019, there was a slightly decreased trend in EVAR cases by 0.2 cases per year (P=0.007). Conclusion: A significant reduction of average OAR cases and increase in EVAR cases were observed over the study period. Vascular surgery training programs may need to introduce further training programs in open surgical repair to ensure vascular surgery trainees have the required technical skills and expertise to perform such a high-risk procedure safely and independently.

European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on Radiation Safety

Article

Sep 2022
EUR J VASC ENDOVASC

Understanding Radiation Exposure and Improving Safety for Vascular Surgery Trainees

Article

Aug 2022
J VASC SURG

Objective Despite having a robust radiation safety education procedures and policies, we discovered that trainees at our ACGME approved integrated vascular surgery residency and fellowship program were exceeding yearly radiation exposure limits. This quality improvement project describes identification of root causes and implementation of policies to improve radiation safety education, oversite and ultimately exposure levels amongst our trainees. Methods A committee comprised of faculty, fellows, radiology nurses and radiation safety officers from each of the programs affiliated hospitals convened to identify potential root causes of increased radiation exposure and potential modifiable actions. Radiation exposure reports for PGY 4-7 trainees were evaluated pre- and post-intervention. Results Excessive radiation exposure was found to be more prevalent than anticipated, with multiple trainees surpassing yearly exposure limits. The committee classified factors at play and interventions into four categories: policies and procedures, curriculum, environment, resources and equipment. The multi-site status of our program was a key factor associated with increased radiation exposure, in addition we found that excessive radiation levels occurred primarily at a single hospital site. Following interventions, the monthly average levels at this site fell considerably from 936 mrem to 272 mrem. Conclusions It is alarming that safety policies in place at vascular residency and fellowship programs are inadequate in securing the safety of its trainees. We found interventions such as inventorying and ensuring availability of safety equipment, hands on instruction to complement traditional didactics, lowering default frame rates and converting to real-time dosimetry to be effective measures for reducing radiation exposure.

National Survey of Vascular Surgery Residents & Fellows on Radiation Exposure and Safety Practices

Article

Jan 2022
J VASC SURG

Objective The objective of this study was to evaluate radiation safety practices, radiation training, and radiation exposure among senior vascular residents and fellows in ACGME accredited programs across the United States. Methods Anonymous surveys were sent to all ACGME program directors to be distributed to post graduate year 4-7 vascular trainees for completion. Survey questions focused upon program type (single or multiple hospital site), familiarity with their radiation officer, formal radiation training, frequency of radiation feedback, use of safety equipment, and adherence to ALARA principles. Results There were a total of 95 respondents (27% response rate). Forty-nine (51.6%) individuals reported they had never met their radiation safety officer. Seventy-four (77.9%) reported that they had received formal radiation safety education. A total of 50 (53%) individuals reported feedback regarding monthly radiation exposure and 24 (25%) trainees reported never having received feedback on radiation exposure levels. All findings were found to be more common among multiple hospital site program respondents Conclusion It should be of significant concern that such a high number of trainees are exceeding radiation exposure limits. Programs should strive to reduce radiation exposure through formal training, provision of safety equipment, modeling by attendings of adherence to ALARA principles, and timely exposure feedback.

Validity Evidence for Vascular Skills Assessment: The Feasibility of Fundamentals of Vascular Surgery in General Surgery Residency

Article

Aug 2021

Objective As the Fundamentals of Laparoscopic Surgery (FLS) and Fundamentals of Endoscopic Surgery (FES) have been used for general surgery assessment, the Fundamentals of Vascular Surgery (FVS) has recently been developed to evaluate core operative skills for vascular trainees. This study examines the 3 year implementation of FVS for general surgery residents and it gathers validity evidence using Messick's framework. We hypothesized that the curriculum and assessment tool enhance general surgery resident training and assessment. Design This is a retrospective review of FVS assessments of residents using descriptive and multivariate analyses. Setting This study was conducted at an academic institution, where simulation-based teaching sessions occur in coordination between the general surgery and the integrated vascular surgery residency programs. Participants Seventeen general surgery residents were assessed in FVS skills by an expert rater from 2018 to 2020. Results Overall, 86 assessments were completed. Content: Assessment focuses on 3 open vascular skills (End-to-Side Anastomosis, Patch Angioplasty and Clockface Suturing). Response Process: 7 items comprise a graded rating for a skills score. Additionally, a global summary score is designated. Internal Structure: The assessment tool has a Cronbach's alpha of 0.87, demonstrating good internal consistency. Addition of the second rater correlated with Cohen's kappa -0.69 (p < 0.001), indicating poor interrater reliability. Relationships to other variables: The most significant improvement occurred in total scores between PGY2s (17.4 ± 2.37) and PGY4s (23.2 ± 3.00), p < 0.001, indicating adequate level discernment. Conclusions The validity evidence of FVS assessment in this study supports its use in general surgery residency at a time when opportunities for open vascular skills assessment may be decreasing due to case availability and shifting paradigms. Further study into quality rater training is needed to optimize national implementation of FVS and ensure consistency in grading.

Appropriateness of surgery performed for abdominal aortic aneurysm at tertiary hospitals in Spain

Article

Jun 2021
Int Angiol

Background: To analyze the appropriateness of the type of repair (open or endovascular) performed for abdominal aortic aneurysm (AAA) in five university hospitals in Spain, according to evidence-based recommendations. Methods: A multicenter, retrospective cross-sectional study of patients with AAA who underwent elective open surgical repair (OSR) or endovascular aneurysm repair (EVAR). Data were collected on demographic and clinical variables and type of surgical repair. A pair of vascular surgeons from each participating hospital performed a blinded assessment based on GRADE recommendations. The concordance between the two evaluators and the agreement between their evidence-based recommendation and the procedure actually performed were assessed. Results: A total of 186 patients were selected; 179 were included. Mean age was 72.5 years (standard deviation [SD], 8.4), mean Charlson Comorbidity Index (CCI) was 2.04 (SD, 1.9). OSR was performed in 53.2% (n=99) and EVAR in 46.8% (n=87) of cases. Overall, 65.9% (118/179) of interventions performed were considered appropriate: 50% (47/94) of OSRs and 83.5% (71/85) of EVARs. The patient characteristics were similar for all the hospitals, but the chosen surgical technique did show significant differences among these centers. There were no significant differences among the hospitals in the proportion of cases judged as appropriate, either overall (p=0.346) or for each type of procedure (p=0.531 and p=0.538 for OSR and EVAR, respectively). Conclusions: In this study, the majority of the AAA repairs performed were appropriate according to GRADE recommendations. A higher proportion of EVARs were considered appropriate than OSRs. Choice of AAA repair should be standardized through the use of evidence-based clinical practice guidelines, while incorporating patient preferences, to reduce the existing variability and ensure appropriate selection of AAA repair technique.

Addressing Contemporary Management of Vascular Trauma: Optimization of Patient Care Through Collaboration

Article

Mar 2021

Physician Impact on Use of Fluoroscopy During Endovascular Procedures to Improve Radiation Safety

Article

Mar 2021
J VASC SURG

Objectives To determine whether differences exist in fluoroscopy time and radiation exposure during lower extremity endovascular procedures performed by fellowship trained vascular surgeons versus general surgeons, to minimize radiation exposure to operating room staff. Methods A retrospective review of all lower extremity endovascular procedures was performed from August 1st, 2014 to January 29th, 2016. The procedures were performed by the surgical department’s 4 surgeons with endovascular privileges: 2 vascular surgeons and 2 general surgeons. Only procedures involving lower extremity arterial angiograms with balloon angioplasty, stenting, or atherectomy were included. The operative records were reviewed for each case. The total fluoroscopy time, and total radiation dose for each procedure were recorded. Procedures were grouped according to the number of endovascular interventions as 1-2 interventions, 3-4 and ≥5 interventions performed. Statistical analysis was performed with a p-value of <.05 as significant. Results About 271 lower extremity endovascular procedures were performed during the study period by 4 surgeons. The average age of the patient population was 70 years. The total number of procedures performed over the study period were 112, 45, 91, and 25 for surgeons 1-4 respectively. On average, 3.24 interventions were performed during each procedure. Vascular surgeons were found to have shorter fluoroscopy time for procedures involving 1-2 (7.8 vs. 30.1, p<.01), 3-4 (9.3 vs. 34.2, p<.01), and ≥5 (11.5 vs. 51.9, p<.01) interventions. Vascular surgeons were also found to have less radiation exposure compared to general surgeons in procedures with 1-2 (1.69 vs. 3.53, p=.001) and ≥5 (2.3 vs. 5.4, p=.003) interventions. There was no significant difference in radiation exposure between vascular and general surgeons for procedures with 3-4 interventions (5.86 vs. 5.59, p=.95). Conclusion In this small series at our institution, lower extremity endovascular procedures performed by specialty-trained vascular surgeons were associated with both decreased operative fluoroscopy time and decreased radiation exposure when compared to general surgeons.

