1
|
Rouby AF, Neumann N, Vento V, Lejay A, Kuntz S, Bourcier T, Oulehri W, Bismuth J, Chakfé N. Fundamental Technical Skills of Endovascular Surgery: A Preliminary Study on Its Impact on Skills and Stress during Procedures. Ann Vasc Surg 2024; 108:84-91. [PMID: 38942373 DOI: 10.1016/j.avsg.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 05/18/2024] [Accepted: 05/31/2024] [Indexed: 06/30/2024]
Abstract
BACKGROUND Our objective is twofold: determining if simulation allows residents to reach proficient surgeons' performance concerning fundamental technical skills of endovascular surgery (FEVS) while investigating effects of the program on surgeons' stress. METHODS Using a FEVS training simulator, 8 endovascular FEVS were performed by vascular surgery residents (simulator-naive or simulator-experienced residents [SER]) and seniors. Total time needed to complete the 8 tasks, called total completion time (TCT), was the main evaluation criterion. Analgesia Nociception Index (ANI) was monitored during simulation. Likert scale questionnaire was filled out after each simulation. RESULTS For each task, TCT was significantly lower for SER and seniors than simulator-naive residents (P = 0.0163). After only 5 simulations, SER were able to reach and even exceed the seniors' level in terms of TCT, with a median time of 10.8 min for SER and 11.9 min for seniors, and wire's movements with a median distance during cannulation of 4.44 m for SER and 4.17 m for seniors. Seniors remained better than SER in terms of precise wire manipulation (wire movement after cannulation), 4.17 m against 4.44 m (3.72-5.96), respectively. Based on the Likert scale stress analysis, seniors felt less stressed than both residents' groups (P = 0.0618). Seniors' initial ANI and mean ANI over the session were significantly lower than those of the residents, P = 0.0358 and P = 0.0250, respectively. CONCLUSIONS We showed that 5 simulation sessions allowed residents to reach experienced surgeons' capacities on FEVS concerning TCT. Subjectively, seniors felt less stressed than residents, contrary to the results of our objective measures of stress.
Collapse
Affiliation(s)
- Anne-Florence Rouby
- GEPROMED, Strasbourg, France; Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France; Faculty of Medicine of Strasbourg, UNISIMES (UNIté de SIMulation Européenne en Santé), Strasbourg, France
| | | | - Vincenzo Vento
- GEPROMED, Strasbourg, France; Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France; Faculty of Medicine of Strasbourg, UNISIMES (UNIté de SIMulation Européenne en Santé), Strasbourg, France
| | - Anne Lejay
- GEPROMED, Strasbourg, France; Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France; Faculty of Medicine of Strasbourg, UNISIMES (UNIté de SIMulation Européenne en Santé), Strasbourg, France
| | - Salomé Kuntz
- GEPROMED, Strasbourg, France; Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France; Faculty of Medicine of Strasbourg, UNISIMES (UNIté de SIMulation Européenne en Santé), Strasbourg, France
| | - Tristan Bourcier
- GEPROMED, Strasbourg, France; Department of Ophthalmology, University Hospital of Strasbourg, Strasbourg, France
| | - Walid Oulehri
- GEPROMED, Strasbourg, France; Faculty of Medicine of Strasbourg, UNISIMES (UNIté de SIMulation Européenne en Santé), Strasbourg, France; Department of Anaesthesiology and Intensive Care, University of Strasbourg, Strasbourg, France
| | - Jean Bismuth
- Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
| | - Nabil Chakfé
- GEPROMED, Strasbourg, France; Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France; Faculty of Medicine of Strasbourg, UNISIMES (UNIté de SIMulation Européenne en Santé), Strasbourg, France.
| |
Collapse
|
2
|
Roth A, Moreno O, Santos T, Khan H, Marks N, Ascher E, Hingorani A. Impact of the endovascular revolution on vascular training through analysis of national data case reports. J Vasc Surg 2024; 79:1498-1506.e12. [PMID: 38367849 DOI: 10.1016/j.jvs.2024.01.207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 01/09/2024] [Accepted: 01/10/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND In the last couple of decades, there has been a shift in use of endovascular procedures in vascular surgery. We aim to examine the impact of this endovascular shift on vascular trainees, determine whether the surgical experiences of trainees in the integrated residency and fellowship program changed over time, and identify differences between the two training paradigms. METHODS Data were extracted from the Accreditation Council for Graduate Medical Education National Data Case Logs for the vascular surgery fellowship (1999-2021) and integrated residency (2012-2021) programs. Every procedure was categorized as open or endovascular, then designated into the following subcategories: thoracic aneurysm repairs, cerebrovascular, abdominal aneurysm repairs, venous, vascular access, peripheral arterial disease, visceral, or miscellaneous. We compared the prevalence of open and endovascular cases in the fellowship and integrated residency using data from overlapping years (2012-2021). In addition, we compared the mean number of cases per trainee per year within designated time intervals. The vascular surgery fellowship was grouped into three intervals: 1999 to 2006, 2006 to 2013, and 2013 to 2021; the integrated vascular surgery residency was grouped into two intervals: 2012 to 2017 and 2017 to 2021. Data were standardized to represent the average number of cases per trainee per year. RESULTS Within the fellowship, we found a 362.37% increase in endovascular procedures (mean, 56.80 ± 32.57 vs 262.63 ± 9.91; P < .001), although there was only a 32.47% increase in open procedures (220.19 ± 4.55 vs 291.68 ± 8.20) between the first and last time intervals. There was a decrease in abdominal aneurysm repair (24.46 ± 7.30 vs 13.85 ± 0.58; P < .001) and visceral (6.41 ± 0.44 vs 5.80 ± 0.42; P = .039) open procedures. For the integrated residency, there was an increase in open procedures by 8.52% (352.18 ± 8.23 vs 382.20 ± 5.84; P < .001). Residents had greater total, open, and endovascular procedures per year than fellows (all P < .001). Chief residents had approximately one-half as many cases as vascular fellows per year. Fellows performed more open abdominal aneurysm repair (14.04 ± 0.80 vs 12.40 ± 1.32; P = .007) and visceral (5.83 ± 0.41 vs 4.88 ± 0.46; P > .001) procedures than residents. Overall, 52% to 53% of cases performed by trainees per year were open procedures in both the fellowship and integrated residency (288.56 ± 12.10 vs 261.27 ± 10.13, 365.52 ± 17.23 vs 319.58 ± 6.62; both P < .001). Within the subcategories, only cerebrovascular, vascular access, and miscellaneous had more open procedures performed per trainee. CONCLUSIONS Vascular surgery training has incorporated new endovascular techniques and technologies while maintaining operative training in open procedures. Despite changes in vascular surgery training, trainees are still performing more open procedures than endovascular procedures per year. However, there are evolving deficits in specific types of procedures.
Collapse
Affiliation(s)
- Alexis Roth
- College of Medicine, State University of New York, Downstate Health Sciences University, Brooklyn, NY.
| | - Oscar Moreno
- Department of Vascular Surgery, University of Michigan, Ann Arbor, MI
| | - Tyler Santos
- College of Medicine, St. George's University School of Medicine, St. George, Grenada
| | - Hason Khan
- College of Medicine, Kansas City University, Kansas City, MO
| | - Natalie Marks
- Total Vascular Care, Brooklyn, NY; Department of Surgery, NYU Langone Hospital, Brooklyn, NY
| | - Enrico Ascher
- Total Vascular Care, Brooklyn, NY; Department of Surgery, NYU Langone Hospital, Brooklyn, NY
| | - Anil Hingorani
- Total Vascular Care, Brooklyn, NY; Department of Surgery, NYU Langone Hospital, Brooklyn, NY
| |
Collapse
|
3
|
Soenens G, Doyen B, Vlerick P, Hertault A, Maurel B, Kellens PJ, Bacher K, Van Herzeele I. Development, Feasibility, and Knowledge Impact of a Massive Open Online Course on Radiation Safety: A Multicentre Prospective Cohort Study. Eur J Vasc Endovasc Surg 2024; 67:838-846. [PMID: 38042252 DOI: 10.1016/j.ejvs.2023.11.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 10/31/2023] [Accepted: 11/28/2023] [Indexed: 12/04/2023]
Abstract
OBJECTIVE This study reports the development of an innovative, interactive Massive Open Online Course (MOOC) teaching radiation safety principles in the vascular workplace, using stepwise e-learning with multiple choice question tests (MCQs), educational videos, and a serious game. The aim was to study the MOOC impact on radiation safety knowledge and assess its feasibility and acceptability. METHODS An international multicentre prospective study included team members active in the hybrid operating room. The MOOC was offered voluntarily via a secure online learning platform. A standardised MCQ test (15 questions) assessed radiation safety knowledge pre- and post-course (range 0 - 100%). Acceptability and feasibility were tested via the previously validated, Evaluating e-learning system success (EESS) model, using five point Likert scales. RESULTS In eight centres across four countries, 150 of 203 invited endovascular team members consented. Over a seven week study period, surgeons (28%, including vascular surgery trainees and consultants), nurses (27%, including scrub, circulating and anaesthetic nurses), anaesthetists (43%, including trainees and consultants), and radiographers (3%) participated. Of those, 67% completed the course. The average radiation knowledge improved by 22.8% (95% CI 19.5 - 26.0%; p < .001) after MOOC completion, from 48% to 71% (standard deviation [SD] 14 and 15% respectively), requiring a mean time investment of 169 minutes (SD 89 minutes). In centres with a radiographer, mean knowledge gain after MOOC completion was significantly smaller (14%, SD 19% vs. 24%, SD 16%, p = .036). The course was deemed feasible and acceptable according to the EESS model with a total mean score of 3.68/5. CONCLUSION This newly developed, multimodal MOOC was deemed feasible and effective across multiple international centres. The MOOC significantly contributes to radiation safety education of the entire endovascular team, improving radiation safety knowledge. The course may optimise workplace radiation safety behaviour and therefore enhance team and patient safety.
