1
|
Herrold JA, Adnan S, Romagnoli A, Madurska MJ, Betzold R, DuBose J, Scalea T, Morrison JJ. Certification in endovascular hemostasis for trauma surgeons: Possible and practical? J Trauma Acute Care Surg 2021; 91:775-780. [PMID: 34108419 DOI: 10.1097/ta.0000000000003234] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Endovascular hemostasis is commonplace with many practitioners providing services. Accruing sufficient experience during training could allow acute care surgeons (ACSs) to expand their practice. We quantified case load and training opportunities at our center, where dedicated dual-trained ACS/vascular surgery faculty perform these cases. Our aim was to assess whether ACS fellows could obtain sufficient experience in 6 months of their fellowship in order to certify in these techniques, per the requirements of other specialties. METHODS We performed a retrospective case series where we reviewed 6 years (2013-2018) of endovascular activity at an academic, level I trauma center quantifying arterial access, angiography, embolization, stent and stent graft placement, and IVC filter procedures. This was compared with the certification requirements for interventional radiology, vascular surgery, cardiothoracic surgery, and interventional cardiology. RESULTS Between 2013 and 2018, 1,179 patients with a mean ± SD Injury Severity Score of 22.47 ± 13.24, underwent 4960 procedures. Annual rates per procedure, expressed as median (interquartile range), were arterial access 193.5 (181-195.5), diagnostic angiography 352 (321.5-364.5), embolization 90.5 (89.25-93.25), stent placement 24 (13.5-29.25), and IVC filter procedures 16.5 (10-23.75). Our 6-month case volume exceeded or was within 85% of the required number of cases for vascular surgery and interventional radiology training, with the exception of stent-graft deployment for both specialties, and therapeutic procedures for vascular surgery. CONCLUSION The case volume at a large trauma center with a dedicated endovascular trauma service is sufficient to satisfy the case requirements for endovascular certification. Our trainees are already acquiring this experience informally. An endovascular trauma curriculum should now be developed to support certification within ACS fellowship training.
Collapse
|
2
|
A Surgical Endovascular Trauma Service Increases Case Volume and Decreases Time to Hemostasis. Ann Surg 2019; 270:612-619. [DOI: 10.1097/sla.0000000000003486] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
3
|
Schirmer CM, Siddiqui AH, Frid I, Khalessi AA, Mocco J, Griessenauer CJ, Goren O, Dalal S, Weiner G, Arthur AS. Modern Training and Credentialing in Neuroendovascular Acute Ischemic Stroke Therapy. Neurosurgery 2019; 85:S52-S57. [DOI: 10.1093/neuros/nyz014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 01/23/2019] [Indexed: 01/01/2023] Open
Affiliation(s)
- Clemens M Schirmer
- Department of Neurosurgery and Neuroscience Institute, Geisinger, Danville, Pennsylvania
| | - Adnan H Siddiqui
- Toshiba Stroke and Vascular Research Center, Department of Neurosurgery, Department of Radiology, University at Buffalo, State University of New York, Buffalo, New York
| | - Ilya Frid
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania
| | - Alexander A Khalessi
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California
| | - J Mocco
- Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Christoph J Griessenauer
- Department of Neurosurgery and Neuroscience Institute, Geisinger, Danville, Pennsylvania
- Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Oded Goren
- Department of Neurosurgery and Neuroscience Institute, Geisinger, Danville, Pennsylvania
| | - Shamsher Dalal
- Department of Radiology, Geisinger, Danville, Pennsylvania
| | - Gregory Weiner
- Department of Neurosurgery and Neuroscience Institute, Geisinger, Danville, Pennsylvania
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis, Tennessee
| |
Collapse
|
4
|
Tenorio ER, Mirza AK, Kärkkäinen JM, Oderich GS. Lessons learned and learning curve of fenestrated and branched endografts. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 60:23-34. [PMID: 30221895 DOI: 10.23736/s0021-9509.18.10728-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Fenestrated and branched endovascular repair (F-BEVAR) has been increasingly used to treat patients with complex aortic aneurysms involving the renal-mesenteric arteries. As with any new procedure, there is a learning curve associated with mastering the technique. However, proficiency with deployment is only one aspect of the learning process, and ultimately, this curve is defined not by one quality parameter, but by patient selection, the performance of the entire team, the surgeon's ability to adapt to unexpected events, and the durability of the repair. This article reviews the importance of novel training paradigms, learning curve, and factors affecting outcomes of complex endovascular aneurysm repair.