Current utilization and future directions of robotic-assisted endovascular surgery

Article

Aug 2020

Introduction Endovascular surgery has become the standard of care to treat most vascular diseases using a minimal invasive approach. The CorPath system further enhances the potential and enables surgeons to perform robotic-assisted endovascular procedures in interventional cardiology, peripheral vascular surgery, and neurovascular surgery. With the introduction of this technique, the operator can perform multiple steps of endovascular interventions outside of the radiation field with high precision movements even from long-geographical distances. Areas covered The first and second-generation CorPath systems are currently the only commercially available robotic devices for endovascular surgery. This review article discusses the clinical experiences and outcomes with the robot, the advanced navigational features, and the results with recent hardware and software modifications, which enables the use of the system for neurovascular interventions, and long-distance interventional procedures. Expert opinion A high procedural success was achieved with the CorPath robotic systems in coronary and peripheral interventions, and the device seems promising in neurovascular procedures. More experience is needed with robotic neurovascular interventions and with complex peripheral arterial cases. In the future, long-distance endovascular surgery can potentially transform the management and treatment of acute myocardial infarction and stroke, with making endovascular care more accessible for patients in remote areas.

Comparative outcomes of open, hybrid, and fenestrated branched endovascular repair of extent II and III thoracoabdominal aortic aneurysms

Article

Nov 2019
J VASC SURG

Objective: Open repair of extent II and III thoracoabdominal aortic aneurysms (TAAA) is associated with substantial morbidity. Alternative strategies, such as hybrid operations combining proximal thoracic endovascular aortic repair with either staged open distal TAAA repair or visceral debranching (hybrid), as well as fenestrated/branched endografts (FEVAR), have been increasingly reported; however, benefits of these approaches compared with direct open surgery remain unclear. The purpose of this study was to compare outcomes of these three different strategies in the management of extent II/III TAAA. Methods: All extent II/III TAAA repairs (2002-2018) for nonmycotic, degenerative aneurysm or chronic dissection at a single institution were reviewed. The primary end point was 30-day mortality. Secondary end points included incidence of spinal cord ischemia (SCI), complications, unplanned re-operation, 90-day readmission, and out-of-hospital survival. To mitigate impact of covariate imbalance and selection bias, intergroup comparisons were made using inverse probability weighted-propensity analysis. Cox regression was used to estimate survival while cumulative incidence was used to determine reoperation risk. Results: One hundred ninety-eight patients (FEVAR, 92; hybrid, 40; open, 66) underwent repair. In unadjusted analysis, compared with hybrid/open patients, FEVAR patients were significantly older with more cardiovascular risk factors, but less likely to have a connective tissue disorder or dissection-related indication. Unadjusted 30-day mortality and complication rates were: 30-day mortality, FEVAR 4%, hybrid 13%, open 12% (P = .01); and complications, FEVAR 36%, hybrid 33%, open 50% (P = .11). Permanent SCI was not different among groups (FEVAR 3%, hybrid 3%, open 6%; P = .64). In adjusted analysis, 30-day mortality risk was greater for open vs FEVAR (hazard ratio, 3.6; 95% confidence interval, 1.4-9.2; P = .01) with no difference for hybrid vs open/FEVAR. There was significantly lower risk of any SCI for open vs FEVAR (hazard ratio, 0.3; 95% confidence interval, 0.09-0.96; P = .04); however, no difference in risk of permanent SCI was detected among the three groups. There was no difference in complications or unplanned reoperation, but open patients had the greatest risk of unplanned 90-day readmission. There was a time-varying effect on survival probability, with open repair having a significant survival disadvantage in the first 1 to 6 months after the procedure compared with hybrid/FEVAR patients (Cox model P = .03), but no difference in survival at 1 and 5 years (1- and 5-year survival: FEVAR, 86 ± 3%, 55 ± 8%; hybrid, 86 ± 5%, 60 ± 11%; open 69 ± 7%, 59 ± 8%; Cox-model P = .10). Conclusions: Extent II/III TAAA repair, regardless of operative strategy, is associated with significant morbidity risk. FEVAR is associated with the lowest 30-day mortality risk compared with hybrid and open repair when estimates are adjusted for preoperative risk factors. These data support greater adoption of FEVAR as first-line therapy to treat complex TAAA disease in anatomically suitable patients who present electively.

Descriptive and follow-up study of patients treated surgically for abdominal aortic aneurysm at tertiary hospitals in Spain

Article

Sep 2019
Int Angiol

Background: To assess potential variability in the clinical characteristics and treatment of patients undergoing elective surgery for abdominal aortic aneurysm (AAA) across five hospitals in Spain. Methods: Multicenter, retrospective cohort study of patients diagnosed with AAA and treated with open surgical repair (OSR) or endovascular aneurysm repair (EVAR). We evaluated clinical and demographic variables, including comorbidity (Charlson Comorbidity Index [CCI]); anatomic characteristics; surgical risk (ASA score); aneurysm characteristics; and in-hospital and overall mortality. All patients were followed for three years. Results: A total of 186 patients were included, Mean age 72.5 (standard deviation [SD], 8.4), Mean CCI 2.04 (SD, 1.9). The surgical technique was EVAR in 46.8% of cases (n=87) and OSR in 53.2% (n=99). The in-hospital mortality rate was 2.2%, with no differences between groups. The overall mortality rate during follow up (mean, 2.9 years) was 24.1% for EVAR versus 8.1% for the OSR group (odds ratio [OR], 3.62; 95% confidence interval [CI], 3.60-3.64; P =0.004). EVAR was the only independent risk factor for mortality (OR, 3.89; 95% CI, 3.87-3.92; P = 0.004). Inter-centre variability in the type of surgery was high, with EVAR accounting for 19.4% to 75% of the surgical procedures, depending on the treating centre (P < 0.001). Conclusions: In this study the in hospital mortality rates for elective EVAR and OSR were similar. However, after the follow-up, patients who underwent EVAR had a three-fold greater mortality rate than those treated with OSR. There was substantial inter-hospital variability, underscoring the need to standardize treatment selection in patients who undergo elective surgery for AAA repair.

Thirty-Day Outcomes following Open Revascularization for Acute Mesenteric Ischemia from American College of Surgeons National Surgical Quality Improvement Program

Article

Aug 2019

Background: Open revascularization for acute mesenteric ischemia (AMI) is associated with high perioperative morbidity and mortality; however, results from contemporary studies are varied. Therefore, we evaluated 30-day mortality after open revascularization for AMI and identified preoperative factors associated with mortality. Methods: We performed a retrospective cohort study of patients in the American College of Surgeons National Surgical Quality Improvement Program database undergoing open mesenteric revascularization for AMI from 2005 to 2017. The primary outcome was 30-day mortality. We used multivariable logistic regression to identify preoperative factors independently associated with 30-day mortality. Results: The study cohort included 918 patients; their median age was 70 years (interquartile range: 59-80 years), 62% were female, and 90% were white. Thirty-day mortality after open revascularization for AMI was 32%, specifically 35% after embolectomy, 31% after thromboendarterectomy, and 28% after mesenteric bypass. Mortality was higher in patients requiring concomitant bowel resection (38% vs. 29%, respectively, P < 0.01). The preoperative factor most strongly associated with 30-day mortality was disseminated cancer (odds ratio = 8.8, 95% confidence interval = 2.4-32, P = 0.001). Other factors independently associated with mortality were renal dysfunction, preoperative intubation, preoperative blood transfusion, diabetes, elevated preoperative international normalized ratio, elevated preoperative white blood cell count, and increasing age. Conclusions: In this retrospective cohort study using a real-world, nationwide cohort, open revascularization for AMI was associated with high mortality, with nearly one-third of patients dying within 30 days of their operation. The factors identified to be independently associated with 30-day mortality, particularly disseminated cancer, preoperative renal dysfunction, and elevated preoperative WBC count, are an important tool for preoperative risk stratification.

Radiation exposure during non-thrombotic iliac vein stenting

Article

May 2019

Fluoroscopic-guided interventions have become a major part of the modern vascular surgeon’s practice. Imaging is typically required to safely and effectively perform both simple and complex endovascular interventions. With an ever-increasing volume of fluoroscopic-guided interventions being performed each year, the minimization of harmful radiation exposure has become of paramount concern for both patients and providers. The purpose of this study was to identify the extent of radiation exposure associated with venography and iliac vein stenting, an intervention utilized in the management of chronic venous insufficiency.