Collapse
Affiliation(s)
- Gilles Soenens
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium.
| | - Bart Doyen
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Peter Vlerick
- Department of Work, Organisation and Society, Ghent University, Ghent, Belgium
| | - Adrien Hertault
- Department of Vascular Surgery, Ramsay Santé, Hôpital Privé de Villeneuve d'Ascq, France
| | - Blandine Maurel
- Department of Vascular Surgery, University Hospital Centre of Nantes, Nantes, France
| | - Pieter-Jan Kellens
- Medical Physics, Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Klaus Bacher
- Medical Physics, Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Isabelle Van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
4
|
Clauss N, Kuntz S, Colvard B, Ohana M, Mertz L, Lejay A, Chakfe N. Intraoperative Staff Radiation Exposure During Aortic Endovascular Procedures. Ann Vasc Surg 2024; 106:16-24. [PMID: 38641000 DOI: 10.1016/j.avsg.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/30/2023] [Accepted: 01/01/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND The risk of radiation exposure in the surgical operating room (OR) and/or catheterization laboratory is now well established. Complex endovascular procedures often require multiple approaches and different positioning of the staff members around the patient, potentially increasing the levels of radiations exposure. Our goal was to evaluate the levels of radiation exposure of the members of the staff during endovascular aortic procedures in order to propose radioprotection optimization. METHODS We included 41 aortic endovascular procedures out of 114 procedures performed between January 12, 2014, and August 31, 2015, including 24 standard endovascular aortic aneurysm repair (EVAR), 7 EVAR with iliac branch (EVARib), 8 complex fenestrated/branched EVAR (F/B EVAR), and 2 thoracic EVAR (TEVAR). Procedures were performed in an OR equipped with a carbon fiber table and a mobile fluoroscopy C-arm. We collected the usual dosimetry data given by the C-arm as well as the patient's peak skin dose (PSD). In all staff members, radiation exposure was measured with thermoluminescent chip dosimeters placed on both temples, on posterior sides of both hands, and on both lower legs. RESULTS PSD levels were low for EVAR because 24 patients had values below the reading threshold. PSD significantly increased with more complex procedures. Main operator (MO) received the higher level of irradiation on whole body, hands, and ankles. Eye lenses irradiation was higher on both assistant operators (AOs). Other members received low levels of irradiation. We found a high ranges of radiation exposure with a high risk of exposure for the AO, mainly for F/B EVAR and EVARib. CONCLUSIONS Even if all personal protections are used, staff positioning is a major point that must be considered. If MO is supposed to be the most exposed to X-rays, specific conditions of positioning of the AO may be at risk of exposure.
Collapse
Affiliation(s)
- Nicolas Clauss
- Unit of Radiophysic and Radioprotection, Les Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France
| | - Salomé Kuntz
- GEPROMED, Strasbourg, France; Department of Vascular Surgery and Kidney Transplantation, Les Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France
| | - Benjamin Colvard
- University Hospitals Harrington Heart & Vascular Institute, Cleveland, OH
| | - Mickael Ohana
- Department of Radiology, Les Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France
| | - Luc Mertz
- Unit of Radiophysic and Radioprotection, Les Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France
| | - Anne Lejay
- Unit of Radiophysic and Radioprotection, Les Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France; GEPROMED, Strasbourg, France; Fédération de Médecine Translationelle (FMTS), Faculté de Médecine, Institut de Physiologie, Equipe d'Accueil EA3072 "Mitochondrie, Stress Oxydant et Protection Musculaire", Université de Strasbourg, Strasbourg, France
| | - Nabil Chakfe
- Unit of Radiophysic and Radioprotection, Les Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France; GEPROMED, Strasbourg, France; Fédération de Médecine Translationelle (FMTS), Faculté de Médecine, Institut de Physiologie, Equipe d'Accueil EA3072 "Mitochondrie, Stress Oxydant et Protection Musculaire", Université de Strasbourg, Strasbourg, France.
| |
Collapse
|
5
|
Kim Y, Cui CL, Williams ZF, Long CA. Impact of Integrated Vascular Surgery Residency on General Surgery Resident and Vascular Fellow Operative Volume: A National Analysis. Vasc Endovascular Surg 2024; 58:302-307. [PMID: 37918823 DOI: 10.1177/15385744231213299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
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, R2 = .80, P < .0001) among GS residents. Major vascular cases decreased among GS residents from 138 to 101 cases (-2.4 cases/yr, R2 = .58, P < .0001) with a decrease in proportion of chief-level vascular cases from 30.4% to 11.9% (-1.0%/yr, R2 = .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, R2 = .63, P = .01). Total VS fellow major case volume also increased from 369 to 444 cases (+3.5 cases/yr, R2 = .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.
Collapse
Affiliation(s)
- Young Kim
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, NC, USA
| | - Christina L Cui
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, NC, USA
| | - Zachary F Williams
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, NC, USA
| | - Chandler A Long
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Durham, NC, USA
| |
Collapse
|
6
|
Cui CL, West-Livingston LN, Loanzon RS, Latz CA, Coleman DM, Long CA, Kim Y. Concerning Trends in Vascular Surgery Trainee Operative Experience in Venous Disease. Ann Vasc Surg 2024; 100:25-30. [PMID: 38122970 DOI: 10.1016/j.avsg.2023.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/13/2023] [Accepted: 10/16/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Comprehensive vascular care includes both arterial and venous disease management. However, operative training in venous disease is often significantly overshadowed by arterial procedures, despite the public health burden of acute and chronic venous disease. The purpose of this study is to evaluate the case-mix and volume of venous procedures performed by graduating integrated vascular surgery residents and fellows in the United States. METHODS Accreditation Council for Graduate Medical Education national operative log reports were compiled for graduating integrated VSR (vascular surgery residency) and traditional vascular surgery fellowship (VSF) trainees from academic years 2013 to 2022. Only cases categorized as "surgeon fellow", "surgeon chief", or "surgeon junior" were included. Linear regression analysis was utilized to evaluate trends in case-mix and volume. RESULTS Over the 10-year study period, total vascular cases increased for both VSR (mean 870.5 ± 9.3 cases, annual change +9.5 cases/year, R2 = 0.77, P < 0.001) and VSF (mean 682.1 ± 6.9 cases, annual change +6.7 cases/year, R2 = 0.85, P < 0.001) trainees. Concurrently, the proportion of venous cases in the VSR group decreased from 12.5% to 7.3% (annual change -3.7 cases/year, R2 = 0.72, P < 0.001). VSR trainees experienced an annual decrease in 4 of the top 5 venous case types performed, including venous angioplasty/stenting (-1.6 cases/year, P = 0.002), vena cava filter placement (-0.9 cases/year, P = 0.002), endoluminal ablation (-0.2 cases/year, P = 0.47), diagnostic venography (-1.7 cases/year, P < 0.001), and varicose vein treatment (-1.0 cases/year, P < 0.001). Venous cases proportions also decreased in the VSF group from 8.4% to 6.2% (annual change -2.2 cases/year, R2 = 0.54, P = 0.002). VSF trainees experienced an annual decrease in 4 of the top 5 venous case types, including venous angioplasty/stenting (-1.5 cases/year, P = 0.003), diagnostic venography (-1.2 cases/year, P < 0.001), vena cava filter placement (-0.2 cases/year, P = 0.44), endoluminal ablation (-0.6 cases/year, P < 0.001), and varicose vein treatment (-0.1 cases/year, P = 0.04). Both VSR and VSF trainee groups graduated with fewer than 5 cases for each of the following venous procedures-percutaneous mechanical thrombectomy, venous thrombolysis, open venous reconstruction, sclerotherapy, venous embolectomy, portal-systemic shunting, venous ulceration treatment, and arteriovenous malformation treatment. CONCLUSIONS Current vascular residents and fellows have limited exposure to venous procedures, in part due to a proportional decline in venous cases. More robust venous operative experience is needed during surgical training. Further studies are needed to understand whether this discrepancy in venous and arterial training impacts career progression and patient outcomes.
