Vascular surgery training, exposure, and knowledge during general surgery residency: implications for the future

Outcomes of vascular trauma associated with an evolution in the use of endovascular management

BACKGROUND

The availability of endovascular techniques has led to a paradigm shift in the management of vascular injury. While previous reports showed trends towards the increased use of catheter-based techniques, there have been no contemporary studies of practice patterns and how these approaches differ by anatomic distributions of injury. The objective of this study is to provide a temporal assessment of the use of endovascular techniques in the management of torso, junctional (subclavian, axillary, iliac), and extremity injury and to evaluate any association with survival and length of stay.

METHODS

The American Association for the Surgery of Trauma (AAST) Prospective Observational Vascular Injury Treatment registry (PROOVIT) is the only large multicenter database focusing specifically on the management of vascular trauma. Patients in the AAST PROOVIT registry from 2013-2019 with arterial injuries were queried, and radial/ulnar, and tibial artery injuries were excluded. The primary aim was to evaluate the frequency in use of endovascular techniques over time and by body region. A secondary analysis evaluated the trends for junctional injuries and compared the mortality between those treated with open vs. endovascular repair.

RESULTS

Of the 3,249 patients included, 76% were male, and overall treatment type was 42% nonoperative, 44% open, 14% endovascular. Endovascular treatment increased an average of 2% per year from 2013-2019 (Range: 17-35%, R² =.61). The use of endovascular techniques for junctional injuries increased by 5% per year (Range: 33%-63%, R² =.89). Endovascular treatment was more common for thoracic, abdominal, and cerebrovascular injuries, and least likely in upper and lower extremity injuries. Injury severity score (ISS) was higher for patients receiving endovascular repair in every vascular bed except lower extremity. Endovascular repair was associated with significantly lower mortality than open repair for thoracic (5% vs. 46%, p<.001) and abdominal injuries (15% vs 38%, p<.001). For junctional injuries, endovascular repair was associated with a non-statistically significant lower mortality (19% vs. 29%, p=.099), despite higher ISS (25 vs. 21, p=.003) compared to open repair.

CONCLUSION

The reported use of endovascular techniques within the PROOVIT registry increased more than 10% over a 6-year period. This increase was associated with improved survival, especially for patients with junctional vascular injuries. Practices and training programs should account for these changes by providing access to endovascular technologies and instruction in the catheter-based skill sets to optimize outcomes in the future.

Setting standards of performance expected in neurosurgery residency: A study on entrustable professional activities in competency-based medical education

BACKGROUND

Competency-based medical education requires evaluations of residents' performances of tasks of the discipline (ie. entrustable professional activities (EPAs)). Using neurosurgical Faculty perspectives, this study investigated whether a sample of neurosurgical EPAs accurately reflected the expectations of general neurosurgical practice.

METHOD

A questionnaire was sent to all Canadian neurosurgery Faculty using a SurveyMonkey® platform.

RESULTS

The proportion of respondents who believed the EPAs were representative of general neurosurgery competences varied significantly across all EPAs [47%-100%] (p < 0.0001). For 9/15 proposed EPAs, ≥75% agreed they were appropriate for general neurosurgery training and expected residents to attain the highest standard of performance. However, a range of 27-53% of the respondents felt the other six EPAs would be more appropriate for fellowship training and thus, require a lower standard of performance from graduating residents.

CONCLUSION

The shift towards subspecialization in neurosurgery has implications for curriculum design, delivery and certification of graduating residents.

Should we develop a core international curriculum for Vascular and Endovascular Surgery?

Vascular and endovascular surgery has undergone a period of extraordinary change during the last 20 years. This is in part due to changes in patient profiles, the development of new, potent drugs and the technological advances in imaging and interventional products. These changes have effectively resulted in the development of an independent specialty, which has needed to define the competencies required for specialist recognition and credentialing. This paper discusses the key aspects of contemporary training in Vascular and Endovascular Surgery, and raises the possibility of developing an agreed core international curriculum.

The U.S. trauma surgeon's current scope of practice: can we deliver acute care surgery?

BACKGROUND

The evolving discipline of acute care surgery as an expansion of trauma surgery is undergoing intense critique. As we envision this new paradigm of surgical practice, an evaluation of our current status across the nation's trauma centers is an essential step. The purpose of this study is to determine the practice patterns of trauma surgeons at major trauma centers throughout the United States.

METHODS

A survey was sent to the trauma directors of the 1,288 designated trauma centers in the United States, as listed by the American Trauma Society. As proposed, acute care surgery would encompass performing emergent abdominal, vascular, and thoracic trauma procedures as well as providing critical care. The addition of simple orthopedic and neurosurgical procedures has been considered.

RESULTS

The survey response rate was 72% among the Level I/II/III centers (n = 515) with 92% of Level I, 72% of Level II, and 59% of Level III centers responding. Of the 169 Level I centers, 31 (18%) reported their trauma surgeons perform the full complement of thoracic, vascular, and abdominal cases. Trauma surgeons managed the full range of injuries at 11 (6%) of the 187 Level II centers and 7 (4%) of the 159 Level III centers. At these 49 centers, only 41% of surgeons perform elective thoracic and vascular cases. The remaining 466 centers enlist a combination of vascular and thoracic surgeons to manage trauma patients. Finally, trauma surgeons performed cranial burr holes at eight trauma centers, placement of ICP monitors at four, and open fracture washout at three trauma centers.

CONCLUSIONS

The model of the acute care surgeon is attractive and timely, but only a limited number of trauma surgeons currently practice this proposed range of operative procedures; even fewer surgeons have an elective surgical practice to maintain key operative skills. Fellowship training programs need to incorporate vascular and thoracic procedures to enable the specialty of acute care surgery.