Collapse
Affiliation(s)
- Emanuel R Tenorio
- Division of Vascular and Endovascular Surgery, Mayo Clinic Aortic Center, Rochester, MN, USA
| | - Aleem K Mirza
- Division of Vascular and Endovascular Surgery, Mayo Clinic Aortic Center, Rochester, MN, USA
| | - Jussi M Kärkkäinen
- Division of Vascular and Endovascular Surgery, Mayo Clinic Aortic Center, Rochester, MN, USA
| | - Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, Mayo Clinic Aortic Center, Rochester, MN, USA -
| |
Collapse
|
5
|
Calligaro KD, Amankwah KS, D'Ayala M, Brown OW, Collins PS, Eslami MH, Jain KM, Kassavin DS, Propper B, Sarac TP, Shutze WP, Webb TH. Guidelines for hospital privileges in vascular surgery and endovascular interventions: Recommendations of the Society for Vascular Surgery. J Vasc Surg 2018; 67:1337-1344. [DOI: 10.1016/j.jvs.2018.02.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
6
|
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: 169] [Impact Index Per Article: 24.1] [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
|
7
|
Simonte G, Parlani G, Farchioni L, Isernia G, Cieri E, Lenti M, Cao P, Verzini F. Lesson Learned with the Use of Iliac Branch Devices: Single Centre 10 Year Experience in 157 Consecutive Procedures. Eur J Vasc Endovasc Surg 2017; 54:95-103. [DOI: 10.1016/j.ejvs.2017.03.026] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 03/31/2017] [Indexed: 01/29/2023]
|
8
|
Creager MA, Goldstone J, Hirshfeld JW, Kazmers A, Kent KC, Lorell BH, Olin JW, Pauly RR, Rosenfield K, Roubin GS, Sicard GA, White CJ, Merli FG, Rodger GP, Tracy CM, Weitz HH. ACC/ACP/SCAI/SVMB/SVS Clinical Competence statement. Vasc Med 2016; 9:233-48. [PMID: 15675194 DOI: 10.1191/1358863x04vm562xx] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
9
|
Inui T, Bandyk DF. Can interventionalists do endovascular aortic aneurysm repair as well as vascular surgeons? Adv Surg 2014; 48:43-52. [PMID: 25293606 DOI: 10.1016/j.yasu.2014.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
|
10
|
Practice or perish: why bedside toxicology is essential to the survival of our specialty. J Med Toxicol 2013; 9:6-8. [PMID: 23275211 DOI: 10.1007/s13181-012-0284-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
|
11
|
Ullery BW, Nathan DP, Jackson BM, Wang GJ, Fairman RM, Woo EY. Qualitative Impact of the Endovascular Era on Vascular Surgeons’ Comfort Level and Enjoyment With Open and Endovascular AAA Repairs. Vasc Endovascular Surg 2012; 46:150-6. [DOI: 10.1177/1538574411432147] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To evaluate the qualitative impact of training in the endovascular era (post-2000) on vascular surgeons’ comfort level and enjoyment with abdominal aortic aneurysm (AAA) repairs. Methods: A sample of vascular surgeons (n = 1754) were sent a survey pertaining to their fellowship training and practice of AAA repair. The influence of training- and practice-related variables on qualitative outcomes was assessed. Results: A total of 382 (22%) surgeons completed the survey. Surgeons who performed more endovascular aneurysm repairs (EVARs) than open AAA repairs were more likely to enjoy EVAR ( P < .001). Those completing fellowship after 2000 reported a higher level of procedure-related comfort with EVAR ( P = .001) compared to those completing fellowship before 2000. Conversely, surgeons completing fellowship before 2000 reported a higher level of procedure-related comfort with open AAA repair ( P = .001). Conclusion: The advent of EVAR has changed fellowship training of AAA repair and has translated into changes in both practice patterns and comfort level.
Collapse
Affiliation(s)
- Brant W. Ullery
- Division of Vascular Surgery and Endovascular Therapy, University of Pennsylvania, Philadelphia, PA, USA
| | - Derek P. Nathan
- Division of Vascular Surgery and Endovascular Therapy, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin M. Jackson
- Division of Vascular Surgery and Endovascular Therapy, University of Pennsylvania, Philadelphia, PA, USA
| | - Grace J. Wang
- Division of Vascular Surgery and Endovascular Therapy, University of Pennsylvania, Philadelphia, PA, USA
| | - Ronald M. Fairman
- Division of Vascular Surgery and Endovascular Therapy, University of Pennsylvania, Philadelphia, PA, USA
| | - Edward Y. Woo
- Division of Vascular Surgery and Endovascular Therapy, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
12
|
Bech B, Lönn L, Falkenberg M, Bartholdy N, Räder S, Schroeder T, Ringsted C. Construct Validity and Reliability of Structured Assessment of endoVascular Expertise in a Simulated Setting. Eur J Vasc Endovasc Surg 2011; 42:539-48. [DOI: 10.1016/j.ejvs.2011.05.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 05/05/2011] [Indexed: 11/30/2022]
|
13
|
Riga CV, Bicknell CD, Hamady MS, Cheshire NJW. Evaluation of robotic endovascular catheters for arch vessel cannulation. J Vasc Surg 2011; 54:799-809. [PMID: 21620623 DOI: 10.1016/j.jvs.2011.03.218] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Revised: 03/02/2011] [Accepted: 03/04/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Conventional catheter instability and embolization risk limits the adoption of endovascular therapy in patients with challenging arch anatomy. This study investigated whether arch vessel cannulation can be enhanced by a remotely steerable robotic catheter system. METHODS Seventeen clinicians with varying endovascular experience cannulated all arch vessels within two computed tomography-reconstructed pulsatile flow phantoms (bovine type I and type III aortic arches), under fluoroscopic guidance, using conventional and robotic techniques. Quantitative (catheterization times, catheter tip movements, vessel wall hits, catheter deflection) and qualitative metrics (Imperial College Complex Endovascular Cannulation Scoring Tool [IC3ST]) performance scores were compared. RESULTS Robotic catheterization techniques resulted in a significant reduction in median carotid artery cannulation times and the median number of catheter tip movements for all vessels. Vessel wall contact with the aortic arch wall was reduced to a median of zero with robotic catheters. During stiff guidewire exchanges, robotic catheters maintained stability with zero deflection, independent of the distance the catheter was introduced into the carotid vessels. Overall IC3ST performance scores (interquartile range) were significantly improved using the robotic system: Type I arch score was 26/35 (20-30.8) vs 33/35 (31-34; P = .001), and type III arch score was 20.5/35 (16.5-28.5) vs 26.5/35 (23.5-28.8; P = .001). Low- and medium-volume interventionalists demonstrated an improvement in performance with robotic cannulation techniques. The high-volume intervention group did not show statistically significant improvement, but cannulation times, movements, and vessel wall hits were significantly reduced. CONCLUSION Robotic technology has the potential to reduce the time, risk of embolization and catheter dislodgement, radiation exposure, and the manual skill required for carotid and arch vessel cannulation, while improving overall performance scores.