Collapse
Affiliation(s)
- Christina L Cui
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Lauren N West-Livingston
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Roberto S Loanzon
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Christopher A Latz
- Division of Vascular and Endovascular Surgery, Department of Surgery, Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Dawn M Coleman
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Chandler A Long
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Young Kim
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
| |
Collapse
|
7
|
Phair J, Choinski K, Inglesby DC, Diamond S, Sultan SM. Targeted muscle reinnervation: A narrative review of a novel tool for the management of neuropathic pathology in major lower extremity amputations. Vascular 2024; 32:154-161. [PMID: 36062583 DOI: 10.1177/17085381221124982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
Collapse
Affiliation(s)
- John Phair
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Krystina Choinski
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dani C Inglesby
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shawn Diamond
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Steven M Sultan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
8
|
Cui CL, Loanzon RS, Southerland KW, Coleman DM, Waldrop HW, Williams ZF, Long CA, Kim Y. A national analysis of vascular surgery resident operative experience in peripheral artery disease. J Vasc Surg 2023; 78:1541-1547. [PMID: 37558145 DOI: 10.1016/j.jvs.2023.07.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 07/25/2023] [Accepted: 07/29/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND 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 Surgical Therapy in Patients With Critical Limb Ischemia trial has further emphasized the importance of open surgical techniques in the treatment of peripheral arterial disease. The purpose of this study was 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 to 2013 and 2021 to 2022. 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/year (R2 = 0.77; P < .0001). Major vascular case volume also increased at a rate of 5.7 ± 1.2 cases/year (R2 = 0.74; P < .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/year, R2 = 0.93; P < .001). No changes were seen in volume of open peripheral cases, including suprainguinal bypass (+0.1 ± 0.2 cases/year; R2 = 0.08; P = .40) or femoropopliteal bypass procedures (-0.1 ± 0.2 cases/year; R2 = 0.17; P = .20). Infrapopliteal bypass (+0.4 ± 0.1 cases/year; R2 = 0.48; P = .006), iliac/femoral endarterectomy (+1.3 ± 0.2 cases/year; R2 = 0.82; P < .001), and leg thromboembolectomy (+0.4 ± 0.1 cases/year; R2 = 0.64; P < .001) all demonstrated annual growth. For endovascular peripheral cases, aortoiliac revascularization (+3.4 ± 0.3 cases/year; R2 = 0.94; P < .001), femoropopliteal revascularization (+5.4 ± 0.2 cases/year; R2 = 0.98; P < .001), and tibioperoneal revascularization (+2.0 ± 0.2 cases/year; R2 = 0.92; P < .001) all increased in volume. Lower extremity amputations, including above-knee amputation (+0.6 ± 0.2 cases/year; R2 = 0.65; P < .001) and below-knee amputation (+0.9 ± 0.2 cases/year; R2 = 0.72; P < .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.
Collapse
Affiliation(s)
- Christina L Cui
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Medical Center, Durham, NC
| | - Roberto S Loanzon
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Medical Center, Durham, NC
| | - Kevin W Southerland
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Medical Center, Durham, NC
| | - Dawn M Coleman
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Medical Center, Durham, NC
| | - Heather W Waldrop
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Medical Center, Durham, NC
| | - Zachary F Williams
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Medical Center, Durham, NC
| | - Chandler A Long
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Medical Center, Durham, NC
| | - Young Kim
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University, Medical Center, Durham, NC.
| |
Collapse
|
9
|
Blitzer D, Benintende AJ, Nemeth S, Kurlansky P, Antkowiak M, Fischkoff K, Argenziano M, Takayama H. 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. Am Surg 2023; 89:5512-5519. [PMID: 36797046 DOI: 10.1177/00031348231157417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
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.
Collapse
Affiliation(s)
- David Blitzer
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Andrew J Benintende
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Samantha Nemeth
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Paul Kurlansky
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Mark Antkowiak
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Katherine Fischkoff
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Michael Argenziano
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Hiroo Takayama
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| |
Collapse
|
10
|
Beaulieu-Jones BR, de Geus SWL, Rasic G, Woods AP, Papageorge MV, Sachs TE. A propensity score matching analysis: Impact of senior resident versus fellow participation on outcomes of complex surgical oncology. Surg Oncol 2023; 48:101925. [PMID: 36913848 PMCID: PMC10200751 DOI: 10.1016/j.suronc.2023.101925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/12/2023] [Accepted: 03/05/2023] [Indexed: 03/11/2023]
Abstract
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.
Collapse
Affiliation(s)
- Brendin R Beaulieu-Jones
- Department of Surgery, Boston Medical Center, Boston, MA, USA; Boston University School of Medicine, Boston, MA, USA
| | | | - Gordana Rasic
- Department of Surgery, Boston Medical Center, Boston, MA, USA; Boston University School of Medicine, Boston, MA, USA
| | - Alison P Woods
- Department of Surgery, Boston Medical Center, Boston, MA, USA; Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Teviah E Sachs
- Department of Surgery, Boston Medical Center, Boston, MA, USA; Boston University School of Medicine, Boston, MA, USA.
| |
Collapse
|
11
|
The Impact of Endovascular Repair of Abdominal Aortic Aneurysms on Vascular Surgery Training in Open Aneurysm Repair. Ann Vasc Surg 2023; 92:1-8. [PMID: 36754163 DOI: 10.1016/j.avsg.2023.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 01/12/2023] [Accepted: 01/15/2023] [Indexed: 02/08/2023]
Abstract
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.
Collapse
|
12
|
Modarai B, Haulon S, Ainsbury E, Böckler D, Vano-Carruana E, Dawson J, Farber M, Van Herzeele I, Hertault A, van Herwaarden J, Patel A, Wanhainen A, Weiss S, Esvs Guidelines Committee, Bastos Gonçalves F, Björck M, Chakfé N, de Borst GJ, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kakkos SK, Koncar IB, Kolh P, Lindholt JS, Trimarchi S, Tulamo R, Twine CP, Vermassen F, Document Reviewers, Bacher K, Brountzos E, Fanelli F, Fidalgo Domingos LA, Gargiulo M, Mani K, Mastracci TM, Maurel B, Morgan RA, Schneider P. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on Radiation Safety. Eur J Vasc Endovasc Surg 2023; 65:171-222. [PMID: 36130680 DOI: 10.1016/j.ejvs.2022.09.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 09/15/2022] [Indexed: 01/24/2023]
|
13
|
Bhinder J, O'Brien-Irr M, Reilly B, Montross B, Khan S, Rivero M, Cherr G, Harris L. Understanding radiation exposure and improving safety for vascular surgery trainees. J Vasc Surg 2023; 77:269-278. [PMID: 35953003 DOI: 10.1016/j.jvs.2022.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/21/2022] [Accepted: 08/01/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Despite having robust radiation safety education procedures and policies in place, we discovered that the trainees at our Accreditation Council for Graduate Medical Education-approved integrated vascular surgery residency and fellowship program were exceeding the annual radiation exposure limits. In the present report, we have described our quality improvement project to identify the root causes and implement policies to improve radiation safety education, oversite, and, ultimately, the exposure levels of our trainees. METHODS A committee of faculty, fellows, radiology nurses, and radiation safety officers from each of the programs affiliated hospitals convened to identify the potential root causes of the increased radiation exposure and potential modifiable actions. The radiation exposure reports for postgraduate year 4 to 7 trainees were evaluated before and after the interventions. RESULTS Excessive radiation exposure was found to be more prevalent than anticipated, with multiple trainees surpassing the annual exposure limits. The committee classified the factors at play and interventions into four categories: policies and procedures, curriculum, environment, resources, and equipment. The multisite status of our program was a key factor associated with the increased radiation exposure. In addition, we found that excessive radiation levels were occurring primarily at a single hospital site. After the interventions, the monthly average levels at this site had decreased considerably from 936 mrem to 272 mrem. CONCLUSIONS We found it alarming that the safety policies in place at vascular residency and fellowship programs were inadequate in securing the safety of their trainees. We found interventions such as inventorying and ensuring the availability of safety equipment, hands-on instruction to complement traditional didactics, lowering the default frame rates, and converting to real-time dosimetry to be effective measures for reducing radiation exposure.