Peripheral arterial occlusive disease operative case volume in the final years of 5+2 and 0+5 vascular training paradigms

Article

Apr 2019

Background: Peripheral arterial occlusive disease constitutes a substantial portion of clinical practice in vascular surgery and, as such, trainees must graduate with proficiency in endovascular and open procedures to become capable vascular surgeons. Case volume for 0+5 integrated vascular surgery residents in the chief and junior years was compared with their 5+2 fellowship counterparts for the treatment of peripheral arterial occlusive disease. Methods: In this retrospective review, operative volume for peripheral arterial occlusive disease cases in both vascular training paradigms was evaluated. "Surgeon chief" cases in the final year of residency training, and "surgeon junior" cases for postgraduate year 4 and below were gathered for the integrated vascular surgery residents group. Annual fellow's case volume was collected using cases logged as "surgeon fellow." Procedures were divided by the following anatomic region and compared: aortoiliac, femoropopliteal, and infrapopliteal. Student's t tests were used to assess these differences. Results: An aggregate of 887 residents and fellows from 137 programs were identified. Vascular surgery fellows consistently performed 1.7-fold (P < .001) and 1.6-fold (P < .001) more total peripheral cases than their integrated vascular surgery residents chief and junior counterparts, respectively. They also performed 1.8-fold (P = .002) and 1.5-fold (P = .004) more peripheral endovascular cases than their 0+5 chief and junior counterparts respectively. With respect to endovascular treatment of peripheral arterial occlusive disease by subgroup, we found the overall volume of aortoiliac and femoropopliteal increased, whereas infrapopliteal case volume decreased. Vascular surgery fellows were performing many more of these cases per year than the integrated vascular surgery residents chiefs and junior residents. When looking at 3 index open procedures, aortobifemoral bypass, femoropopliteal bypass with vein, and infrapopliteal bypass with vein in the academic year 2017-2018, the vascular surgery fellow trainees performed more cases than the integrated vascular surgery residents chief and junior residents. Conclusion: Earlier studies have compared the operative volume of vascular surgery fellows and integrated vascular surgery residents in their entire tenure of training. Our study specifically evaluated the years of training that confer the greatest level of autonomy. Vascular surgery fellows are performing more endovascular and open cases than their 0+5 counterparts for peripheral arterial occlusive disease during the final phase of training. These findings suggest that current suspected equipoise of vascular surgery training paradigms may not reflect what is occurring in practice and therefore warrants further investigation.

A Binational Need Assessment to Define the Level of Endovascular Expertise Required by Vascular Surgical Trainees

Article

Jul 2019

Background: There has been a shift toward competency-based surgical education programs to improve trainee performance and achieve better patient outcomes. Endovascular procedures comprise a significant volume of vascular surgery, but the current methods for assessing the endovascular competence of vascular trainees in Australia and New Zealand are suboptimal. The objective of this study was to perform a need assessment to define the scope of endovascular expertise required by vascular surgical trainees to later aid in the development of novel surgical training assessment tools. Methods: A modified Delphi method was used to achieve expert consensus. Fifty-three key stakeholders in vascular surgical education and training (SET) in Australia and New Zealand were invited to take part in the 2-stage survey. Experts were asked which procedures they considered to be requisite for vascular surgery trainees and at which SET level competence should be achieved. The results were reiterated to the expert panel in the second stage, and consensus considered achieved if over 75% of experts were in agreement. Results: In the first stage 25 experts reached consensus that competence in 18 of the 26 procedures should be requisite for SET trainees. Twenty-two experts responded to the second stage and consensus was achieved for 12 out of 14 of the procedural items with mean percentage of experts in agreement being 90%. Conclusions: A need assessment using a modified Delphi method has achieved consensus among experts in vascular surgery regarding the endovascular procedures considered to be requisite for vascular surgery trainees in Australia and New Zealand.

Simulation in Vascular Surgery

Chapter

Jan 2019

Increasingly stringent restrictions of duty hours for residents have led to decreasing experience with complex open vascular interventions; simulation is a promising avenue for both skills training and skill assessment. Various different forms of simulation are now available including benchtop models, animal models, cadavers, and high-fidelity simulators. This chapter reviews the available modalities, the evidence supporting their use in both open and endovascular surgical training, components of a successful simulation training program, and the application of simulation training in the context of two academic centers – LSU and OHSU.

Comparative Outcomes of Open, Hybrid, and Fenestrated Branched Endovascular Repair of Extent II and III Thoracoabdominal Aortic Aneurysms

Article

Jan 2019
J VASC SURG

High-Resolution Scanning Fiber Angioscopy as an Adjuvant to Fluoroscopy During Endovascular Interventions

Article

Aug 2018

Purpose: To demonstrate the feasibility and potential utility of high-resolution angioscopy during common endovascular interventions. Methods: A 3.7-F scanning fiber angioscope was used in 6 Yorkshire pigs to image branch vessel selection, subintimal dissection, wire snaring, and stent placement. The angioscope was introduced in a coaxial fashion within a standard 6-F guide catheter. A clear field of view was provided using continuous heparinized saline flush through the outer guide catheter. The flush flow rate was manually adjusted to provide clear imaging depending on the diameter of the vessel and local blood flow conditions. Results: The scanning fiber angioscope was compatible with off-the-shelf catheters and devices commonly used in peripheral and aortic interventions. Video-rate, high-resolution images were obtained during all the interventions tested and provided information that was complementary to simultaneously acquired fluoroscopy. The scanning fiber angioscope was able to detect subintimal dissection and branch vessel stent coverage with higher resolution than fluoroscopy alone. Conclusion: Endoluminal imaging with the scanning fiber angioscope is feasible with current endovascular devices and provides additional relevant information that cannot be assessed fluoroscopically. The scanning fiber angioscope represents a novel optical platform on which new endovascular techniques may be developed that will minimize radiation and contrast doses for patients.

Declining Resident Experience in Open Vascular Operations Threatens the Status of Vascular Surgery as an Essential Content Area of General Surgery Training

Article

Jul 2018

Objective: The objective of this study was to document trends in the performance of open arterial vascular surgery procedures (OAVP) by general surgery residents (GSR). Background: The ACGME Review Committee for Surgery considers vascular surgery (VS) to be an "essential content area." However, the operative experience in VS for GSRs is threatened by 1) increasing numbers of GSRs, 2) increasing numbers of VS trainees, and 3) the proliferation of endovascular surgery. Methods: The last 16 years of ACGME national reports of case logs for completing GSRs were reviewed. Total vascular operations and OAVPs performed as "surgeon" were recorded and analyzed. The number of individuals completing ACGME programs in general and vascular surgery annually over that period were also recorded and analyzed. To better understand long-term and more recent trends, trends were analyzed for the 15-year period spanned by the 16 years of data as well as the most recent 10- and 5-year periods. Results: The number of individuals completing both general and vascular surgery programs increased significantly. Over 15 years, the total vascular operations performed by GSRs significantly declined as did the total OAVPs and the OAVPs in 7 of 9 categories. In just the last 5 years, significant declines occurred in 5 OAVP categories. Conclusions: Operative experience in OAVPs for GSRs has significantly declined. Because fundamental VS skills are necessary for operative general surgery, VS should remain an essential content area. However, programs cannot solely depend on operative experience to teach fundamental VS skills.

Has Anatomic Complexity of Abdominal Aortic Aneurysms Undergoing Open Surgical Repair Changed after the Introduction of Endovascular Treatment? Systematic Review and Meta-analysis of Comparative Studies

Article

Jun 2018

Purpose: At a time when endovascular aneurysm repair (EVAR) is increasingly used to treat abdominal aortic aneurysms (AAAs), lesions undergoing open surgical repair (OSR) may present significant differences compared to those treated before wide EVAR availability. We aim to record discrepancies in AAAs surgically treated before and after the introduction of EVAR. Methods: We conducted a systematic review of the literature and meta-analysis of comparative studies. The MEDLINE, CENTRAL, and OpenGray databases were searched up to October 2017. Outcome measures were anatomic complexity, procedural details and post-operative outcomes. The random effects model was used to calculate combined overall effect sizes. Data are presented as odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CI). Results: Five observational studies were included. These involved 1091 patients treated in the Pre-EVAR era and 802 in the Post-EVAR era. In general, patients undergoing OSR during the first period presented more comorbidities. Increased anatomic complexity was found among patients in the second group as demonstrated by the increased rate of supra-renal clamping (10.5% vs 22.3%, OR 0.34, 95%CI 0.24-0.50), left renal vein division (10.3%vs 18.8%, OR 0.46, 95%CI 0.25-0.88), iliac aneurysm (28.3% vs 44.9%, OR 0.48, 95%CI 0.37-0.64) and iliac occlusive disease (13.1% vs 20.2%, OR 0.59, 95%CI 0.39-0.88). Intra-operative use of blood products was greater during the latter period but this difference did not reach statistical significance. Procedural duration was slightly increased in the same group. Morbidity and mortality were similar among groups. Conclusion: After the wide availability of endolumunal grafting, more compromised patients tend to be managed with EVAR, leaving a fitter patient population to undergo OSR. At the same time, anatomic complexity of AAAs undergoing open surgery has considerably increased requiring advanced proximal aortic surgical expertise to deal with these complex aortic pathologies Overall, morbidity and mortality remained unchanged, possibly due to the counterbalancing effects of these factors.