Collapse
Affiliation(s)
- Celia V Riga
- Imperial Vascular Unit, St. Mary's Hospital, Imperial College London, London, UK.
| | | | | | | |
Collapse
|
14
|
Riga CV, Bicknell CD, Sidhu R, Cochennec F, Normahani P, Chadha P, Kashef E, Hamady M, Cheshire NJW. Advanced catheter technology: is this the answer to overcoming the long learning curve in complex endovascular procedures. Eur J Vasc Endovasc Surg 2011; 42:531-8. [PMID: 21388839 DOI: 10.1016/j.ejvs.2011.02.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Accepted: 02/02/2011] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Advanced endovascular procedures require a high degree of skill with a long learning curve. We aimed to identify differential increases in endovascular skill acquisition in novices using conventional (CC), manually steerable (MSC) and robotic endovascular catheters (RC). MATERIALS/METHODS 10 novices cannulated all vessels within a CT-reconstructed pulsatile-flow arch phantom in the Simulated Endovascular Suite. Subjects were randomly assigned to conventional/manually-steerable/robotic techniques as the first procedure undertaken. The operators repeated the task weekly for 5 weeks. Quantitative (cannulation times, wire/catheter-tip movements, vessel wall hits) and qualitative metrics (validated rating scale (IC3ST)) were compared. RESULTS Subjects exhibited statistically significant differences when comparing initial to final performance for total procedure times and catheter-tip movements with all catheter types. Sequential non-parametric comparisons identified learning curve plateau levels at weeks 2 or 3(RCs, MSCs), and at week 4(CCs) for the majority of metrics. There were significantly fewer catheter-tip movements using advanced catheter technology after training (Week 5: CC 74 IQR(59-89) versus MSC 62(44-81); p = 0.028, and RC 33 (28-44); p = 0.012). RCs virtually eliminated wall hits at the arch (CC 29(28-76) versus RC 8(6-9); p = 0.005) and produced significantly higher overall performance scores (p < 0.02). CONCLUSION Advanced endovascular catheters, although more intricate, do not seem to take longer to master and in some areas offer clear advantages with regards to positional control, at a faster rate. RCs seem to be the most intuitive and advanced skill acquisition occurs with minimal training. Robotic endovascular technology may have a significantly shorter path to proficiency allowing an increased number of trainees to attempt more complex endovascular procedures earlier and with a greater degree of safety.
Collapse
Affiliation(s)
- C V Riga
- Regional Vascular & Endovascular Unit, Imperial College London, United Kingdom.
| | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Franz RW. General Versus Vascular Surgeon: Impact of a Vascular Fellowship on Clinical Practice, Surgical Case Load, and Lifestyle. Ann Vasc Surg 2010; 24:196-204. [DOI: 10.1016/j.avsg.2008.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2008] [Revised: 10/31/2008] [Accepted: 11/06/2008] [Indexed: 11/16/2022]
|
16
|
Connors JJ, Sacks D, Black CM, McIff EB, Stallmeyer MJB, Cole JW, Rowley HA, Wojak JC, Mericle RA, Murphy KJ, Cardella JF. Training guidelines for intra-arterial catheter-directed treatment of acute ischemic stroke: a statement from a special writing group of the Society of Interventional Radiology. J Vasc Interv Radiol 2010; 20:1507-22. [PMID: 19944980 DOI: 10.1016/j.jvir.2009.10.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2009] [Revised: 10/11/2009] [Accepted: 10/13/2009] [Indexed: 10/20/2022] Open
Affiliation(s)
- J J Connors
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Reed AB, Rhodes R, Ricotta J. Determining who trains vascular surgery fellows in endovascular techniques. J Vasc Surg 2010; 51:756-9. [PMID: 20045620 DOI: 10.1016/j.jvs.2009.10.109] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Revised: 10/19/2009] [Accepted: 10/19/2009] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Vascular surgery training has evolved from a single clinical year after general surgery training to a multi-year training program to encompass such entities as noninvasive vascular laboratory, office-based procedures, and endovascular techniques. Simultaneously, members of the vascular surgery community have had to undergo significant training to become facile with endovascular techniques. We surveyed vascular surgery trainees on the online Vascular Surgery In-Training Examination (VSITE) in 2008 and 2009 to assess who trained them in percutaneous techniques. METHODS Vascular surgery trainees in the Independent (2-year) and Integrated (5-year) training programs were asked to participate in a survey upon completion of the VSITE in 2008 and 2009. Examinees were asked to select whether vascular surgeons, cardiologists, or interventional radiologists trained them in carotid angioplasty and stenting (CAS), thoracic endografts (TEVAR), endovascular abdominal aortic aneurysm repair (EVAR), renal artery intervention, iliac stenting, superficial femoral artery (SFA), and tibial artery percutaneous interventions. RESULTS Survey response rate was 79.6% (191 of 240). Results of the survey are shown in Table I. In 2009, vascular surgeons provided more than 84% of the training to vascular surgery residents. Only six respondents had >50% of their percutaneous training with interventional radiology and two with cardiologists. CONCLUSION Vascular surgeons involved in resident education have been able to retrain themselves in endovascular techniques such that they are now able to provide greater than 80% of the endovascular experience to vascular surgery residents.