Collapse
Affiliation(s)
- Jasmine Bhinder
- Department of Vascular Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY.
| | - Monica O'Brien-Irr
- Department of Vascular Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
| | - Brendon Reilly
- Department of Vascular Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
| | - Brittany Montross
- Department of Vascular Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
| | - Sikandar Khan
- Department of Vascular Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
| | - Mariel Rivero
- Department of Vascular Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
| | - Gregory Cherr
- Department of Vascular Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
| | - Linda Harris
- Department of Vascular Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
| |
Collapse
|
14
|
Treil L, Neumann N, Chanes N, Lejay A, Bourcier T, Bismuth J, Lee JT, Sheahan M, Rouby AF, Chakfé N, Eidt J, Georg Y, Mitchell EL, Rigberg D, Shames M, Thaveau F, Sheahan C. Objective Evaluation of Clock Face Suture Using the Objective Structured Assessment of Technical Skill (OSATS) Checklist. EJVES Vasc Forum 2022; 57:5-11. [DOI: 10.1016/j.ejvsvf.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 09/30/2022] [Accepted: 10/06/2022] [Indexed: 11/07/2022] Open
|
15
|
Bhinder J, Fakhoury E, O'Brien-Irr M, Reilly B, Dryjski M, Dosluoglu H, Cherr G, Harris L. National Survey of Vascular Surgery Residents & Fellows on Radiation Exposure and Safety Practices. J Vasc Surg 2022; 76:274-279.e1. [PMID: 35065221 DOI: 10.1016/j.jvs.2021.12.080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/26/2021] [Indexed: 11/17/2022]
Abstract
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.
Collapse
Affiliation(s)
- Jasmine Bhinder
- Division of Vascular Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
| | - Elias Fakhoury
- Division of Vascular Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
| | - Monica O'Brien-Irr
- Division of Vascular Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
| | - Brendon Reilly
- Division of Vascular Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
| | - Maciej Dryjski
- Division of Vascular Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
| | - Hasan Dosluoglu
- Division of Vascular Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
| | - Gregory Cherr
- Division of Vascular Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
| | - Linda Harris
- Division of Vascular Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY.
| |
Collapse
|
16
|
Schmiederer IS, Kearse LE, Korndorffer JR, Lee E, Sgroi MD, Lee JT. Validity Evidence for Vascular Skills Assessment: The Feasibility of Fundamentals of Vascular Surgery in General Surgery Residency. JOURNAL OF SURGICAL EDUCATION 2021; 78:e201-e209. [PMID: 34446383 DOI: 10.1016/j.jsurg.2021.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/09/2021] [Accepted: 07/16/2021] [Indexed: 06/13/2023]
Abstract
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.
Collapse
Affiliation(s)
- Ingrid S Schmiederer
- Stanford University Medical Center, Department of Surgery, Stanford, California.
| | - LaDonna E Kearse
- Stanford University Medical Center, Department of Surgery, Stanford, California
| | - James R Korndorffer
- Stanford University Medical Center, Department of Surgery, Stanford, California
| | - Edmund Lee
- Inova Fairfax Hospital, Department of Surgery, Falls Church, Annandale, Virginia
| | - Michael D Sgroi
- Stanford University Medical Center, Department of Surgery, Stanford, California
| | - Jason T Lee
- Stanford University Medical Center, Department of Surgery, Stanford, California
| |
Collapse
|
17
|
Bonfill X, Quintana MJ, Escudero JR, Miralles M, Fité J, Mikelarena E, Castejón B, Garnica M, Fernández DE Valderrama I, Rodriguez-Montalban A, Pijoan JI, Bellmunt-Montoya S. Appropriateness of surgery performed for abdominal aortic aneurysm at tertiary hospitals in Spain. INT ANGIOL 2021; 40:289-296. [PMID: 34060282 DOI: 10.23736/s0392-9590.21.04654-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
Collapse
Affiliation(s)
- Xavier Bonfill
- Department of Clinical Epidemiology and Public Health, University Hospital de la Santa Creu i Sant Pau (IIB Sant Pau), Barcelona, Spain - .,CIBER for Epidemiology and Public Health (CIBERESP), Madrid, Spain - .,Autonomous University of Barcelona, Barcelona, Spain -
| | - M Jesús Quintana
- Department of Clinical Epidemiology and Public Health, University Hospital de la Santa Creu i Sant Pau (IIB Sant Pau), Barcelona, Spain.,CIBER for Epidemiology and Public Health (CIBERESP), Madrid, Spain.,Autonomous University of Barcelona, Barcelona, Spain
| | - Jose R Escudero
- Autonomous University of Barcelona, Barcelona, Spain.,Joint Service of Angiology, Vascular and Endovascular Surgery, University Hospital de la Santa Creu i Sant Pau-Hospital Dos de Maig, Barcelona, Spain.,CIBER for Cardiovascular Diseases (CIBERCV), Madrid, Spain
| | - Manuel Miralles
- Department of Surgery, University of Valencia, Valencia, Spain
| | - Joan Fité
- Joint Service of Angiology, Vascular and Endovascular Surgery, University Hospital de la Santa Creu i Sant Pau-Hospital Dos de Maig, Barcelona, Spain
| | | | | | | | | | | | - José I Pijoan
- CIBER for Epidemiology and Public Health (CIBERESP), Madrid, Spain.,Clinical Epidemiology Unit, Cruces University Hospital. Biocruces-Bizkaia Health Research Institute, Barakaldo, Spain
| | - Sergi Bellmunt-Montoya
- Autonomous University of Barcelona, Barcelona, Spain.,CIBER for Cardiovascular Diseases (CIBERCV), Madrid, Spain.,Department of Angiology, Vascular and Endovascular Surgery, Vall d'Hebron University Hospital, Barcelona, Spain.,Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | | |
Collapse
|
18
|
Smith BK, Sheahan MG, Sgroi M, Weis T, Singh N, Rigberg D, Coleman DM, Lee JT, Shames ML, Mitchell EL. Addressing Contemporary Management of Vascular Trauma: Optimization of Patient Care Through Collaboration. Ann Surg 2021; 273:e171-e172. [PMID: 33824252 DOI: 10.1097/sla.0000000000004861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Brigitte K Smith
- Division of Vascular Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Malachi G Sheahan
- Division of Vascular and Endovascular Surgery, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Michael Sgroi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University, Palo Alto, CA
| | - Tahlia Weis
- Vascular Surgery at Marshfield Clinic Health System, Marshfield, WI
| | - Niten Singh
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - David Rigberg
- Division of Vascular Surgery, Department of Surgery, University of California - Los Angeles, Los Angeles, CA
| | - Dawn M Coleman
- Division of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Jason T Lee
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University, Palo Alto, CA
| | - Murray L Shames
- Division of Vascular Surgery, Department of Surgery, University of South Florida, Tampa, FL
| | - Erica L Mitchell
- Academic Sabbatical, Masters in Healthcare Delivery Science, Dartmouth, Hanover, NH
| |
Collapse
|
19
|
Physician impact on use of fluoroscopy during endovascular procedures to improve radiation safety. J Vasc Surg 2021; 74:958-962. [PMID: 33684480 DOI: 10.1016/j.jvs.2021.02.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 02/16/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To determine whether differences exist in fluoroscopy time and radiation exposure during lower extremity endovascular procedures performed by fellowship trained vascular surgeons vs general surgeons, to minimize radiation exposure to operating room staff. METHODS A retrospective review of all lower extremity endovascular procedures was performed from August 1, 2014, to January 29, 2016. The procedures were performed by the surgical department's four surgeons with endovascular privileges: two vascular surgeons and two 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 one to two interventions, three to four interventions, and five or more interventions performed. Statistical analysis was performed with a P value of less than .05 considered 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 through 4, respectively. On average, 3.24 interventions were performed during each procedure. Vascular surgeons were found to have shorter fluoroscopy time for procedures involving one to two (7.8 vs 30.1; P < .01), three to four (9.3 vs 34.2; P < .01), and five or more (11.5 vs 51.9; P < .01) interventions. Vascular surgeons were also found to have less radiation exposure compared with general surgeons in procedures with one to two (1.69 vs 3.53; P = .001) and five or more (2.3 vs 5.4; P = .003) interventions. There was no significant difference in radiation exposure between vascular and general surgeons for procedures with three to four interventions (5.86 vs 5.59; P = .95). CONCLUSIONS 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 with general surgeons.
Collapse
|
20
|
Legeza P, Britz GW, Loh T, Lumsden A. Current utilization and future directions of robotic-assisted endovascular surgery. Expert Rev Med Devices 2020; 17:919-927. [PMID: 32835546 DOI: 10.1080/17434440.2020.1814742] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Endovascular surgery has become the standard of care to treat most vascular diseases using a minimally 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.