Evaluating the Construct Validity of a Pulsatile Fresh Frozen Human Cadaver Circulation Model for Endovascular Training

Article

May 2018

Objectives: We recently described a pulsatile fresh frozen human cadaver model (PHCM) for training endovascular practitioners. This current study aims to assess the construct validity of PHCM; its ability to differentiate between participants of varying expertise. Methods: 23 participants with varying endovascular experience (12 novice, 4 intermediate, 7 expert) were recruited. Each attempted catheterisation of the left renal artery on PHCM within 10 minutes under exam conditions. Performances were video recorded and scored using a validated scoring tool by two independent endovascular experts, blinded to performer status. Each participant was given a task specific checklist score (TSC), global rating score (GRS), and overall procedure score (OPS). Finally, examiners were asked whether they would be happy to supervise the participant in theatre, with each participant graded as "fail", "borderline" or "pass". Results: All expert and intermediate participants completed the index procedure within the allotted 10 minutes, however only one of the 12 novice participants achieved this (p<0.0005). Endovascular novices had significantly lower TSC, GRS and OPS than both intermediate participants and endovascular experts. There were no significant differences in TSC, GRS or OPS between intermediate participants and endovascular experts. When participants were graded as "fail", "borderline" or "pass" there were significant differences between groups (p=0.001). All of the intermediate and expert participants received a pass. Out of the 12 novice participants, 2 received a pass, 6 received a borderline and 4 were failed. Conclusion: The PHCM demonstrates construct validity. Further work is required to determine its educational impact in endovascular training.

National trends in open surgical, endovascular, and branched-fenestrated endovascular aortic aneurysm repair in Medicare patients

Article

Dec 2017
J VASC SURG

Background: Open repair effectively prevents rupture for patients with abdominal aortic aneurysm (AAA) and is commonly studied as a metric reflecting hospital and surgeon expertise in cardiovascular care. However, given recent advances in endovascular aneurysm repair (EVAR), such as branched-fenestrated EVAR, it is unknown how commonly open surgical repair is still used in everyday practice. Methods: We analyzed trends in open AAA repair, EVAR, and branched-fenestrated EVAR for AAA in Medicare beneficiaries from 2003 to 2013. We used Medicare Part B claims to ascertain counts of these repair types annually during the study period. We assessed regional and national trends in characteristics of the patients and procedure volume. Results: Between 2003 and 2013, the total number of AAA repairs performed in fee-for-service Medicare patients declined by 26% from 31,582 to 23,421 (P < .001), after a peak number of 32,540 was performed in 2005 (28% decline since 2005). The number of open AAA repairs steadily declined by a total of 76%, from 20,533 in 2003 to 4916 in 2013 (P < .001). Whereas the number of EVARs increased from 11,049 in 2003 to 19,247 in 2011 (P < .001), it has since declined a total of 15% to only 16,362 repairs in 2013 (P < .001). After its introduction in 2011, the number of branched-fenestrated EVAR cases continuously rose from 335 procedures in 2011 to 2143 procedures in 2013 (P < .001). By 2013, virtually all hospital referral regions in the United States had rates of open AAA repair that would have been in the lowest quintile of volume in 2003. Conclusions: The number of open AAA repairs fell by nearly 80% during the last decade, whereas traditional EVAR declined slightly and branched-fenestrated EVAR rapidly disseminated into national practice. These results suggest that open AAA repair is now performed too infrequently to be used as a metric in the assessment of hospital and surgeon quality in cardiovascular care. Furthermore, surgical training paradigms will need to reflect the changing dynamics necessary to ensure that surgeons and interventionists can safely perform these high-risk surgical procedures.

A Pulsatile Fresh Frozen Human Cadaver Circulation Model for Endovascular Training; A Trial of Face Validity

Article

Sep 2017

Objectives: Determine the face validity of a pulsatile fresh frozen human cadaver model (PHCM) for training endovascular practitioners. Methods: 12 endovascular clinicians performed the same two procedures (catheterisation of the left renal artery and left subclavian artery) on PHCM, and Simbionix angiomentor virtual reality simulator (SVR). They were randomised to begin on either the PHCM or SVR. A pre-trial questionnaire determined participants' endovascular experience. After training, participants rated statements relating to their experience on a numerical scale from 1 to 5, with 1 representing the strongest agreement with the statement. Results: When participants were asked to compare the realism of training modalities with live patients, PHCM scored significantly higher than SVR on statements regarding "realism of vascular access" (p=0.002) "guide-wire manipulation" (p=0.001) and "vessel catheterisation" (p=0.004). Candidates again favoured PHCM as "a valuable learning exercise" (p=0.016) and strongly favoured PHCM as a "useful training model" compared to SVR (p=0.004). Conclusions: This is the first published trial in world literature to assess the validity of a PHCM for training endovascular practitioners. The PHCM demonstrates good face validity when compared to both real patients and the SVR model, and holds exciting potential.

Evaluating the venous experience in vascular surgery training

Article

May 2017

Objective There is an increasing recognition and treatment of venous disease in the United States; results of the Society for Vascular Surgery 2014 membership survey showed that venous disease represents 18.8% of a vascular surgeon's current practice. Despite this, there are no operative objectives or case requirements specific to venous disease for vascular surgery trainees. The objective of this study was to examine the current venous surgical training experience of graduating vascular surgery trainees. Methods Following Institutional Review Board waiver and Association of Program Directors in Vascular Surgery and Residency Review Committee approval, results of the 2014 Association of Program Directors in Vascular Surgery Educational Needs Assessment Survey pertinent to venous training as well as the Vascular Surgery In-Training Examination (VSITE) venous scores were summarized. Using the Residency Review Committee case log database, venous case logs of 0/5 resident and 5/2 fellow vascular surgery graduates from 2012 to 2015 differentiated by Current Procedural Technology code were summarized. Venous case logs of 0/5 vascular surgery residents were compared with those of 5/2 fellows using a Student t-test, with results considered statistically significant at P < .05. Results Of the recent vascular surgery graduates, 15% thought they encountered training gaps in venous procedures; 54% thought this was due to a gap in vascular surgery training, whereas 43% thought this was due to evolution in technology. Venous VSITE scores were similar between 0/5 residents and 5/2 fellows (69% vs 76% correct answers, respectively), as were overall VSITE scores (70% vs 74% correct answers, respectively). The 0/5 residents completed between 11 and 264 cases and 5/2 fellows completed between 1 and 188 cases during their training. The 0/5 residents' venous cases were 8.1% of overall cases and the 5/2 fellows' cases were 4.3% of overall cases during their training. Conclusions Current vascular surgery trainee experience is highly variable and not consistent with future vascular surgery clinical practice. Vascular surgery trainee fund of knowledge does not appear affected. Program directors should consider developing a better-defined venous curriculum that includes venous case minimums in defined categories.

Trends in Resident Operative Teaching Opportunities for Treatment of Intracranial Aneurysms

Article

Apr 2017

Objective: The International Subarachnoid Aneurysm Trial heralded a paradigm shift in the treatment of intracranial aneurysms. During this same time frame neurosurgical training programs increased in size and scope. The present study examines the impact of trends in surgical clipping and the endovascular treatment of intracranial aneurysms, over one decade, and the neurosurgical resident complement on the resident teaching environment using the Nationwide Inpatient Sample (NIS). Methods: The NIS was used to estimate the number of aneurysms treated with either surgical clipping and endovascular methods from 2002 through 2011 at teaching institutions. Teaching opportunities per year per resident or chief resident were calculated as the ratio of number of specified case/average number of neurosurgical trainees by year. Annualized trends were assessed. Results: Over the study period, the percent change in odds of occurrence of a clipped ruptured aneurysm was -15.6% per year (p<0.001) and of ruptured aneurysms undergoing endovascular treatment was +18.7% per year (p<0.001) within teaching institutions. This corresponded to a decline in teaching opportunities for clipped ruptured aneurysms for both residents and chief residents (p<0.001). In contrast, teaching opportunities for endovascular treatment of both ruptured and unruptured aneurysms increased dramatically over the study period. Conclusion: There has been a significant decrease in opportunity for operative exposure to craniotomy for ruptured aneurysm clipping over the past decade, while the volume of endovascular procedures for aneurysms has dramatically increased, highlighting the need for a shift in training strategy for those neurosurgeons graduating from residency desiring to subspecialize in neurovascular neurosurgery.