Collapse
Affiliation(s)
- Amy B Reed
- Division of Vascular Surgery, University of Cincinnati Medical Center, Cincinnati, OH 45267, USA.
| | | | | |
Collapse
|
18
|
Connors JJ, Sacks D, Furlan AJ, Selman WR, Russell EJ, Stieg PE, Hadley MN, Wojak JC, Koroshetz WJ, Heros RC, Strother CM, Duckwiler GR, Durham JD, Tom-sick TO, Rosenwasser RH, McDougall CG, Haughton VM, Derdeyn CP, Wechsler LR, Hudgins PA, Alberts MJ, Raabe RD, Gomez CR, Cawley CM, Krol KL, Futrell N, Hauser RA, Frank JI. Training, competency, and credentialing standards for diagnostic cervicocerebral angiography, carotid stenting, and cerebrovascular intervention: a joint statement from the American Academy of Neurology, the American Association of Neurological Surgeons, the American Society of Interventional and Therapeutic Neuroradiology, the American Society of Neuroradiology, the Congress of Neurological Surgeons, the AANS/CNS Cerebrovascular Section, and the Society of Interventional Radiology. J Vasc Interv Radiol 2009; 20:S292-301. [PMID: 19560013 DOI: 10.1016/j.jvir.2009.04.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
|
19
|
Sacks D, Connors JJ. Carotid stenting, stroke prevention, and training. J Vasc Interv Radiol 2009; 20:S302-5. [PMID: 19560014 DOI: 10.1016/j.jvir.2009.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- David Sacks
- Department of Radiology, Reading Hospital and Medical Center, Sixth and Spruce Streets, West Reading, PA 19603, USA.
| | | |
Collapse
|
20
|
Karmy-Jones R, Kouchoukos NT. Endovascular credentialing and assembling the endovascular team. J Card Surg 2009; 24:334-42. [PMID: 19438793 DOI: 10.1111/j.1540-8191.2009.00839.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Riyad Karmy-Jones
- Department of Thoracic and Vascular Surgery, Southwest Washington Medical Center, Vancouver, Washington, USA
| | | |
Collapse
|
21
|
Vascular surgery training trends from 2001-2007: A substantial increase in total procedure volume is driven by escalating endovascular procedure volume and stable open procedure volume. J Vasc Surg 2009; 49:1339-44. [PMID: 19217743 DOI: 10.1016/j.jvs.2008.12.019] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2008] [Revised: 11/17/2008] [Accepted: 12/08/2008] [Indexed: 11/27/2022]
Abstract
BACKGROUND Endovascular procedure volume has increased rapidly, and endovascular procedures have become the initial treatment option for many vascular diseases. Consequently, training in endovascular procedures has become an essential component of vascular surgery training. We hypothesized that, due to this paradigm shift, open surgical case volume may have declined, thereby jeopardizing training and technical skill acquisition in open procedures. METHODS Vascular surgery trainees are required to log both open and endovascular procedures with the Accreditation Council for Graduate Medical Education (ACGME). We analyzed the ACGME database (2001-2007), which records all cases (by Current Procedural Terminology [CPT] code) performed by graduating vascular trainees. Case volume was evaluated according to the mean number of cases performed per graduating trainee. RESULTS The mean number of total major vascular procedures performed per trainee increased by 174% between 2001 and 2007 (from 298.3 to 519.2). Endovascular diagnostic and therapeutic procedures increased by 422% (from 63.7 to 269.1) and accounted for 93.0% of the increase in total procedures. The number of open aortic procedures (aneurysm, occlusive, mesenteric, renal) decreased by 17.1% (from 49.7 to 41.2), while the number of endovascular aortic aneurysm repair procedures increased by 298.8% (from 16.9 to 50.5). Specifically, open aortic aneurysm procedures decreased by 21.8%, aortobifemoral bypass increased by 3.2%, and open mesenteric or renal procedures decreased by 13%. Infrainguinal bypass procedures remained relatively constant (from 37.6 to 36.5, 2.9% decrease), and the number of carotid endarterectomy procedures performed did not change significantly (from 43.6 to 42.2, 3.2% decrease). CONCLUSION Vascular surgery trainees are performing a vastly increased total number of procedures. This increase in total procedure volume is almost entirely attributable to the recent increase in endovascular procedures. Aside from a small decline in open aortic procedures, the volume of open surgical procedures has largely remained stable. It is essential that vascular surgery training programs continue to focus on both endovascular and open surgical skills in order for vascular surgeons to remain the premier specialists to care for patients with vascular disease.