Collapse
Affiliation(s)
- Peter Legeza
- Department of Cardiovascular Surgery, Houston Methodist Hospital , Houston, Texas, USA.,Department of Vascular Surgery, Semmelweis University , Budapest, Hungary
| | - Gavin W Britz
- Department of Neurological Surgery and Neurological Institute, Houston Methodist Hospital , Houston, Texas, USA
| | - Thomas Loh
- Department of Cardiovascular Surgery, Houston Methodist Hospital , Houston, Texas, USA
| | - Alan Lumsden
- Department of Cardiovascular Surgery, Houston Methodist Hospital , Houston, Texas, USA
| |
Collapse
|
21
|
Arnaoutakis DJ, Scali ST, Beck AW, Kubilis P, Huber TS, Martin AJ, Laquian L, Back M, Giles KA, Fatima J, Beaver TM, Upchurch GR. Comparative outcomes of open, hybrid, and fenestrated branched endovascular repair of extent II and III thoracoabdominal aortic aneurysms. J Vasc Surg 2020; 71:1503-1514. [DOI: 10.1016/j.jvs.2019.08.236] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 08/02/2019] [Indexed: 11/26/2022]
|
22
|
Bonfill X, Quintana MJ, Bellmunt S, Suclupe S, Gómez E, Fernandez de Valderrama I, Castejón B, Miralles M, Pérez E, Escudero JR. Descriptive and follow-up study of patients treated surgically for abdominal aortic aneurysm at tertiary hospitals in Spain. INT ANGIOL 2019; 38:402-409. [PMID: 31566318 DOI: 10.23736/s0392-9590.19.04206-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The aim of this study was 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-center variability in the type of surgery was high, with EVAR accounting for 19.4% to 75% of the surgical procedures, depending on the treating center (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.
Collapse
Affiliation(s)
- Xavier Bonfill
- Department of Clinical Epidemiology and Public Health, de la Santa Creu i Sant Pau (IIB Sant Pau) University Hospital, Barcelona, Spain.,CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain.,Autonomous University of Barcelona, Barcelona, Spain
| | - M Jesús Quintana
- Department of Clinical Epidemiology and Public Health, de la Santa Creu i Sant Pau (IIB Sant Pau) University Hospital, Barcelona, Spain - .,CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Sergi Bellmunt
- Department of Angiology, Vascular and Endovascular Surgery, Vall d'Hebron University Hospital, Barcelona, Spain.,Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Stefanie Suclupe
- Department of Clinical Epidemiology and Public Health, de la Santa Creu i Sant Pau (IIB Sant Pau) University Hospital, Barcelona, Spain.,Autonomous University of Barcelona, Barcelona, Spain
| | - Efrem Gómez
- Joint Service of Angiology, Vascular and Endovascular Surgery, University Hospital Sant Pau-Hospital Dos de Maig, Barcelona, Spain
| | | | | | - Manuel Miralles
- Department of Surgery, University of Valencia, Valencia, Spain
| | | | - José R Escudero
- Autonomous University of Barcelona, Barcelona, Spain.,Joint Service of Angiology, Vascular and Endovascular Surgery, University Hospital Sant Pau-Hospital Dos de Maig, Barcelona, Spain.,CIBER of Cardiovascular Diseases (CIBERCV), Madrid, Spain
| | | |
Collapse
|
23
|
Nesbitt CI, Tingle SJ, Williams R, McCaslin JE, Searle R, Mafeld S, Stansby GP. Educational Impact of a Pulsatile Human Cadaver Circulation Model for Endovascular Training. Eur J Vasc Endovasc Surg 2019; 58:602-608. [PMID: 31495728 DOI: 10.1016/j.ejvs.2019.03.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 03/16/2019] [Accepted: 03/23/2019] [Indexed: 12/24/2022]
Abstract
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.
Collapse
Affiliation(s)
- Craig I Nesbitt
- Department of Vascular Surgery, Northern Vascular Centre, Freeman Hospital, UK.
| | - Samual J Tingle
- Faculty of Medical Sciences, Newcastle Medical School, Newcastle Upon Tyne, UK
| | - Robin Williams
- Department of Interventional Radiology, Northern Vascular Centre, Freeman Hospital, Newcastle Upon Tyne, UK
| | - James E McCaslin
- Department of Vascular Surgery, Northern Vascular Centre, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Roger Searle
- Anatomy and Clinical Skills, Newcastle University, Newcastle Upon Tyne, UK
| | - Sebastian Mafeld
- Department of Interventional Radiology, Northern Vascular Centre, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Gerard P Stansby
- Department of Vascular Surgery, Northern Vascular Centre, Freeman Hospital, Newcastle Upon Tyne, UK
| |
Collapse
|
24
|
Swerdlow NJ, Varkevisser RRB, Soden PA, Zettervall SL, McCallum JC, Li C, Wyers MC, Schermerhorn ML. Thirty-Day Outcomes After Open Revascularization for Acute Mesenteric Ischemia From the American College of Surgeons National Surgical Quality Improvement Program. Ann Vasc Surg 2019; 61:148-155. [PMID: 31382003 DOI: 10.1016/j.avsg.2019.05.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 05/01/2019] [Accepted: 05/06/2019] [Indexed: 12/25/2022]
Abstract
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.
Collapse
Affiliation(s)
- Nicholas J Swerdlow
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Rens R B Varkevisser
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Peter A Soden
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Sara L Zettervall
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - John C McCallum
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Chun Li
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Mark C Wyers
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
| |
Collapse
|
25
|
McLachlan RHP, Burgess A, Wagner T, Freeman AJ. A Binational Need Assessment to Define the Level of Endovascular Expertise Required by Vascular Surgical Trainees. JOURNAL OF SURGICAL EDUCATION 2019; 76:982-989. [PMID: 30711424 DOI: 10.1016/j.jsurg.2019.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 12/12/2018] [Accepted: 01/08/2019] [Indexed: 06/09/2023]
Abstract
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.
Collapse
Affiliation(s)
- Rohan H P McLachlan
- Faculty of Medicine and St George Hospital Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Annette Burgess
- Faculty of Medicine and Health, The University of Sydney School of Medicine, Sydney, NSW, Australia
| | - Timothy Wagner
- Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
| | - Anthony J Freeman
- Faculty of Medicine and Health, The University of Sydney School of Medicine, Sydney, NSW, Australia.
| |
Collapse
|
26
|
Chait J, Davis N, Ostrozhynskyy Y, Rajaee S, Marks N, Hingorani A, Ascher E. Radiation exposure during non-thrombotic iliac vein stenting. Vascular 2019; 27:617-622. [PMID: 31067208 DOI: 10.1177/1708538119848558] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Objective 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. Methods This was a single-center, retrospective analysis of 40 venograms performed on 29 unique patients over a three-month period. Patients with signs and symptoms of chronic venous insufficiency who failed conservative therapy underwent evaluation of the vena cava and iliofemoral veins with venography and intravascular ultrasound. Stent placement was performed if a >50% cross-sectional area or diameter reduction was identified via intravascular ultrasound. All patients were found to have non-thrombotic iliac vein lesions. All patients wore two individual film badge dosimeters – one on their chest and the other on the abdomen. The same mobile C-arm system was used for all interventions. Results There were 15 males and 14 females, with an average age of 70.6 years old (SD ± 9.5; range 53–89) and a mean body mass index of 33.9 kg/m2. Sixteen limbs had C6 disease, 10 had C4 disease, and 14 had C3 disease. Thirty-eight of the 40 procedures resulted in stent placement, with an average of 1.13 stents placed per intervention. The average fluoroscopy time was 76.5 s (SD ± 36.9; range 7.8–209.5), and the mean cumulative air kerma was 1.08 mGy (SD ± 0.55; range 0.362–2.24). Average cumulative air kerma was higher in procedures resulting >1 stent placement compared to those with placement of ≤1 stent (1.44 vs. 1.02 mGy; p = 0.04). Fluoroscopy time was also higher in procedures with >1 stent placed (120.1 vs. 68.8 s; p = 0.0004). The mean deep dose equivalent per procedure from the patient-worn abdominal badge was 0.221 mSv. Conclusion With the adjunctive use of intravascular ultrasound, iliac vein stenting can be safely and effectively performed with very low utilization of fluoroscopy, and therefore radiation exposure can be minimized for both patients and surgeons. Placement of >1 iliac vein stent resulted in higher cumulative air kerma and fluoroscopy time.
