Effect of Endovascular Interventions on General Surgery Trainee Operative Experience; a Comparison of Case Log Reports

Decreasing Resident Vascular Case Volumes Have Not Changed National Numbers of Vascular Fellowship Applications in US General Surgery Residents Over the Past Twenty Years

OBJECTIVES

With an aging workforce and high prevalence of vascular disease, the US is expected to face a pronounced shortage of vascular surgeons over the next 2 decades. This has driven initiatives to expand vascular surgery training positions leading to the rise of integrated residency programs (0 + 5) and the expansion of traditional fellowships (VSFs, 5 + 2). Given the increase in dedicated vascular surgery training positions, there has been a growing concern that general surgery residents (GSRs) are experiencing decreased vascular case volumes. We aim to evaluate trends in vascular surgery specialty choice relative to vascular case volumes for US GSRs over the last 20 years.

DESIGN

Using the Accreditation Council for Graduate Medical Education (ACGME) Case Log Graduate Statistics National Report, a retrospective analysis of ACGME-accredited GSR vascular case volumes was performed from academic year 1999-2000 to 2021-2022. Fellowship data was retrospectively reviewed using the available National Resident Matching Program (NRMP) Fellowship Match Data & Reports for 2004-2023.

RESULTS

Graduating GSRs logged increasing numbers of major cases between AY 1999-2000 and AY 2021-2022 (p < 0.001) with 2022 graduates logging on average 98 more cases per resident compared to 2000 graduates. Mean total vascular cases decreased (p = 0.005) with 2022 graduates logging approximately 78 fewer vascular cases on average compared to the 2000 graduates, a 40% decrease in vascular case volume. Despite the decrease, US GSRs have applied to VSF at a relatively consistent rate: 8.5% in 2001-2002, 8% in 2011-2012, and 6% in 2021-2022. 2023 demonstrated an increase to 8.3%.

CONCLUSION

Over the past 2 decades, GSRs have experienced a substantial decrease in exposure to vascular surgery cases during their training; however, residents continue to apply for VSF at a relatively constant rate suggesting that interest in the specialty may be related to factors other than exposure to vascular cases.

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

BACKGROUND

Since the introduction of endovascular aneurysm 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 the future training of vascular surgeons that need to be appropriately addressed. Our objective is to analyze trends in OAR and EVAR 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 OAR and EVAR for graduating vascular surgery fellows (VSFs) finishing 5 + 2 programs between 2002 and 2019 and vascular surgery integrated residents (VSRs) between 2013 and 2019. VSF case totals were calculated by combining average total cases of open and endovascular supra- and infrarenal 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 2 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). For VSR, while no significant trend was observed in the mean number of OAR cases (Coef. -0.3, P = 0.2) due to the limited time frame, the proportion of open cases was significantly lower compared to endovascular cases. Additionally, there were 2 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).

CONCLUSIONS

A significant reduction in average OAR cases and an 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 expertize to perform such a high-risk procedure safely and independently.

Recruitment of General Surgery Residents into Vascular Surgery

BACKGROUND

Vascular surgery fellowship applications among general surgery residents have declined. Given this steady downward trend in vascular applicants in conjunction with a predicted critical shortage of vascular surgeons, a call to action for increased recruitment is needed. To improve recruitment efforts, a subgroup analysis of general surgery residents was performed to explore factors that influence interest in vascular surgery.

METHODS

A cross-sectional national survey of residents (n = 467) was conducted from September 2016 to May 2017. In addition to collection of demographic and occupational characteristics, assessment of psychological, work-life balance, and job-satisfaction variables were obtained. Residents were grouped based on their interest in pursuing a fellowship. Chi-squared and Fisher's exact test was performed to determine significant variables.

RESULTS

Residents were grouped into "interest in non-vascular fellowship" (n = 350), "interest in vascular fellowship" (n = 21), and "not interested in fellowship" (n = 96). Significant variables between the groups included age, geographic location, residency size, and type of institution (p < 0.05). Those interested in vascular surgery tended to be older. Residents not interested in fellowship were more commonly located in the Midwest and at smaller, community residencies. No significant difference was found between mental wellness and work-life balance variables. Those residents interested in a vascular surgery fellowship were more dissatisfied with their current salary as compared to other residents (p = 0.021).