Operative Autonomy among Senior Surgical Trainees during Infrainguinal Bypass Operations Is Not Associated with Worse Long-term Patient Outcomes

Article

Oct 2016
ANN VASC SURG

Background: In an era of rapidly evolving surgical training, intra-operative teaching remains paramount to the education of surgical trainees. The impact of surgical trainees' level of expertise on outcomes after infra-inguinal bypass surgery, a technically demanding operation, remains unknown. The purpose of this study was to explore the effects of surgical residents' experience on outcomes after infra-inguinal bypass surgery. Methods: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, we identified patients who underwent infra-inguinal bypass from 2005-2012. Patients were stratified according to training level of the most senior operating trainee. Univariate and multivariate analyses, as well as propensity score matched analysis, were performed to compare patient cohorts on operative time, length of hospital stay (LOS), bleeding, early graft failure, unplanned readmission, and 30-day mortality. Results: A total of 19,579 patients were identified, of which 35.6% were female and 64.4% were male; mean age was 67.6 years. A PGY1 was the highest level trainee operating on 2.5%, a PGY2-4 for 26.2%, and a PGY5+ for 37.1%. Attending surgeons operated without trainees on 34.2%. PGY5+s were more likely to operate on patients who were younger, non-white, male, and on dialysis. In multivariable analysis, involvement of any surgical trainee was associated with procedures that took a greater length of time, had a greater odds of blood transfusion, and necessitated a longer hospital LOS relative to procedures performed by an attending surgeon alone. Only bypasses wherein PGY5+s were involved were associated with greater odds of early graft failure, unplanned readmission, and 30-day mortality when compared to procedures done without trainee involvement. After excluding lower extremity bypasses in which an attending surgeon operated without a trainee, propensity score matching analysis showed that patients operated on by PGY5+s had longer operative time (4.11 vs 3.96 hours, P<0.0001) and greater rates of postoperative bleeding (9.77% vs 8.15%, P=0.004) relative to patients operated on by attendings assisted by PGY1-4s, but no statistically significant difference in LOS, early graft failure, unplanned readmission, and perioperative mortality. Conclusion: Operative involvement of senior trainees was associated with worse outcomes during infra-inguinal bypass, potentially reflecting a lesser extent of attending surgeon involvement, but no difference in patient outcomes after bypass procedure.

Integrated fellowship in vascular surgery and intervention radiology - A new paradigm in vascular training

Article

Oct 2002

Objective To evaluate an integrated fellowship in vascular surgery and interventional radiology initiated to train vascular surgeons in endovascular techniques and to train radiology fellows in clinical aspects of vascular diseases. Summary Background Data The rapid evolution of endovascular techniques for the treatment of vascular diseases requires that vascular surgeons develop proficiency in these techniques and that interventional radiologists develop proficiency in the clinical evaluation and management of patients who are best treated with endovascular techniques. In response to this need the authors initiated an integrated fellowship in vascular surgery and interventional radiology and now report their interim results. Methods Since 1999 vascular fellows and radiology fellows performed an identical year-long fellowship in interventional radiology. During the fellowship, vascular surgery and radiology fellows perform both vascular and nonvascular interventional procedures. Both vascular surgery and radiology-based fellows spend one quarter of the year on the vascular service performing endovascular aortic aneurysm repairs and acquiring clinical experience in the vascular surgery inpatient and outpatient services. Vascular surgery fellows then complete an additional year-long fellowship in vascular surgery. To evaluate. the type and number of interventional radiology procedures, the authors analyzed records of cases performed by all interventional radiology and vascular surgery fellows from a prospectively maintained database. The attitudes of vascular surgery and interventional radiology faculty and fellows toward the integrated fellowship were surveyed using a formal questionnaire. Results During the fellowship each fellow performed an average of 1,201 procedures, including 808 vascular procedures (236 diagnostic angiograms, 70 arterial interventions, 59 diagnostic venograms, 475 venous interventions, and 43 hemodialysis graft interventions) and 393 nonvascular procedures. On average fellows performed 20 endovascular aortic aneurysm repairs per year. There was no significant difference between the vascular surgery and radiology fellows in either the spectrum or number of cases performed. Eighty-eight percent (23/26) of the questionnaires were completed and returned. Both interventional radiologists and vascular surgeons strongly supported the integrated fellowship model and favored continuation of the integrated program. Vascular surgery and interventional radiology faculty members wanted additional training in clinical vascular surgery for the radiology-based fellows. With the exception of the radiology fellows there was uniform agreement that vascular surgery fellows benefit from training in nonvascular aspects of interventional radiology. Conclusions Integration of vascular surgery and interventional radiology fellowships is feasible and is mutually beneficial to both disciplines. Furthermore, the integrated fellowship provides exceptional training for vascular surgery and interventional radiology fellows in all catheter-based techniques that far exceeds the minimum requirements for credentialing suggested by various professional societies. There is a clear need for cooperation and active involvement on the parts of the American Board of Radiology and the American Board of Surgery and its Vascular Board to create hybrid training programs that meet mutually agreed-on criteria that document sufficient acquisition of both the cognitive and technical skills required to manage patients undergoing endovascular procedures safely and effectively.

Trends in aortic aneurysm surgical training for general and vascular surgery residents in the era of endovascular abdominal aortic aneurysm repair

Article

Oct 2002
J VASC SURG

Hypothesis. The emergence of endovascular abdominal aortic aneurysm (AAA) repair may negatively impact the open AAA experience of general surgery residents. Methods. Prospectively collected data on general and vascular surgery resident training in AAA repair for a 5-year period (1997 to 2001) at a single institution were retrospectively reviewed. Five general surgery residents and one vascular resident completed training yearly. Institutional volume of open and endovascular repair of AAA was also assessed. Results. The cumulative mean general surgical resident experience with open AAA repair fell significantly over a 5-year period; 9.5 +/- 2.5 cases were performed per general surgical resident finishing in 1997, 7.5 +/- 0.3 cases in 1998, 4.6 +/- 0.4 cases in 1999, 4.0 +/- 1.3 cases in 2000, and 4.2 +/- 1.0 cases in 2001 (P = .03). The vascular resident experience with open AAA repair did not change significantly over the 5 -year period. However, the active development of an endovascular AAA program increased total AAA exposure of the vascular resident from 26 cases in 1997 to a mean of 70 cases in 2000 and 2001. The institution volume of open nonsuprarenal AAA repairs fell 38% during the 5-year period (P = .33) during a period when endovascular AAA repair increased from 9 (1996) to 55 (2000) cases (P <.001). The complexity of open AAA surgery also increased: 23.3% of open cases (7/30) in 2000 were juxta/pararenal versus 2.9% (1/35) in 1996 (P = .05). Conclusion: The introduction of endovascular AAA repair may have negatively impacted general surgical resident training in open AAA repair. The number of open AAA cases declined, and their complexity significantly increased. Many uncomplicated AAAs were managed with endovascular means. At programs with such a paradigm shift in AAA treatment, expectation that general surgery residents gain the proficiency necessary to safely perform AAA repair without additional training may be unrealistic.

To What Extent Has Endovascular Aneurysm Repair Influenced Abdominal Aortic Aneurysm Management in the State of Illinois?

Article

Sep 2005

Transfemoral Intraluminal Graft Implantation for Abdominal Aortic Aneurysms

Article

Dec 1991

This study reports on animal experimentation and initial clinical trials exploring the feasibility of exclusion of an abdominal aortic aneurysm by placement of an intraluminal, stent-anchored, Dacron prosthetic graft using retrograde cannulation of the common femoral artery under local or regional anesthesia. Experiments showed that when a balloon-expandable stent was sutured to the partially overlapping ends of a tubular, knitted Dacron graft, friction seals were created which fixed the ends of the graft to the vessel wall. This excludes the aneurysm from circulation and allows normal flow through the graft lumen. Initial treatment in five patients with serious co-morbidities is described. Each patient had an individually tailored balloon diameter and diameter and length of their Dacron graft. Standard stents were used and the diameter of the stent-graft was determined by sonography, computed tomography, and arteriography. In three of them a cephalic stent was used without a distal stent. In two other patients both ends of the Dacron tubular stent were attached to stents using a one-third stent overlap. In these latter two, once the proximal neck of the aneurysm was reached, the sheath was withdrawn and the cephalic balloon inflated with a saline/contrast solution. The catheter was gently removed caudally towards the arterial entry site in the groin to keep tension on the graft, and the second balloon inflated so as to deploy the second stent. Four of the five patients had heparin reversal at the end of the procedure. We are encouraged by this early experience, but believe that further developments and more clinical trials are needed before this technique becomes widely used.

Endovascular interventions training and credentialing for vascular surgeons

Article

Feb 1999
J VASC SURG

This article reviews issues concerning the training and credentialing of vascular surgeons in the use of endovascular techniques in the peripheral vascular system. These guidelines update a prior document that was published in 1993. They have been rewritten to accommodate the rapid evolution that has occurred in the field and to provide the appropriate requirements that a vascular surgeon should fulfill to be competent in the basic skills needed to safely and effectively perform all presently accepted diagnostic and therapeutic endovascular procedures.