Collapse
|
22
|
Qureshi AI, Abou-Chebl A, Jovin TG. Qualification Requirements for Performing Neurointerventional Procedures: A Report of the Practice Guidelines Committee of the American Society of Neuroimaging and the Society of Vascular and Interventional Neurology. J Neuroimaging 2008; 18:433-47. [DOI: 10.1111/j.1552-6569.2007.00210.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
23
|
Henke PK, Brant-Zawadzki PB, Kraiss LW. Basic research by vascular surgeons: why it is important and how to keep it going. J Vasc Surg 2008; 47:882-5. [PMID: 18381151 DOI: 10.1016/j.jvs.2007.11.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2007] [Revised: 11/14/2007] [Accepted: 11/21/2007] [Indexed: 11/17/2022]
|
24
|
Guidelines for hospital privileges in vascular and endovascular surgery: Recommendations of the Society for Vascular Surgery. J Vasc Surg 2008; 47:1-5. [DOI: 10.1016/j.jvs.2007.10.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2007] [Revised: 09/28/2007] [Accepted: 10/03/2007] [Indexed: 11/22/2022]
|
25
|
Passman MA, Fleser PS, Dattilo JB, Guzman RJ, Naslund TC. Should simulator-based endovascular training be integrated into general surgery residency programs? Am J Surg 2007; 194:212-9. [PMID: 17618806 DOI: 10.1016/j.amjsurg.2006.11.029] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2006] [Revised: 11/12/2006] [Accepted: 11/14/2006] [Indexed: 01/22/2023]
Abstract
BACKGROUND The impact of high-fidelity simulators as an adjunct for endovascular training of general surgery residents has not yet been defined. The purpose of this study was to evaluate general surgery resident perspectives on the value of a simulator-based endovascular training program by using various measurement tools. METHODS General surgery residents in postgraduate years 1 to 5 (n = 50) participated in a focused endovascular training course covering aortoiliac, renal, and carotid artery disease. The components of the course included didactic lecture, self-learning course material and computer training modules, hands-on exposure to endovascular instruments, and endovascular procedure simulation using a mobile SimSuite unit (Medical Simulation Corporation, Denver, CO). Course participants completed pre- and postcourse questionnaires, knowledge-based testing, and endovascular simulator metric testing. RESULTS Of the 50 general surgery residents who completed the precourse questionnaire and knowledge-based testing, 41 completed the entire program including the postcourse questionnaire and knowledge-based testing, and 33 completed endovascular simulation metric testing. Subjective responses from pre- and postcourse surveys highlighting the residents' perceptions of the potential role of endovascular simulation as part of general surgery residency training showed favorable responses. On completion of the course, mean knowledge-based test scores had statistically significant improvement (pretest, n = 50, 59.5% +/- 12.1% correct and posttest, n = 41, 69.1% +/- 15.4% correct [P = .003]). For metric testing of a simulated endovascular procedure (n = 33), 93.9% completed all of the defined tasks within the allotted time period (mean time, 12.2 +/- 4.36 minutes; range, 4.1-26.6 minutes; 95% confidence interval for mean 10.8-13.6 minutes). CONCLUSIONS Based on subjective and objective measures, general surgery residents found valuable and benefited in knowledge base from a focused simulator-based endovascular training program. Integrating endovascular simulation into general surgery resident training and its influence on resident interest in vascular specialization as a career choice holds future potential.
Collapse
Affiliation(s)
- Marc A Passman
- Section of Vascular Surgery, University of Alabama at Birmingham, BDB 503, 1808 7th Avenue South, Birmingham, AL 35294-0012, USA.
| | | | | | | | | |
Collapse
|
26
|
Wolff T, Gürke L, Jacob A, Eugster T, Stierli P. Gefäßchirurgische Ausbildung in endovaskulären Techniken am Universitären Gefäßzentrum Aarau-Basel. GEFÄSSCHIRURGIE 2007. [DOI: 10.1007/s00772-007-0531-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
27
|
Schareck W, Bünger C, Nienaber CA, Hofmockel R, Liebold A, Kroeger JC, Rolfs A. URIG*: Charakteristik des Interdisziplinären Gefäßzentrums der Universität Rostock. Visc Med 2006. [DOI: 10.1159/000096614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
28
|
Abstract
In recent years, vascular surgery fellowships have changed substantially to meet the requirements for interventional as well as open surgical training. Data from the Residency Review Committee for Surgery indicate that the average vascular fellow performed fewer than 15 interventional procedures in 2000, but that this volume had increased to more than 200 interventional procedures by 2005, an increase of 255%. During the same interval, there was a slight (4%) decrease in the average number of major open vascular reconstructions performed. In 2005, the average vascular fellow performed 450 primary procedures, nearly equally divided between open and interventional cases. Selected open operations, such as aortic aneurysm repair, have decreased in volume due to the substitution by endovascular procedures. Operative volume for vascular fellows has been preserved in part by a 19% reduction in major vascular operations performed by general surgery residents. However, with added overall volume due to the increased prevalence of vascular disease in the aging population, there appears to be adequate case material to train future vascular surgeons, as long as less commonly performed operations continue to be focused on vascular trainees.
Collapse
Affiliation(s)
- Jack L Cronenwett
- Department of Surgery, Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.
| |
Collapse
|
29
|
Abstract
In the 25 years that formalized vascular surgery training and certification has been, in effect, the treatment of patients with peripheral vascular disease has undergone dramatic changes, largely due to the emergence of a wide variety of endoluminal techniques and devices that enable minimally invasive treatment of conditions that formerly required operative intervention. Unfortunately, vascular surgeons, for the most part, were painfully slow to embrace these new and evolving technologies, which became increasingly complex as they expanded to treat virtually all vascular maladies in all peripheral vascular territories. Not surprisingly, this left vascular surgeons disadvantaged relative to other disciplines for whom these techniques were more familiar, and we have spent the better part of the last decade playing catch-up to master them and regain our role as the only specialty qualified to offer all types of therapies to our patients with vascular disease. This has caused some to question what changes need to be made in our vascular surgery training paradigm for our new trainees to attain and maintain a preeminent role in the evaluation and treatment of patients with peripheral vascular disease. While the knee-jerk response is to consider special or supplemental training programs for these advanced techniques, or even certificates of added qualifications for the more challenging of them, such as carotid stenting, we believe that all that is really needed is for the vascular surgical community as a whole, and particularly those faculty in training programs, to truly embrace these new technologies and apply them to the patients they are already rendering care to. Given the prevalence of vascular disease and overall wealth of clinical material already present in most training programs, the simple willingness to apply endoluminal therapies to our existing patient populations is all that would really be needed to insure that all future graduates of vascular surgery training programs are fully competent in all of the current endoluminal therapies and well-positioned to continue to evolve with the field. The real question to be considering, which is beyond the focus of this article, is how we are to maintain our open surgical skills in the era of minimally invasive treatment of vascular disease.