CONCLUSIONS

There is a predicted critical shortage in the vascular surgery workforce making recruitment of the best and brightest residents into the specialty vital to its future. In order to invigorate and broaden our group of vascular surgeons, focused recruitment of younger, Midwest, general surgery residents at smaller, community programs may provide the most yield. Publicizing the strengths of a vascular surgery career including the diversity of patients, continuity of care, proficiency in technical skill, and higher monetary rewards should be emphasized in recruiting these target populations.

Simulation Training Incorporating a Pulsatile Carotid Endarterectomy Model Results in Increased Procedure-Specific Knowledge, Confidence, and Comfort in Post-graduate Trainees

OBJECTIVES

Surgical simulation has been used to facilitate the acquisition of vascular surgery skills. However, high cost and limited availability may restrict the use of this educational resource. We report how instruction using a low-cost, pulsatile, carotid endarterectomy (CEA) benchtop surgical simulation model can be used to enhance learners' procedure-specific knowledge, comfort, and confidence in performing the steps of a CEA procedure DESIGN: A single instructor engaged each participant in a one-on-one instructional session during which the instructor demonstrated, and then the participants performed, the steps of a CEA. Participants completed a pre- and postintervention assessment of knowledge and attitudes about preforming a CEA and use of simulation as a learning tool. Postintervention, participants rated the impact of the simulation model on their learning. A Related T-test and Wilcoxin signed Rank Test were used to compare pre- and postintervention results.

SETTINGS

University of Virginia Health System, Charlottesville, Virginia.

PARTICIPANTS

Seventeen postgraduate trainees.

RESULTS

A significant difference was observed in pre- and postknowledge scores (48% vs 91% correct, p < 0.01). Trainee confidence (1.65 vs 2.88, p < 0.01) and comfort (1.59 vs 2.82, p < 0.01) with doing the procedure also increased significantly. Sixteen (94%) responded that use of the simulator was extremely or very important as a tool for learning. All 17 trainees (100%) reported that the simulation experience was either essential or very useful in helping them learn how to perform a CEA. Sixty-five percent responded that they were extremely likely to apply the skills learned during the intervention the next time they performed a CEA.

CONCLUSIONS

A low-cost, pulsatile CEA simulation model used as an educational tool increased procedure-specific knowledge, comfort, and confidence among trainees. Learner's increased confidence and affirmation that they are likely to apply the learned skills in a clinical setting support the use of this educational approach to impact trainee behaviors.

Comparing Accuracy of Implant Installation with a Navigation System (NS), a Laboratory Guide (LG), NS with LG, and Freehand Drilling

The aim of this study was to compare the accuracy of implant placement by using the conventional freehand method, the surgical guide alone, the dental navigation system alone, and the dental navigation system with a surgical guide. The participants were aged 20 years or older and were requiring dental implant surgery according to an assessment made by a dentist between July 2014 and December 2017. A total of 128 dental implants were inserted, 32 dental implants in each group, and participants with similar or identical age (i.e., 20–50 years or 50 years or above) and missing tooth locations were paired for comparison. Accuracy was measured by overlaying the real position in the postoperative Cone Beam Computerized Tomography (CBCT) on the virtual presurgical placement of the implant in a CBCT image. Using the dental navigation system with a surgical guide could help dentists to position implants more accurately. Total, longitudinal, and angular error deviation were significantly different (p < 0.0001). The same level of accuracy could be obtained for the different jaws and tooth positions. The one-way analysis of variance (ANOVA) showed that the total, longitudinal, and angular errors differed significantly (p < 0.0001). A comparison of the four dental implant surgical methods indicated that the combination of a dental implant navigation system and a surgical guide kit achieved the highest accuracy in terms of the different tooth positions and jaws.