Collapse
Affiliation(s)
- Jesse Chait
- Vascular Institute of New York, Brooklyn, NY, USA
| | | | | | - Sareh Rajaee
- Vascular Institute of New York, Brooklyn, NY, USA
| | | | | | | |
Collapse
|
27
|
Quintana MJ, Gich I, Librero J, Bellmunt-Montoya S, Escudero JR, Bonfill X. Variation in the choice of elective surgical procedure for abdominal aortic aneurysm in Spain. Vasc Health Risk Manag 2019; 15:69-79. [PMID: 31040686 PMCID: PMC6459220 DOI: 10.2147/vhrm.s191451] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- M Jesús Quintana
- Department of Clinical Epidemiology and Public Health, University Hospital de la Santa Creu i Sant Pau (IIB Sant Pau), Barcelona, Spain, .,CIBER of Epidemiology and Public Health (CIBERESP), Barcelona, Spain,
| | - Ignasi Gich
- Department of Clinical Epidemiology and Public Health, University Hospital de la Santa Creu i Sant Pau (IIB Sant Pau), Barcelona, Spain, .,CIBER of Epidemiology and Public Health (CIBERESP), Barcelona, Spain, .,Universitat Autònoma de Barcelona, Barcelona, Spain,
| | - Julián Librero
- Navarrabiomed-UPNA -Departamento de Salud, IDISNA, Pamplona, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Bilbao, Spain
| | - Sergi Bellmunt-Montoya
- Department of Angiology, Vascular and Endovascular Surgery, Vall d'Hebron University Hospital, Barcelona, Spain.,Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - José R Escudero
- Universitat Autònoma de Barcelona, Barcelona, Spain, .,Joint Service of Angiology, Vascular and Endovascular Surgery, Sant Pau-Dos de Maig Hospital, Barcelona, Spain.,CIBER Cardiovascular Diseases (CIBERCV), Barcelona, Spain
| | - Xavier Bonfill
- Department of Clinical Epidemiology and Public Health, University Hospital de la Santa Creu i Sant Pau (IIB Sant Pau), Barcelona, Spain, .,CIBER of Epidemiology and Public Health (CIBERESP), Barcelona, Spain, .,Universitat Autònoma de Barcelona, Barcelona, Spain, .,Iberoamerican Cochrane Centre, Barcelona, Spain,
| |
Collapse
|
28
|
Phair J, Carnevale ML, Teveris VG, Koleilat I, Indes JE. Peripheral arterial occlusive disease operative case volume in the final years of 5+2 and 0+5 vascular training paradigms. Surgery 2019; 166:198-202. [PMID: 30967238 DOI: 10.1016/j.surg.2019.02.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/28/2019] [Accepted: 02/28/2019] [Indexed: 10/27/2022]
Abstract
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.
Collapse
Affiliation(s)
- John Phair
- Albert Einstein College of Medicine, Bronx, NY; Division of Vascular Surgery, Montefiore Medical Center, Bronx, NY
| | - Matthew L Carnevale
- Albert Einstein College of Medicine, Bronx, NY; Division of Vascular Surgery, Montefiore Medical Center, Bronx, NY
| | - Victoria G Teveris
- Department of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Issam Koleilat
- Albert Einstein College of Medicine, Bronx, NY; Division of Vascular Surgery, Montefiore Medical Center, Bronx, NY
| | - Jeffrey E Indes
- Albert Einstein College of Medicine, Bronx, NY; Division of Vascular Surgery, Montefiore Medical Center, Bronx, NY.
| |
Collapse
|
29
|
Vascular fellow and resident experience performing infrapopliteal revascularization with endovascular procedures and vein bypass during training. J Vasc Surg 2019; 68:1533-1537. [PMID: 30360842 DOI: 10.1016/j.jvs.2018.01.054] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 01/25/2018] [Indexed: 11/24/2022]
Abstract
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.
Collapse
|
30
|
Irfan W, Sheahan C, Mitchell EL, Sheahan MG. The pathway to a national vascular skills examination and the role of simulation-based training in an increasingly complex specialty. Semin Vasc Surg 2019; 32:48-67. [DOI: 10.1053/j.semvascsurg.2018.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
|
31
|
Simulation in Vascular Surgery. COMPREHENSIVE HEALTHCARE SIMULATION: SURGERY AND SURGICAL SUBSPECIALTIES 2019. [DOI: 10.1007/978-3-319-98276-2_26] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
32
|
Declining Resident Experience in Open Vascular Operations Threatens the Status of Vascular Surgery as an Essential Content Area of General Surgery Training. Ann Surg 2018; 268:665-673. [DOI: 10.1097/sla.0000000000002951] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
33
|
McVeigh PZ, Moloney T, Wilson BC, Wheatcroft M. High-Resolution Scanning Fiber Angioscopy as an Adjuvant to Fluoroscopy During Endovascular Interventions. J Endovasc Ther 2018; 25:617-623. [PMID: 30122139 DOI: 10.1177/1526602818794663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
Collapse
Affiliation(s)
- Patrick Z McVeigh
- 1 Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,2 Department of Physics, Ryerson University, Toronto, Ontario, Canada.,3 Division of Vascular Surgery, St Michael's Hospital/University of Toronto, Toronto, Ontario, Canada
| | | | - Brian C Wilson
- 1 Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,5 Techna Institute, University Health Network, Toronto, Ontario, Canada
| | - Mark Wheatcroft
- 3 Division of Vascular Surgery, St Michael's Hospital/University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
34
|
Prouse AF, Langner P, Plomondon ME, Ho PM, Valle JA, Barón AE, Armstrong EJ, Waldo SW. Temporal trends in the management and clinical outcomes of lower extremity arterial thromboembolism within a national Veteran population. Vasc Med 2018; 24:41-49. [PMID: 30105938 DOI: 10.1177/1358863x18793210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
Collapse
Affiliation(s)
- Andrew F Prouse
- 1 Department of Medicine, Division of Cardiology, University of Colorado, Aurora, CO, USA
| | - Paula Langner
- 2 Department of Medicine, Division of Cardiology, VA Eastern Colorado Healthcare System, Denver, CO, USA
| | - Mary E Plomondon
- 2 Department of Medicine, Division of Cardiology, VA Eastern Colorado Healthcare System, Denver, CO, USA
| | - P Michael Ho
- 2 Department of Medicine, Division of Cardiology, VA Eastern Colorado Healthcare System, Denver, CO, USA
| | - Javier A Valle
- 1 Department of Medicine, Division of Cardiology, University of Colorado, Aurora, CO, USA.,2 Department of Medicine, Division of Cardiology, VA Eastern Colorado Healthcare System, Denver, CO, USA
| | - Anna E Barón
- 2 Department of Medicine, Division of Cardiology, VA Eastern Colorado Healthcare System, Denver, CO, USA
| | - Ehrin J Armstrong
- 1 Department of Medicine, Division of Cardiology, University of Colorado, Aurora, CO, USA.,2 Department of Medicine, Division of Cardiology, VA Eastern Colorado Healthcare System, Denver, CO, USA
| | - Stephen W Waldo
- 1 Department of Medicine, Division of Cardiology, University of Colorado, Aurora, CO, USA.,2 Department of Medicine, Division of Cardiology, VA Eastern Colorado Healthcare System, Denver, CO, USA
| |
Collapse
|
35
|
Kontopodis N, Tavlas E, Georgakarakos E, Galanakis N, Chronis C, Tsetis D, Ioannou CV. 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. Ann Vasc Surg 2018; 52:292-301. [PMID: 29886211 DOI: 10.1016/j.avsg.2018.03.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 03/24/2018] [Accepted: 03/29/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND 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 with 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 OpenGrey databases were searched up to October 2017. Outcome measures were anatomic complexity, procedural details, and postoperative 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 (CIs). RESULTS Five observational studies were included. These involved 1,091 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 suprarenal 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). Intraoperative 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 the groups. CONCLUSIONS After the wide availability of endoluminal 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.
Collapse
Affiliation(s)
- Nikolaos Kontopodis
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University Hospital of Heraklion, University of Crete Medical School, Heraklion, Crete, Greece.
| | - Emmanouil Tavlas
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University Hospital of Heraklion, University of Crete Medical School, Heraklion, Crete, Greece
| | | | - Nikolaos Galanakis
- Interventional Radiology Unit, Department of Radiology, University Hospital of Heraklion, University of Crete Medical School, Heraklion, Crete, Greece
| | - Christos Chronis
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University Hospital of Heraklion, University of Crete Medical School, Heraklion, Crete, Greece
| | - Dimitrios Tsetis
- Interventional Radiology Unit, Department of Radiology, University Hospital of Heraklion, University of Crete Medical School, Heraklion, Crete, Greece
| | - Christos V Ioannou
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University Hospital of Heraklion, University of Crete Medical School, Heraklion, Crete, Greece
| |
Collapse
|
36
|
Evaluating the Construct Validity of a Pulsatile Fresh Frozen Human Cadaver Circulation Model for Endovascular Training. Ann Vasc Surg 2018; 52:237-243. [PMID: 29787852 DOI: 10.1016/j.avsg.2018.03.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 03/01/2018] [Accepted: 03/02/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND We recently described a pulsatile fresh frozen human cadaver model (PHCM) for training endovascular practitioners. This present study aims to assess the construct validity of PHCM; its ability to differentiate between participants of varying expertise. METHODS Twenty-three participants with varying endovascular experience (12 novice, 4 intermediate, and 7 expert) were recruited. Each attempted catheterization of the left renal artery on PHCM within 10 min under exam conditions. Performances were video recorded and scored using a validated scoring tool by 2 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 theater, with each participant graded as "fail", "borderline," or "pass". RESULTS All expert and intermediate participants completed the index procedure within the allotted 10 min; 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. CONCLUSIONS The PHCM demonstrates construct validity. Further work is required to determine its educational impact in endovascular training.