Collapse
Affiliation(s)
- Colleen M Johnson
- Department of Surgery, Division of Vascular Surgery, Southern Illinois School of Medicine, Springfield, IL, USA
| | | |
Collapse
|
30
|
Gaines P, Nicholson T. A suggested training programme for carotid artery stenting (CAS). Eur J Radiol 2006; 60:37-9. [PMID: 16860505 DOI: 10.1016/j.ejrad.2006.05.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2006] [Accepted: 05/29/2006] [Indexed: 10/24/2022]
Abstract
Carotid artery stenting as an alternative to traditional carotid endartrectomy is becoming increasingly important in the treatment of transient ischemic attack and stroke. Physicians from several different medical disciplines are interested in treating appropriate patients by this method. Patients are entitled to know what training and experience the surgeon or clinician has before giving consent. This should involve endovascular experience in all systems and experience and knowledge of cerebral angiography and intervention. A multidisciplinary approach and reporting of adverse events is vital for patient safety.
Collapse
Affiliation(s)
- Peter Gaines
- Sheffield Vascular Institute, Northern General Hospital, Sheffield, UK.
| | | |
Collapse
|
31
|
Sarac TP, Ouriel K. Impact of carotid artery stent trials on the education and training of vascular surgeons. Semin Vasc Surg 2006; 19:92-5. [PMID: 16782514 DOI: 10.1053/j.semvascsurg.2006.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Clinical trials directed at evaluating the efficacy and safety of carotid artery stenting (CAS) have accelerated development of didactic and technical training programs for both newly trained and experienced vascular surgeons. This report reviews the current status of guidelines for CAS and the evolution of related educational programs necessary to impart the clinical, cognitive, and technical skills required for the optimal care of patients with this new technology.
Collapse
Affiliation(s)
- Timur P Sarac
- Department of Vascular Surgery, The Cleveland Clinic Lerner School of Medicine, Cleveland, OH 44195, USA.
| | | |
Collapse
|
32
|
McLucas B. Endovascular training for obstetrician-gynecologists: Suggestions for credentialing. MINIM INVASIV THER 2006; 14:352-6. [PMID: 16754180 DOI: 10.1080/13645700500393896] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This article suggests guidelines for training and credentialing of obstetrician-gynecologists to perform endovascular procedures. It concentrates on the performance of uterine artery embolization for symptomatic myomata. Comparison is made between other recommended case numbers for credentialing of surgeons, radiologists, and cardiologists. Educational courses are discussed, as are the credits obtained for a typical uterine artery embolization. Two paradigms of endovascular credentialing are appropriate for comparison: Cardiology standards for coronary artery interventions and vascular surgery standards for endovascular stent placement. Both require a course including laboratory and participation in 100 cases, 50 of which as primary operator. In addition, many countries require a certificate of fluoroscopy safety. A credentialing board will be created to verify both the standards and completion of course requirement and proctored cases. Credentialing will benefit both patients and obstetrician gynecologists who will be able to provide continuity of care not currently available. The gynecologist will be able to manage all complications, including myomata, which cannot be done under current circumstances.
Collapse
|
33
|
Abstract
The rapid evolution of catheter-based technologies during the last 5 years has created a critical need for development of effective resident level and postgraduate education programs in both open and endovascular techniques and associated cognitive and clinical skills. Currently, significant variability exists in endovascular training formats and in the number of endovascular procedures performed during the course of a graduate or postgraduate program. Little information on the quality of these programs exists and in the subsequent practice patterns of the trainees. This report reviews recommended credentialing requirements, training paradigms, and the growing experience of vascular surgical trainees since 2000.
Collapse
Affiliation(s)
- Wei Zhou
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA.
| | | | | | | |
Collapse
|
34
|
Weaver FA, Hood DB, Shah H, Alexander J, Katz S, Rowe V, Yellin AE. Current guidelines produce competent endovascular surgeons. J Vasc Surg 2006; 43:992-8; discussion 998. [PMID: 16678695 DOI: 10.1016/j.jvs.2006.01.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2005] [Accepted: 01/30/2006] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study was conducted to evaluate the safety of percutaneous endovascular procedures (PEPs) during integration of endovascular skills into an urban academic vascular surgery practice and assess the hypothesis that currently accepted guidelines are a valid benchmark for endovascular competency. METHODS From 2000 through 2004, an endovascular training paradigm was instituted to integrate endovascular procedures into an academic endovascular practice. The paradigm involved individual mentoring of vascular surgery faculty by a partner with mature endovascular skills. Mentoring continued until each surgeon achieved a procedural experience of 100 diagnostic angiograms and 50 percutaneous endovascular interventions. Once achieved, privileges were granted for independent endovascular practice. To assess the effectiveness of the training process and competency of the newly trained endovascular practitioner, the surgeon-specific 30-day incidence of major complications and deaths for all PEPs performed during and after the mentoring process was determined. Complications and deaths were assigned to the mentor during the training process and to the individual surgeon once endovascular privileges were granted. Complications were classified as local vascular, local nonvascular, or systemic/remote. RESULTS From 2000 through 2004, 1208 PEPs were performed. During this time, three faculty surgeons achieved sufficient endovascular procedural experience and were granted endovascular privileges. Major complications consisted of 17 local vascular, three local nonvascular, and four systemic/remote. Three deaths occurred. Renal percutaneous transluminal angioplasty/stent procedures had the highest complication and death rate at 9%. The major complication and death rate per year was 1.8% to 4.9% (P = .32) and did not significantly vary. The major complication and death rate for all 1208 PEPs was 2.2%. The surgeon-specific complication and death rate was 1.9% to 3.6% (P = .14) and did not vary between surgeons. CONCLUSION Endovascular skills can be safely transferred using a vascular surgeon-based training paradigm. When the training paradigm is directed at satisfying currently recommended guidelines for endovascular privileging, competent endovascular surgeons are the result.