Peripheral Arterial Endovascular Procedures Performed in a Non-Hospital-Based Facility by First-Year Vascular Surgery Fellows

Objective:

Traditionally, vascular surgery fellows (VSFs) have learned to perform peripheral arterial endovascular procedures in a hospital setting. Many vascular surgeons currently perform these procedures in an “outpatient” non-hospital-based setting. Loss of these cases from the hospital setting may impact vascular surgery fellowship endovascular volume. We assessed the safety of first-year VSFs performing peripheral endovascular procedures under the supervision of vascular surgery attending surgeons in a non-hospital-based facility.

Methods:

Between January 1, 2012, and December 31, 2016, 166 patients underwent 193 endovascular procedures in a non-hospital-based ambulatory facility: 136 interventions (65 femoral, 40 iliac, 13 popliteal, and 9 infrapopliteal arteries) and 31 diagnostic arteriograms for claudication (57.8%; 85), rest pain (11.6%; 17), tissue loss (12.9%; 19), and failing grafts (17.7%; 26). Interventions included balloon angioplasty alone in 8.8% (12/136) of cases, stents in 16.9% (23/136), covered stents in 14% (19/136), atherectomy in 60.3% (82/136), and mechanical thrombolysis in 0.7% (1/136).

Results:

First-year VSFs performed an increasing percentage of these procedures during this interval: academic year 2012 to 2013 = 0% (0/49), 2013 to 2014 = 31% (17/54), 2014 to 2015 = 93% (56/60), and 2015 to 2016 = 82% (57/70). All but 5 (3%) patients having 167 procedures were discharged home after 2 to 6 hours of bed rest without any 30-day adverse outcomes. Four patients were immediately transferred to our hospital after the intervention: 2 for respiratory issues (hypoxia), 1 for groin hematoma (observation only), and 1 for arterial occlusion (required tibial stent not available at outpatient center). One patient returned to our hospital with rest pain due to treatment site occlusion the following day.

Conclusion:

Our results demonstrate that complex peripheral arterial endovascular procedures can be performed safely by first-year VSFs under vascular attending supervision in an outpatient, non-hospital-based setting.

The Value of Carotid Endarterectomy as a Learning Tool for Trainees

BACKGROUND

Carotid endarterectomy (CEA) intervention needs a specific training and a sufficient learning curve to obtain optimal results in terms of outcome. A formative program was settled up in a single academic center to optimize training of standard CEA procedures. This study aims to evaluate the 11-year results of the teaching CEA program.

METHODS

The trainees CEA teaching program is carried on during the 5-year vascular surgery residency period, and it is stratified as follows: learning theory and intervention assistance (minimum 50 procedures per year) in the first and second residency year; performing CEA as second operator in the third and fourth residency year (minimum 50 procedures per year); CEA execution as first operator with attending supervision in the last residency year. All CEA procedures from 2005 to 2015 were retrospectively collected and the 30-day results were compared according to the expertise of the first operator: experienced vascular surgeons (EVSs) versus trainees. All CEA procedures were performed in general anesthesia, with routine shunting and patching.

RESULTS

In the study period, 1,379 (361 [26.2%] symptomatic; 1,018 [73.8%] asymptomatic) CEAs were performed. Trainees performed 199 (14.4%) CEAs as first operator. Patients submitted to CEA by trainees were similar in terms of preoperative clinical characteristics except for the patients' age (trainees 72.4 years versus EVS 70.8 years, P = 0.02) and smoking history (trainees 30.7% versus EVS 24.1%, P = 0.04). The 30-day complication rates were similar in CEA performed by trainees versus EVS: stroke 0.5% vs. 1.1%, P = 0.5; death 0.0% vs. 0.5%, P = 0.6; stroke/death 0.5% vs. 1.7%, P = 0.24; hematoma 3.0% vs. 2.2%, P = 0.48; and cranial nerve injury 9.0% vs. 7.8%, P = 0.47, respectively. The intervention time was significantly longer in CEAs performed by trainees compared with EVS: 104 ± 1.9 min versus 98 ± 1.0 min, P = 0.02.

CONCLUSIONS

With a defined CEA teaching program, trainees can obtain results similar to those of more experienced surgeons in terms of clinical outcome at the price of an increased intervention time.