Evolution of vascular fellowship training in the new era of endovascular techniques

Article

Mar 2001
J VASC SURG

The endovascular technique has revolutionized the treatment of infrarenal abdominal aortic aneurysm (AAA). At our institution, we examined the impact of an endovascular program on the traditional operative training of the vascular fellows in the treatment of infrarenal AAA. We examined the records of our vascular fellows' experience from July 1995 to May 2000. We introduced the endovascular treatment for infrarenal AAA in 1995. The fellows have performed increasing numbers of endovascular cases each year, with a predicted number of 124 cases for 1999-2000. However, despite an increase in the overall volume of patients with infrarenal AAA (102 cases in 1998-1999 and a predicted 160 cases in 1999-2000), the trainees will experience a reduction in the number of open AAAs from 61 cases in 1998-1999 to a predicted 36 cases in 1999-2000. However, the volume of open suprarenal AAA has also increased from eight cases in 1998 to 1999 to a predicted 24 cases in 1999-2000. With no significant change in the open aortoiliac occlusive cases from previous years, the current fellows will graduate with a similar volume of open aortic procedures as their predecessors. With the recent advances in endovascular technology, our traditional operative approach to the treatment of AAA disease may be lacking in the training of future vascular surgeons. At our institution, although fewer open infrarenal AAA cases were performed, the trainees have maintained the open aortic experience by performing an increased volume of suprarenal AAAs. We have to critically reevaluate and redefine what constitutes adequate vascular fellow experience in the surgical treatment of abdominal aortic aneurysms.

Volume Standards for High-Risk Surgical Procedures: Potential Benefits of the Leapfrog Initiative

Article

Oct 2001
SURGERY

As part of a broader effort aimed at improving hospital safety, a large coalition of employers, the Leapfrog Group, will soon require hospitals caring for their employees to meet volume standards for 5 high-risk surgical procedures. We estimated the potential benefits of full nationwide implementation of these volume standards. METHODS. Using data from Nationwide Inpatient Sample and other sources, we first estimated the total number of each of the 5 procedures-coronary-artery bypass graft, abdominal aortic aneurysm repair, coronary angioplasty, esophagectomy, and carotid endarterectomy-performed each year in hospitals in US metropolitan areas. (Leapfrog exempts hospitals in rural areas to avoid access issues.) We then projected the effectiveness of volume standards (in terms of relative risks of mortality) for each procedure using data from a published structured literature review. With full implementation nationwide, the Leapfrog volume standards would save 2581 lives. Of the procedures, volume standards would save the most lives with coronary-artery bypass graft (1486), followed by abdominal aortic-aneurysm repair (464), coronary angioplasty (345), esophagectomy (168), and carotid endarterectomy (118). In our estimates of the number of lives saved, we considered assumptions about how many patients would be affected and the effectiveness of volume standards (ie, strength of underlying volume-outcome relationships with each procedure). If the Leapfrog volume standards are successfully implemented, employers and health-care purchasers could prevent many surgical deaths by requiring hospital volume standards for high-risk procedures.

Impact of endovascular repair on open aortic aneurysm surgical training

Article

Nov 2001
J VASC SURG

The purpose of this study was to determine the impact of an endovascular stent-graft program on vascular training in open aortic aneurysm surgery. The institutional and vascular surgery fellow experience in aortic aneurysm repair during a 6-year period was reviewed. The 3-year period before introduction of endovascular repair was compared with the 3-year period after introduction of endovascular repair. All patients undergoing abdominal aortic aneurysm (AAA) or thoracoabdominal aortic aneurysm repairs were entered prospectively into a vascular registry and retrospectively analyzed to evaluate the changing patterns in aortic aneurysm treatment and surgical training. Between July 1994 and June 2000, a total of 588 patients with AAA or thoracoabdominal aneurysms were treated at Stanford University Medical Center. There were 296 (50%) open infrarenal AAA repairs, 87 (15%) suprarenal AAA repairs, 47 (8%) thoracoabdominal aneurysm repairs, and 153 (26%) endovascular stent-grafts. The total number of aneurysms repaired per year by vascular fellows before the endovascular program was 71.3 +/- 4.9 (range, 68-77) and increased to 124.7 +/- 35.6 (range, 91-162) after introduction of endovascular repair (P <.05). This increase was primarily caused by the addition of endovascular stent-graft repairs by vascular fellows (51.0 +/- 29.0/year [range, 23-81]). There was no change in the number of open infrarenal aortic aneurysm repairs per year, 53.0 +/- 6.6 (range, 48-56) before endovascular repair versus 47.0 +/- 1.7 (range, 46-49) after (P = not significant). There was a significant increase in the number of suprarenal AAA repairs per year by vascular fellows, 10.0 +/- 1.0 (range, 9-11) before endovascular repair compared with 19.0 +/- 6.5 (range, 13-26) after (P <.05). There was no change in the number of thoracoabdominal aneurysm repairs per year between the two groups, 8.0 +/- 3.0 (range, 4-11) before endovascular repair compared with 7.6 +/- 2.3 (range, 5-9) after. Introduction of an endovascular aneurysm stent-graft program significantly increased the total number of aneurysms treated. Although the number of open aneurysm repairs has remained the same, the complexity of the open aneurysm experience has increased significantly for vascular fellows in training.

Trends in aortic aneurysm surgical training for general and vascular surgery residents in the era of endovascular abdominal aortic aneurysm repair

Article

Oct 2002
J VASC SURG

The emergence of endovascular abdominal aortic aneurysm (AAA) repair may negatively impact the open AAA experience of general surgery residents. Prospectively collected data on general and vascular surgery resident training in AAA repair for a 5-year period (1997 to 2001) at a single institution were retrospectively reviewed. Five general surgery residents and one vascular resident completed training yearly. Institutional volume of open and endovascular repair of AAA was also assessed. The cumulative mean general surgical resident experience with open AAA repair fell significantly over a 5-year period; 9.5 +/- 2.5 cases were performed per general surgical resident finishing in 1997, 7.5 +/- 0.3 cases in 1998, 4.6 +/- 0.4 cases in 1999, 4.0 +/- 1.3 cases in 2000, and 4.2 +/- 1.0 cases in 2001 (P =.03). The vascular resident experience with open AAA repair did not change significantly over the 5-year period. However, the active development of an endovascular AAA program increased total AAA exposure of the vascular resident from 26 cases in 1997 to a mean of 70 cases in 2000 and 2001. The institution volume of open nonsuprarenal AAA repairs fell 38% during the 5-year period (P =.33) during a period when endovascular AAA repair increased from 9 (1996) to 55 (2000) cases (P <.001). The complexity of open AAA surgery also increased: 23.3% of open cases (7/30) in 2000 were juxta/pararenal versus 2.9% (1/35) in 1996 (P =.05). The introduction of endovascular AAA repair may have negatively impacted general surgical resident training in open AAA repair. The number of open AAA cases declined, and their complexity significantly increased. Many uncomplicated AAAs were managed with endovascular means. At programs with such a paradigm shift in AAA treatment, expectation that general surgery residents gain the proficiency necessary to safely perform AAA repair without additional training may be unrealistic.

Integrated Fellowship in Vascular Surgery and Intervention Radiology

Article

Nov 2002

To evaluate an integrated fellowship in vascular surgery and interventional radiology initiated to train vascular surgeons in endovascular techniques and to train radiology fellows in clinical aspects of vascular diseases. The rapid evolution of endovascular techniques for the treatment of vascular diseases requires that vascular surgeons develop proficiency in these techniques and that interventional radiologists develop proficiency in the clinical evaluation and management of patients who are best treated with endovascular techniques. In response to this need the authors initiated an integrated fellowship in vascular surgery and interventional radiology and now report their interim results. Since 1999 vascular fellows and radiology fellows performed an identical year-long fellowship in interventional radiology. During the fellowship, vascular surgery and radiology fellows perform both vascular and nonvascular interventional procedures. Both vascular surgery and radiology-based fellows spend one quarter of the year on the vascular service performing endovascular aortic aneurysm repairs and acquiring clinical experience in the vascular surgery inpatient and outpatient services. Vascular surgery fellows then complete an additional year-long fellowship in vascular surgery. To evaluate the type and number of interventional radiology procedures, the authors analyzed records of cases performed by all interventional radiology and vascular surgery fellows from a prospectively maintained database. The attitudes of vascular surgery and interventional radiology faculty and fellows toward the integrated fellowship were surveyed using a formal questionnaire. During the fellowship each fellow performed an average of 1,201 procedures, including 808 vascular procedures (236 diagnostic angiograms, 70 arterial interventions, 59 diagnostic venograms, 475 venous interventions, and 43 hemodialysis graft interventions) and 393 nonvascular procedures. On average fellows performed 20 endovascular aortic aneurysm repairs per year. There was no significant difference between the vascular surgery and radiology fellows in either the spectrum or number of cases performed. Eighty-eight percent (23/26) of the questionnaires were completed and returned. Both interventional radiologists and vascular surgeons strongly supported the integrated fellowship model and favored continuation of the integrated program. Vascular surgery and interventional radiology faculty members wanted additional training in clinical vascular surgery for the radiology-based fellows. With the exception of the radiology fellows there was uniform agreement that vascular surgery fellows benefit from training in nonvascular aspects of interventional radiology. Integration of vascular surgery and interventional radiology fellowships is feasible and is mutually beneficial to both disciplines. Furthermore, the integrated fellowship provides exceptional training for vascular surgery and interventional radiology fellows in all catheter-based techniques that far exceeds the minimum requirements for credentialing suggested by various professional societies. There is a clear need for cooperation and active involvement on the parts of the American Board of Radiology and the American Board of Surgery and its Vascular Board to create hybrid training programs that meet mutually agreed-on criteria that document sufficient acquisition of both the cognitive and technical skills required to manage patients undergoing endovascular procedures safely and effectively.