Collapse
Affiliation(s)
- Fred A Weaver
- Division of Vascular Surgery and Endovascular Therapies, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California 90033, USA.
| | | | | | | | | | | | | |
Collapse
|
35
|
Muhs BE, Maldonado T, Crotty K, Jayanetti C, Lamparello PJ, Adelman MA, Jacobowitz GR, Rockman C, Gagne PJ. Different Endovascular Referral Patterns Are Being Learned in Medical and Surgical Residency Training Programs. Ann Vasc Surg 2006; 20:217-22. [PMID: 16609831 DOI: 10.1007/s10016-006-9018-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2005] [Revised: 11/24/2005] [Accepted: 01/25/2006] [Indexed: 11/28/2022]
Abstract
Physicians in residency training will be the referring physicians of tomorrow. We sought to determine the current surgical and medical trainees' perception of vascular surgery's endovascular qualifications and capabilities. An anonymous survey was sent to all general surgery and internal medicine residents at a single academic institution. Respondents answered the question "Which specialty is the most qualified to perform (1) inferior vena cava (IVC) filter insertion; (2) angiograms, angioplasty, and stenting of the carotid arteries; (3) renal arteries; (4) aorta; and (5) lower extremity arteries?" For each question, respondents chose one response, either vascular surgery, interventional radiology, interventional cardiology, or do not know. One hundred respondents completed the survey (general surgery, n=50; internal medicine, n=50). There was a significant difference in the attitudes of surgery and medicine residents when choosing the most qualified endovascular specialist (p<0.05). Surgery residents chose vascular surgery as the most qualified specialty for each listed procedure: carotid (80%, n=40), IVC (56%, n=28), aorta (100%, n=50), extremity (86%, n=43), renal (78%, n=39). Medicine residents chose vascular surgery as the most qualified specialty less frequently: carotid (66%, n=33), IVC (6%, n=3), aorta (88%, n=44), extremity (72%, n=36), renal (16%, n=8). There was no significant difference in specialty selection based on postgraduate year. There is a large discrepancy between surgical and medical trainees' perception of vascular surgery's endovascular abilities, particularly regarding IVC placement and renal artery interventions. If our own institution mirrors the nation, each passing year a significant portion of the 21,722 graduating internal medicine residents go into practice viewing vascular surgeons as second-tier endovascular providers. A concerted campaign should be undertaken to educate medical residents regarding the skills and capabilities of vascular surgeons.
Collapse
Affiliation(s)
- Bart E Muhs
- Division of Vascular Surgery, New York University School of Medicine, New York, NY 10016, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Abstract
A 300-bed general hospital in a mid-sized city has a busy cardiac catheterization laboratory, with 12 invasive cardiologists and more than 4000 annual procedures. An invasive radiology suite, the only one in town, is staffed by a single invasive radiologist and two vascular surgeons. They perform about 150 diagnostic angiograms and endovascular procedures each year, about half of which are generated by consultation requests from the cardiologists. The invasive radiology team has worked together for the last 5 years, since an endovascular fellowship-trained vascular surgeon joined the staff. The invasive radiologist helped to develop an endovascular team and mentored the more senior vascular surgeon until he could accumulate the requisite number of procedures to become credentialed. The program's finances and work schedule have been arranged to the satisfaction of all three participants. Until recently, whenever cardiologists found evidence of vascular occlusive disease during catheterizations, they changed host arteries; if symptoms and signs indicated a need for therapy, they referred patients to the invasive radiology clinic. Lately, the cardiologists have begun to perform terminal angiograms on all their patients to detect injuries. They have requested clinical privileges to perform peripheral endovascular procedures as well as traditional cardiac work. The hospital administrator is fearful that the cardiologists may leave the hospital if their request is denied. The invasive radiology staff are concerned that the caseload is insufficient to maintain quality if they must divide it with the cardiologists. You are the hospital Chief of Staff and must decide whether to grant the cardiologists privileges which have thus far been reserved to the endovascular team. What should you do?
Collapse
Affiliation(s)
- James W Jones
- The Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX 77030, USA.
| | | | | |
Collapse
|
37
|
Connors JJ. Training, competency, and credentialing standards for carotid stenting. Tech Vasc Interv Radiol 2005; 7:210-4. [PMID: 16084447 DOI: 10.1053/j.tvir.2005.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Appropriate and adequate training is the hallmark of modern medical care. The foundation of medical education in the United States is accredited medical schools combined with formal residencies and fellowship training programs. This concept has been officially recognized by the Accreditation Council of Graduate Medical Education, the Federal Licensing Examination, all state medical boards, the federal government, and all medical professions and societies. Appropriate medical education is of utmost importance for procedures and therapies that offer the greatest risk to patients. There is little doubt that any procedure that has "stroke" as a defined potential risk would qualify as one that should require formal, adequate, and officially provided education. Hospitals and accrediting authorities such as the Joint Commission on Accreditation of Healthcare Organizations are obligated to ensure adequate standards of patient care in the United States.