Collapse
|
37
|
Harris DG, Olson SB, Rosen CB, Kalsi R, Taylor BS, Diaz JJ, Flohr TR, Crawford RS. Early Treatment at a Referral Center Improves Outcomes for Patients with Acute Vascular Disease. Ann Vasc Surg 2018. [PMID: 29518507 DOI: 10.1016/j.avsg.2018.01.088] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients with acute vascular disease frequently need specialized management that may require transfer to a vascular referral center. Although transfer may be medically necessary, it can delay definitive care and is an indicator of incorrect triage to the initial hospital. Regionalization of acute vascular care could improve patient triage and subsequent outcomes. To evaluate the potential benefit from regionalization, we analyzed outcomes of patients treated for acute vascular disease at vascular referral centers. METHODS Using a statewide database capturing all inpatient admissions in Maryland during 2013-2015, patients undergoing noncardiac vascular procedures on an acute basis were identified. Patients admitted to a vascular referral center were stratified by admission status as direct or transfer. The primary outcome was inpatient mortality, and the secondary outcome was resource use. Patient groups were compared by univariable analyses, and the effect of admission status on mortality was assessed by multivariable logistic regression. RESULTS Of 4,873 patients with acute vascular disease managed at vascular referral centers, 2,713 (56%) were admitted directly, whereas 2,160 (44%) were transferred. Transfers to referral centers accounted for 71% of all interhospital transfers. The transfer-group patients were older, had more comorbidities, and higher illness severities. Patients who were transferred had higher mortality (14% vs. 9%, P < 0.0001), longer hospital lengths of stay, greater critical care-resource utilization, and higher costs. After adjusting for demographics, comorbidities, and illness severity, transfer status was independently associated with higher inpatient mortality. CONCLUSIONS Primary treatment at a referral center is independently associated with improved outcomes for patients with acute vascular disease. Direct admission or earlier triage to a specialty center may improve patient and system outcomes and could be facilitated by standardization and regionalization of complex acute vascular care.
Collapse
Affiliation(s)
- Donald G Harris
- Department of Surgery, Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD.
| | - Sarah B Olson
- Department of Surgery, Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Claire B Rosen
- Department of Surgery, Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Richa Kalsi
- Department of Surgery, Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Bradley S Taylor
- Department of Surgery, Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD; Center for Aortic Disease, University of Maryland Medical Center, Baltimore, MD
| | - Jose J Diaz
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Tanya R Flohr
- Department of Surgery, Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD; Center for Aortic Disease, University of Maryland Medical Center, Baltimore, MD
| | - Robert S Crawford
- Department of Surgery, Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD; Center for Aortic Disease, University of Maryland Medical Center, Baltimore, MD
| |
Collapse
|
38
|
Vento V, Cercenelli L, Mascoli C, Gallitto E, Ancetti S, Faggioli G, Freyrie A, Marcelli E, Gargiulo M, Stella A. The Role of Simulation in Boosting the Learning Curve in EVAR Procedures. JOURNAL OF SURGICAL EDUCATION 2018; 75:534-540. [PMID: 28870712 DOI: 10.1016/j.jsurg.2017.08.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 07/26/2017] [Accepted: 08/05/2017] [Indexed: 06/07/2023]
Abstract
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.
Collapse
Affiliation(s)
- Vincenzo Vento
- Vascular Surgery, Department of Experimental Diagnostic and Specialty Medicine (DIMES), University of Bologna, Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Laura Cercenelli
- Laboratory of Bioengineering, Department of Experimental Diagnostic and Specialty Medicine (DIMES), University of Bologna, Policlinico S. Orsola Malpighi, Bologna, Italy.
| | - Chiara Mascoli
- Vascular Surgery, Department of Experimental Diagnostic and Specialty Medicine (DIMES), University of Bologna, Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Enrico Gallitto
- Vascular Surgery, Department of Experimental Diagnostic and Specialty Medicine (DIMES), University of Bologna, Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Stefano Ancetti
- Vascular Surgery, Department of Experimental Diagnostic and Specialty Medicine (DIMES), University of Bologna, Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Gianluca Faggioli
- Vascular Surgery, Department of Experimental Diagnostic and Specialty Medicine (DIMES), University of Bologna, Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Antonio Freyrie
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Emanuela Marcelli
- Laboratory of Bioengineering, Department of Experimental Diagnostic and Specialty Medicine (DIMES), University of Bologna, Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental Diagnostic and Specialty Medicine (DIMES), University of Bologna, Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Andrea Stella
- Vascular Surgery, Department of Experimental Diagnostic and Specialty Medicine (DIMES), University of Bologna, Policlinico S. Orsola Malpighi, Bologna, Italy
| |
Collapse
|
39
|
Suckow BD, Goodney PP, Columbo JA, Kang R, Stone DH, Sedrakyan A, Cronenwett JL, Fillinger MF. National trends in open surgical, endovascular, and branched-fenestrated endovascular aortic aneurysm repair in Medicare patients. J Vasc Surg 2017; 67:1690-1697.e1. [PMID: 29290495 DOI: 10.1016/j.jvs.2017.09.046] [Citation(s) in RCA: 174] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 09/24/2017] [Indexed: 11/18/2022]
Abstract
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.
Collapse
Affiliation(s)
- Bjoern D Suckow
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; VA Outcomes Group, White River Junction, Vt; Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Hanover, NH
| | - Jesse A Columbo
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; VA Outcomes Group, White River Junction, Vt
| | | | - David H Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Art Sedrakyan
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Hanover, NH
| | - Jack L Cronenwett
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Mark F Fillinger
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| |
Collapse
|
40
|
Hicks CW, Kernodle A, Abularrage CJ, Heller JA. A national resident survey about the current state of venous education in vascular surgery training programs. J Vasc Surg Venous Lymphat Disord 2017; 5:897-904.e2. [DOI: 10.1016/j.jvsv.2017.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 06/04/2017] [Indexed: 11/15/2022]
|
41
|
A Pulsatile Fresh Frozen Human Cadaver Circulation Model for Endovascular Training: A Trial of Face Validity. Ann Vasc Surg 2017; 46:345-350. [PMID: 28887245 DOI: 10.1016/j.avsg.2017.07.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 07/20/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND The authors have published their design of a pulsatile fresh frozen human cadaver circulation model (PHCM) for endovascular training the face validity of the PHCM for training endovascular practitioners was subsequently assessed. METHODS Twelve endovascular clinicians performed the same 2 procedures (catheterization of the left renal artery and left subclavian artery) on PHCM and Simbionix angiomentor virtual reality simulator (SVR). They were randomized to begin on either the PHCM or SVR. A pretrial 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 catheterization" (P = 0.004). Candidates again favored PHCM as "a valuable learning exercise" (P = 0.016) and strongly favored 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.
Collapse
|
42
|
Piazza M, Nayak N, Ali Z, Heuer G, Sanborn M, Stein S, Schuster J, Grady MS, Malhotra NR. Trends in Resident Operative Teaching Opportunities for Treatment of Intracranial Aneurysms. World Neurosurg 2017; 103:194-200. [DOI: 10.1016/j.wneu.2017.03.124] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 03/23/2017] [Accepted: 03/25/2017] [Indexed: 11/16/2022]
|
43
|
Siah MC, Abramowitz SD, Haser P, Ricotta J, Woo EY, Macsata R. Evaluating the venous experience in vascular surgery training. J Vasc Surg Venous Lymphat Disord 2017; 5:446-452. [PMID: 28411714 DOI: 10.1016/j.jvsv.2017.01.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 01/02/2017] [Indexed: 11/29/2022]
Abstract
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.
Collapse
Affiliation(s)
- Michael C Siah
- Medstar Heart and Vascular Institute/Georgetown University, Washington, D.C..