Impact of an endovascular program on the operative experience of abdominal aortic aneurysm in vascular fellowship and general surgery residency

Article

Aug 2003
AM J SURG

This study was performed to determine the impact of an endovascular program (EVP) on open and endovascular abdominal aortic aneurysm (AAA) operations in a residency training institution. Over an 8-year period ending in September 2001, hospital records of all patients undergoing open or endovascular AAA repair were retrospectively reviewed. Data were analyzed to determine the changing patterns of case volume, type of operative repair, and complexity of open repair with regards to the training of both general surgical chief residents and vascular fellows. A total of 849 AAA operations were performed during the study period. The initiation of the EVP in 1997 resulted in a steady increase in the total annual AAA cases (P < 0.05), due in part to an increase in endovascular AAA operations despite a decrease in the annual open AAA volume. EVP had a positive impact on the overall operative experience of vascular fellows owing to the large increase in their endovascular AAA experience (annual mean pre-EVP 3 +/- 0.8 versus post-EVP 47 +/- 9.6, P < 0.01). A significant reduction occurred in the vascular fellows' open AAA experience (annual mean pre-EVP 40 +/- 12.7 versus post-EVP 19 +/- 9.4, P < 0.05). EVP did not affect the endovascular AAA experience of general surgery chief residents (annual mean pre-EVP 1 +/- 0.8 versus post-EVP 3 +/- 1.5, not significant). A significant reduction occurred in chief residents' open AAA experience (annual mean pre-EVP 39 +/- 9.7 versus post-EVP 18 +/- 7.4, P < 0.05). EVP did not affect the operative experience of complex open AAA operations in either vascular fellows or general surgery residents. An endovascular program has a positive impact on the aortic aneurysm practice in an academic institution, as evidenced by the significant increase in annual endovascular AAA cases despite a decrease in open AAA operations. Although vascular fellows continued to maintain sufficient experience in both open and endovascular AAA operations, general surgery chief residents suffered a significant decrease in their open AAA experience. Further evaluation of the residency system is warranted to better optimize the training paradigm of both vascular fellowship and general surgery residency.

Influence of endovascular training on fellowship and general surgical training

Article

Nov 2003

As endovascular procedures develop, there is a risk of diminished training of residents and fellows in traditional open surgery. We evaluated the effect of our endovascular program, initiated in 1999 coincident with the Federal Drug Administration's approval of endoluminal vascular aortic grafts, on the number of endovascular procedures and open abdominal aortic aneurysm (AAA) repairs performed in comparison to national trends. The experience of vascular fellows and chief residents at completion of training (1996-2002) was reviewed and compared with the national mean case numbers before and after initiation of our endovascular program. The development of an endovascular program increased the total number of aneurysms repaired at the Robert Wood Johnson (RWJ) Medical School from 49 +/- 15 to 92 +/- 8 per year (P < 0.01). The number of vascular operations performed by the RWJ fellow increased from 320 +/- 48 to 553 +/- 155 per year (P < 0.05). The number of operations performed nationally by vascular fellows also increased during the same period, but did not reach statistical significance. There was no change in the number of open AAA repairs performed by the RWJ fellow or nationally. There was also no change in the average number of vascular operations completed by RWJ chief residents or nationally (160 +/- 17 versus 157 +/- 1 and 192 +/- 4 versus 189 +/- 4, respectively; P > 0.05). However, the average number of open AAA repairs performed nationally by general surgical chief residents decreased from 10 +/- 0.3 to 9 +/- 0.4 (P < 0.05). An endovascular program can increase the total number of AAA repairs performed without influencing the total number of vascular operations performed by general surgical chief residents. There was a decrease in open AAA repairs performed nationally by general surgical chief residents. The advancement of endovascular therapies may decrease the number of open procedures available for trainees in both general and vascular surgery. Perhaps those that will specialize in the field of vascular surgery should have the benefit of those open procedures.

Vascular surgery training in the United States, 1994 to 2003

Article

Nov 2004
J VASC SURG

Jack Cronenwett

Objective: The purpose of this study was to analyze the use of operative training resources for vascular surgery residents (VSRs) and general surgery residents (GSRs) over the past 10 years in the United States, to address questions concerning adequate endovascular versus open surgical training and the potential to expand the number of VSRs to meet future workforce needs. Methods: National operative data from the Residency Review Committee for Surgery (RRC) were analyzed for all vascular surgery (VS) and general surgery (GS) training programs from 1994 to 2003. GSR experience in programs with and without associated VS programs was also compared. Results: Mean total VS volume per VSR increased from 220 operations in 1994 to 368 in 2003, owing to the addition of 140 endovascular procedures by 2003. GSR volume was more stable, with 117 mean total VS operations in 1994 and 122 in 2003. This volume was distributed as approximately 50% major open VS operations for both VSR and GSR. In addition, 39% of VSR experience was endovascular, whereas 32% of GSR experience was vascular access. The average VSR performed 2.7 times more major open VS operations than each GSR, but because of the 10-fold greater number of GSRs, VSRs performed only 20% of the total major operations available for VS training. Selective procedures, such as renal revascularization and open infrarenal abdominal aortic aneurysm repair decreased over time, while endovascular abdominal aortic aneurysm repair increased dramatically, accounting for 46% of aortic aneurysm repairs per VSR in 2003. The mean volume of total interventional procedures per VSR in 2003 was 152 diagnostic and 213 therapeutic. GSRs in programs with and without an associated VS program had very similar operative volumes. Conclusions: Interventional procedures have increased VSR operative volume by 50% in recent years, with only a 12% decrease in major open operations. Nearly all VSRs currently meet RRC minimum requirements for open and endovascular procedures. Mean GSR operative volume has been stable, and far exceeds RRC minimum requirements. Based on the number of major open vascular operations available for training in 2003, the current number of VSR positions could be increased by 50% if GSR operative volume was decreased by 15%. However, increased interventional volume would also be required, for which there is competition with other specialties.

To what extent has endovascular aneurysm repair influenced abdominal aortic aneurysm management in the state of Illinois?

Article

Apr 2005
J VASC SURG

Purpose: This study was performed using population-based data to determine the changing trends in the techniques for abdominal aortic aneurysm (AAA) repair in the state of Illinois during the past 9 years and to examine the extent to which endovascular aneurysm repair (EVAR) has influenced overall AAA management. Methods: All records of patients who underwent AAA repair (1995 to 2003 inclusive) were retrieved from the Illinois Hospital Association COMPdata database. The outcome as determined by in-hospital mortality was analyzed according to intervention type (open vs EVAR) and indication (elective repair vs ruptured AAA). Data were stratified by age, gender, and hospital type (university vs community setting) and then analyzed using both univariate (chi 2 , t tests) and multivariate (stepwise logistic regression) techniques. Results: Between 1995 and 2003, 14,517 patients underwent AAA repair (85% for elective and 15% for ruptured AAA). The average age was 71.4 +/- 7.9 years, and 76% were men. For elective cases, open repair was performed in 86% and EVAR in 14%; and for ruptured cases, open repair in 97% and EVAR in 3%. Elective EVAR was associated with lower in-hospital mortality compared with open repair regardless of age. No differences were observed with age after either type of repair for a ruptured aneurysm. Men had a lower in-hospital mortality compared with women for open repair of both elective and ruptured aneurysms. For EVAR, the mortality of an elective repair was lower in men, but there was no difference after a ruptured AAA. In men, the difference in mortality between elective open repair and EVAR was significant; the type of institution did not influence outcome. Patients >80 years of age had a higher mortality after open repair for both elective and ruptured AAA and after EVAR of a ruptured AAA. The average length of stay was 9.9 days for open elective repair, 13.1 days after open repair of a ruptured AAA, and 3.6 days for EVAR. The independent predictors of higher in-hospital mortality were female gender, age >80 years, diagnosis (ruptured vs open), and procedure (open vs EVAR). The year of the procedure and type of hospital (university vs community) were not predictive of outcome. Conclusions: EVAR has had a significant impact on AAA management in Illinois over a relatively short time period. In this population-based review, EVAR was associated with a significantly decreased in-hospital mortality and length of stay. Octogenarians had higher mortality after both types of repair, with the exception of elective EVAR.

Trends, complications, and mortality in peripheral vascular surgery

Article

Feb 2006
J VASC SURG

Background: The recent evolution in treatments for peripheral vascular disease has dated available mortality statistics for vascular intervention. Moreover, many of our current mortality statistics are derived from single-institution studies that are often not reflective of outcomes in general practice. To provide current and generalizable data regarding mortality and trends for peripheral vascular interventions, we examined two national data sets (Nationwide Inpatient Sample, 1998-2003, and National Hospital Discharge Survey, 1979-2003) and four states (New York, California, Florida, and New Jersey, 1998-2003). Methods: Four procedures--abdominal aortic aneurysm repair (nonruptured), lower extremity revascularization, amputation, and carotid revascularization--were selected by cross-referencing International Classification of Diseases, 9th Revision, diagnostic and procedural codes. For significance, the t test was used for continuous variables, the chi2 test was used for dichotomous variables, and the chi2 test was used for mortality trends. Results: From 1998 to 2003, there was a progressive decrease in the national per capita rate of amputations: 13.2% overall and 21.2% for major amputations (P < .0001). Nationally and regionally, mortality has only slightly declined. For lower extremity revascularization, after a sharp increase during the 1980s to 100,000 open procedures, the volume remained constant for 10 years and began to decline in 1998, reaching 70,000 cases in 2003. In contrast, since 1996, endovascular interventions have increased 40%. Mortality during the 1998 to 2003 period remained virtually stable at 1.5% to 2% for endovascular procedures and 3% to 4% for open procedures. The overall volume of abdominal aortic aneurysm repair has not changed substantially for the past 6 years; however, endovascular repair is now used for nearly half the cases (46.5% regional and 43.0% national). Mortality for open repair has not changed, remaining at approximately 5%, whereas for endovascular repair, mortality has declined from 2.6% in 2000 to less than 1.5% in 2003. After the rapid increase in open carotid revascularization in the early 1990s, the total volume has declined 5% nationally from 1998 to 2003. Regional data demonstrated an overall 12% reduction in carotid revascularization volume since 1998; this reduction was due to a 16% decline in open carotid revascularization. During this same period, the use of angioplasty-stent carotid revascularization doubled. Mortality for the open procedures is 0.5% and is significantly higher (2%-3%) for endovascular carotid revascularization. Stroke rates for endovascular carotid revascularization are also higher: 2.13% vs 1.28% for open procedures (P < .0001). Conclusions: Dramatic shifts in the management of peripheral vascular disease have occurred together with an overall decline in mortality. There seems to be a significant mortality advantage for endovascular as compared with traditional surgery except for carotid endarterectomy. The increasing safety of vascular interventions should be considered when deciding which patients to treat but with the caveat that endovascular interventions are not always safer than open repair.

Training with simulation improves residents endovascular procedure skills

Article

Feb 2007
J VASC SURG

Endovascular procedure simulators are now commercially available and in use for physician training. The purpose of this study was to evaluate the role of simulation-based training in vascular surgery residencies. Residents from vascular surgery programs in a five-state area were invited to participate in a series of 2-day endovascular training programs that used a high-fidelity endovascular procedure simulator (SimSuite; Medical Simulation Corporation, Denver, Colo), didactic instruction, computer-based training, and tabletop procedure demonstrations. The curriculum covered arteriography and intervention for treatment of aortoiliac, renal, and carotid artery disease. Nine residents participated, with one to three per training session. Each completed an average of 9.5 simulated endovascular cases. Performance on a standardized TransAtlantic Inter-Society Consensus B iliac angioplasty/stenting case was used to assess endovascular skills and knowledge at the beginning of the training program, and this was repeated at the completion of the training. Performance metrics were measured by the simulator, faculty observed trainees' performance of simulated cases, and trainees provided their evaluations of the usefulness of the simulation experiences. Endovascular procedural skills on the standardized iliac intervention case improved after completion of the training program. Compared with performance early on day 1, performance improved (P < or = .05; paired t test): total procedure time decreased 54%, volume of contrast decreased 44%, and fluoroscopy time decreased 48% (mean change from baseline). Selection of angioplasty balloon catheters and stents was improved, and the average number of catheters used and stents deployed decreased, although this did not reach statistical significance. Faculty observation allowed identification of shortcomings of knowledge and skills, including common problems with selection of catheter, balloon, and stent sizes; correct positioning of the sheath; and intraprocedural monitoring. Postcourse evaluations indicated support for the use of simulation in vascular surgery residents' endovascular training. Training with a simulator, incorporated into an individual or small group learning session, offers a means to learn and realistically practice endovascular procedures without direct risk to patients, with measurable improvements in key performance metrics. How simulation training affects subsequent clinical performance has yet to be established.

Provider volume and outcomes for abdominal aortic aneurysm repair, carotid endarterectomy, and lower extremity revascularization procedures

Article

Apr 2007
J VASC SURG

Intuitively, vascular procedures performed by high-volume vascular subspecialists working at high-volume institutions should be associated with improved patient outcome. Although a large number of studies assess the relationship between volume and outcome, a single contemporary compilation of such studies is lacking. A review of the English language literature was performed incorporating searches of the Medline, EMBASE, and Cochrane collaboration databases for abdominal aortic aneurysm repair (elective and emergent), carotid endarterectomy, and arterial lower limb procedures for any volume outcome relationship. Studies were included if they involved a patient cohort from 1980 onwards, were community or population based, and assessed health outcomes (mortality and morbidity) as a dependent variable and volume as an independent variable. We identified 74 relevant studies, and 54 were included. All showed either an inverse relationship of variable magnitude between provider volume and mortality, or no volume-outcome effect. The reduction in the risk-adjusted mortality rate (RAMR) for high-volume providers was 3% to 11% for elective abdominal aortic aneurysm (AAA) repair, 2.5 to 5% for emergent AAA repair, 0.7% to 4.7% carotid endarterectomy, and 0.3% to 0.9% for lower limb arterial bypass procedures. Subspeciality training also conferred a considerable morbidity and mortality benefit for emergent AAA repair, carotid endarterectomy, and lower limb arterial procedures. High-volume providers have significantly better outcomes for vascular procedures both in the elective and emergent setting. Subspeciality training also has a considerable impact. These data provide further evidence for the specialization of vascular services, whereby vascular procedures should generally be preformed by high-volume, speciality trained providers.

Regionalization of abdominal aortic aneurysm repair: Evidence of a shift to high-volume centers in the endovascular era

Article

Jul 2008
J VASC SURG

Since the early 1990s, many studies have shown lower mortality for abdominal aortic aneurysm (AAA) repair at high-volume centers compared with low-volume centers. The introduction of endovascular AAA repair (EVAR) also has changed the practice of AAA repair. The goal of this study was to determine if regionalization of AAA repair occurred in the United States. Etiologic factors were examined in addition to any reduction in operative mortality rates. Patient discharges of nonruptured AAA repair were identified from the Nationwide Inpatient Sample between 1998 and 2004. Hospitals were stratified by yearly AAA surgical volume of low (< or =17 cases), medium (18 to 50), and high (>50). A total of 46,901 patients underwent AAA repair (72.7% open vs 27.3% endovascular). The percentage of AAA repairs performed at both low-volume (36.2% to 24.3%) and medium-volume (51.0% to 44.8%) centers fell; whereas, the percentage performed at high-volume centers nearly tripled (12.9% vs 30.9%). In 1998 there were 10 high-volume centers; by 2004 this had increased to 26. The number of low-volume centers decreased, from 412 to 328. EVAR was more rapidly adopted by high-volume centers compared with low-volume centers. By 2004, 64.3% of AAA repairs at high-volume centers were done with endovascular techniques compared with 31.8% in low-volume centers. A concurrent reduction occurred in patient mortality, from 4.4% in 1998 to 2.5% in 2004 (P < .0001). Between 1998 and 2004, a trend towards the regionalization of AAA repair to high-volume centers occurred. Nearly one-third of all AAA repairs were performed at high-volume centers. There was a concurrent increase in the frequency of endovascular AAA repair, especially at high-volume centers. During this period of regionalization of AAA repair to high-volume centers, patient mortality after AAA repair decreased by 23%. Thus, the observed regionalization of AAA repair and the reduction in short-term patient mortality for this operation may be explained by increased utilization of endovascular technologies at high-volume centers.

Vascular surgery training trends from 2001-2007: A substantial increase in total procedure volume is driven by escalating endovascular procedure volume and stable open procedure volume

Abstract

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