| | | | - Paul Haser
- Moncton City Hospital, Moncton, New Brunswick, Canada
| | - John Ricotta
- George Washington University Hospital, Residency Review Committee, Washington, D.C
| | - Edward Y Woo
- Medstar Heart and Vascular Institute/Georgetown University, Washington, D.C
| | - Robyn Macsata
- VAMC/George Washington University Hospital, Washington, D.C
| |
Collapse
|
44
|
Kim JB, Lee J, Park K. Radiation hazards to vascular surgeon and scrub nurse in mobile fluoroscopy equipped hybrid vascular room. Ann Surg Treat Res 2017; 92:156-163. [PMID: 28289670 PMCID: PMC5344806 DOI: 10.4174/astr.2017.92.3.156] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 10/01/2016] [Accepted: 10/17/2016] [Indexed: 11/30/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Jong Bin Kim
- Division of Vascular Surgery, Department of Surgery, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Jaehoon Lee
- Division of Vascular Surgery, Department of Surgery, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Kihyuk Park
- Division of Vascular Surgery, Department of Surgery, Catholic University of Daegu School of Medicine, Daegu, Korea
| |
Collapse
|
45
|
Operative Autonomy among Senior Surgical Trainees during Infrainguinal Bypass Operations Is Not Associated with Worse Long-term Patient Outcomes. Ann Vasc Surg 2017; 38:42-53. [DOI: 10.1016/j.avsg.2016.09.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 09/09/2016] [Accepted: 09/29/2016] [Indexed: 11/20/2022]
|
46
|
Kim BJ, Valsangkar NP, Liang TW, Murphy MP, Zimmers TA, Bell TM, Davies MG, Koniaris LG. Impact of Integrated Vascular Residencies on Academic Productivity within Vascular Surgery Divisions. Ann Vasc Surg 2016; 39:242-249. [PMID: 27671458 DOI: 10.1016/j.avsg.2016.06.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 06/13/2016] [Accepted: 06/21/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Changing training paradigms in vascular surgery have been introduced to reduce overall training time. Herein, we sought to examine how shortened training for vascular surgeons may have influenced overall divisional academic productivity. METHODS Faculty from the top 55 surgery departments were identified according to National Institutes of Health (NIH) funding. Academic metrics of 315 vascular surgery, 1,132 general surgery, and 2,403 other surgical specialties faculty were examined using institutional Web sites, Scopus, and NIH Research Portfolio Online Reporting Tools from September 1, 2014, to January 31, 2015. Individual-level and aggregate numbers of publications, citations, and NIH funding were determined. RESULTS The mean size of the vascular divisions was 5 faculty. There was no correlation between department size and academic productivity of individual faculty members (R2 = 0.68, P = 0.2). Overall percentage of vascular surgery faculty with current or former NIH funding was 20%, of which 10.8% had major NIH grants (R01/U01/P01). Vascular surgery faculty associated with integrated vascular training programs demonstrated significantly greater academic productivity. Publications and citations were higher for vascular surgery faculty from institutions with both integrated and traditional training programs (48 of 1,051) compared to those from programs with integrated training alone (37 of 485) or traditional fellowships alone (26 of 439; P < 0.05). CONCLUSIONS In this retrospective examination, academic productivity was improved within vascular surgery divisions with integrated training programs or both program types. These data suggest that the earlier specialization of integrated residencies in addition to increasing dedicated vascular training time may actually help promote research within the field of vascular surgery.
Collapse
Affiliation(s)
- Bradford J Kim
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Nakul P Valsangkar
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Tiffany W Liang
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Michael P Murphy
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Teresa A Zimmers
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Teresa M Bell
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Mark G Davies
- Division of Vascular Surgery, The University of Texas Health Science Center, San Antonio, TX
| | - Leonidas G Koniaris
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN.
| |
Collapse
|
47
|
Soden PA, Zettervall SL, Curran T, Vouyouka AG, Goodney PP, Mills JL, Hallett JW, Schermerhorn ML. Regional variation in patient selection and treatment for lower extremity vascular disease in the Vascular Quality Initiative. J Vasc Surg 2016; 65:108-118. [PMID: 27692467 DOI: 10.1016/j.jvs.2016.06.105] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 06/21/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Prior studies on the cause and effect of surgical variation have been limited by utilization of administrative data. The Vascular Quality Initiative (VQI), a robust national clinical registry, provides anatomic and perioperative details allowing a more robust analysis of variation in surgical practice. METHODS The VQI was used to identify all patients undergoing infrainguinal open bypass or endovascular intervention from 2009 to 2014. Asymptomatic patients were excluded. The 16 regional groups of the VQI were used to compare variation in patient selection, operative indication, technical approach, and process measures. χ2 analysis was used to assess for differences across regions where appropriate. RESULTS A total of 52,373 interventions were included (31%). Of the 16,145 bypasses, 5% were performed for asymptomatic disease, 26% for claudication, 56% for chronic limb-threatening ischemia (CLI) (61% of these for tissue loss), and 13% for acute limb-threatening ischemia. Of the 35,338 endovascular procedures, 4% were for asymptomatic disease, 40% for claudication, 46% for CLI (73% tissue loss), and 12% for acute limb-threatening ischemia. Potentially unwarranted variation included proportion of prosthetic conduit for infrapopliteal bypass in claudication (13%-41%, median, 29%; P < .001), isolated tibial endovascular intervention for claudication (0.0%-5.0%, median, 3.0%; P < .001), discharge on antiplatelet and statin (bypass: 62%-84%; P < .001; endovascular: 63%-89%; P < .001), and ultrasound guidance for percutaneous access (claudication: range, 7%-60%; P < .001; CLI: 5%-65%; P < .001). Notable areas needing further research with significant variation include proportion of CLI vs claudication treated by bypass (38%-71%; P < .001) and endovascular intervention (28%-63%; P < .001), and use of closure devices in percutaneous access (claudication; 26%-76%; P < .001; CLI: 30%-78%; P < .001). CONCLUSIONS Significant variation exists both in areas where evidence exists for best practice and, therefore, potentially unwarranted variation, and in areas of clinical ambiguity. Quality improvement efforts should be focused on reducing unwarranted variation. Further research should be directed at identifying best practice where no established guidelines and high variation exists.
Collapse
Affiliation(s)
- Peter A Soden
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Sara L Zettervall
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Thomas Curran
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Ageliki G Vouyouka
- Division of Vascular Surgery, Mount Sinai Health Systems, Icahn School of Medicine, New York, NY
| | - Philip P Goodney
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Dartmouth Medical School, Hanover, NH
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, Tex
| | - John W Hallett
- Division of Cardiovascular Surgery, Medical University of South Carolina, Charleston, SC
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
| |
Collapse
|
48
|
Schmitz-Rixen T, Torsello G, Steinbauer M, Grundmann RT. The endovascular performance spectrum of vascular surgery departments in Germany: Results of an online survey among senior department physicians. GEFASSCHIRURGIE 2016; 21:63-70. [PMID: 27546991 PMCID: PMC4974286 DOI: 10.1007/s00772-016-0157-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Aim To survey the scope of vascular surgery services in Germany. Method A total of 308 senior German vascular surgeons received a 19-point questionnaire pertaining to department structure and scope of services. Of these surgeons 223 replied between 16 August 2015 and 23 October 2015 (response rate 72 %), with 62.2 % reporting an additional qualification as an endovascular surgeon according to the guidelines of the German Society for Vascular Surgery and Vascular Medicine (Deutsche Gesellschaft für Gefäßchirurgie und Gefäßmedizin, DGG) and 43.5 % as a DGG® endovascular specialist. Results The number of respondents fully authorized to train in vascular surgery was 71.3 %, while 28.3 % were authorized for limited training. Authorization as a DGG® endovascular surgeon was reported by 24.2 % and authorization as a DGG® endovascular specialist by 17 % of respondents. All respondents performed endovascular interventions on pelvic vessels and 99.1 % also reported carrying out femoral and popliteal endovascular interventions. Endovascular procedures in crural vessels were carried out by 90.1 % and 93.7 % of vascular surgeons performed endovascular procedures in the region of the abdominal aorta (segment V), arteriovenous (AV) fistulas and shunts (85.2 %), upper extremity vessels (80.3 %), the thoracic aorta (segment III, 68.2 %), renal arteries (62.8 %) and visceral aorta (segment IV, 60.5 %). In all 43.5 % of respondents reported experience with endovascular procedures on the carotid bifurcation. Percutaneous arterial procedures formed the focus of endovascular activity, totalling on average 259 interventions per year and department, followed by diagnostic angiography (without intervention) at 166 procedures per year and hybrid arterial interventions at 141 interventions per year. Conclusion This survey revealed a high level of endovascular expertise among vascular surgeons in Germany. This applies not only to the scope of endovascular activities in diagnosis and treatment but also to the number of estimated annual procedures.
Collapse
Affiliation(s)
- T Schmitz-Rixen
- Klinik für Gefäß- und Endovascularchirurgie, Klinikum der Goethe-Universität, Theodor-Stern-Kai-7, 60590 Frankfurt am Main, Deutschland
| | - G Torsello
- Klinik für Vaskuläre und Endovaskuläre Chirurgie, Universitätsklinikum und St. Franziskus Hospital Münster, Münster, Deutschland
| | - M Steinbauer
- Klinik für Gefäßchirurgie, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Deutschland
| | - R T Grundmann
- Deutsches Institut für Gefäßmedizinische Gesundheitsforschung gGmbH, Berlin, Deutschland
| |
Collapse
|
49
|
A comparison of the knowledge base and surgical skills of integrated versus independent vascular surgery trainees. J Vasc Surg 2016; 64:514-519. [DOI: 10.1016/j.jvs.2016.02.050] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 02/23/2016] [Indexed: 11/23/2022]
|
50
|
Pedersen RC, Li Y, Chang JS, Lew WK, Patel K(K. Effect of Endovascular Interventions on General Surgery Trainee Operative Experience; a Comparison of Case Log Reports. Ann Vasc Surg 2016; 33:98-102. [DOI: 10.1016/j.avsg.2016.02.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 02/28/2016] [Accepted: 02/29/2016] [Indexed: 11/28/2022]
|