Collapse
Affiliation(s)
- J J Connors
- Baptist Cardiac & Vascular Institute, 8900 Kendall Drive, Miami, FL 33176, USA.
| |
Collapse
|
38
|
Connors JJ, Sacks D, Furlan AJ, Selman WR, Russell EJ, Stieg PE, Hadley MN. Training, competency, and credentialing standards for diagnostic cervicocerebral angiography, carotid stenting, and cerebrovascular intervention: a joint statement from the American Academy of Neurology, the American Association of Neurological Surgeons, the American Society of Interventional and Therapeutic Neuroradiology, the American Society of Neuroradiology, the Congress of Neurological Surgeons, the AANS/CNS Cerebrovascular Section, and the Society of Interventional Radiology. J Vasc Interv Radiol 2005; 15:1347-56. [PMID: 15590785 DOI: 10.1097/01.rvi.0000147663.23211.9d] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Affiliation(s)
- John J Connors
- Interventional Neuroradiology, Miami Cardiac & Vascular Institute, FL 33176, USA.
| | | | | | | | | | | | | |
Collapse
|
39
|
|
40
|
Connors JJ, Sacks D, Furlan AJ, Selman WR, Russell EJ, Stieg PE, Hadley MN. Training, Competency, and Credentialing Standards for Diagnostic Cervicocerebral Angiography, Carotid Stenting, and Cerebrovascular Intervention. Radiology 2005; 234:26-34. [PMID: 15528261 DOI: 10.1148/radiol.2341041349] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
41
|
Affiliation(s)
- David Sacks
- Department of Radiology, Reading Hospital and Medical Center, Sixth and Spruce Streets, West Reading, Pennsylvania 19603, USA.
| | | |
Collapse
|
42
|
Choi HM, Hobson RW, Goldstein J, Chakhtoura E, Lal BK, Haser PB, Cuadra SA, Padberg FT, Jamil Z. Technical challenges in a program of carotid artery stenting. J Vasc Surg 2004; 40:746-51; discussion 751. [PMID: 15472604 DOI: 10.1016/j.jvs.2004.07.021] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Successful carotid artery stenting (CAS) involves gaining access to the common carotid artery, characterizing and crossing the lesion, deploying an anti-embolic device and stent, and retrieving the anti-embolic device. These steps are critical determinants of the complexity of the procedure. The frequency with which technical challenges are encountered during CAS is ill-defined. The purpose of this investigation was to review the incidence and types of technical challenges encountered during CAS and determine their effect on outcome. METHODS Data were prospectively collected for 194 consecutive CAS procedures (177 patients) and separated into group 1, standard CAS technique, and group 2, procedures with technical challenges requiring modifications to the technique. Technical challenges were defined as difficult femoral arterial access (aortoiliac occlusive disease), complex aortic arch anatomy (elongated or bovine arch, deep takeoff of the innominate artery, tandem stenoses (CCA, innominate artery), difficult internal carotid artery anatomy (tortuosity, high-grade stenosis), and circumferential internal carotid artery calcification. The incidence of technical challenges, types of technical modifications required, and effect on outcomes were determined. RESULTS Fifty technically challenging situations (26%) were encountered in 194 CAS procedures (group 2), which required advanced technical skills. Standard methods were used in the other 144 procedures (group 1, 74%). No significant differences in 30-day stroke and death rates were noted between the groups (group 1, 3.1%; group 2, 2.0%; P = .564). CONCLUSIONS Twenty-six percent of the procedures required a modification in the standard technique for successful CAS. Circumferential calcification and severe tortuosity continue to be relative contraindications to CAS. Recognition of these technical challenges and increasing facility with the methods to manage them will enable expanded use of CAS without increased morbidity and mortality.
Collapse
Affiliation(s)
- H Michael Choi
- Division of Vascular Surgery, Department of Surgery, UMDNJ-New Jersey Medical School, Newark 07101, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Hobson RW, Howard VJ, Roubin GS, Ferguson RD, Brott TG, Howard G, Sheffet AJ, Roberts J, Hopkins LN, Moore WS. Credentialing of surgeons as interventionalists for carotid artery stenting: Experience from the lead-in phase of CREST. J Vasc Surg 2004; 40:952-7. [PMID: 15557910 DOI: 10.1016/j.jvs.2004.08.039] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Credentialing of vascular surgeons to perform carotid artery stenting (CAS) continues to be a major issue confronting the specialty of Vascular Surgery. Cannulation of aortic arch branches, and placement of carotid antiembolic devices and stents constitute the major technical challenges to vascular surgeons becoming credentialed to perform CAS. The multicenter Carotid Revascularization Endarterectomy vs Stenting Trial (CREST), supported by the National Institute of Neurological Disorders and Stroke, National Institute of Health, reviews credentials of interventionalists, including surgeons, for the trial's "lead-in" phase of CAS to treat symptomatic (>50% stenosis) and asymptomatic (>70% stenosis). METHODS Vascular surgeons requesting participation in CREST must have achieved basic interventional credentialing criteria as recommended by the Society of Vascular Surgery. Each interventionalist is asked to submit notes and narrative summaries from a series of 10 to 30 CAS procedures for review by a multi-specialty review committee before being approved to participate in CREST. Thereafter, during the lead-in phase of CREST, each approved interventionalist is asked to perform CAS procedures using the study devices in as many as 20 patients. In this interim report from the CREST lead-phase, the association of specialty of operator (vascular surgeon, neurosurgeon, other specialist) and periprocedural stroke and death rate was examined in patients undergoing CAS. In addition, current enrollment volume in the lead-in phase by specialty of the principal investigator was examined. RESULTS Thirty-two of 134 (23.9%) CREST-credentialed interventionalists are vascular surgeons (n = 22; 16.4%) or neurosurgeons (n = 10; 7.5%). For events monitored through March 31, 2004, 789 patients had undergone CAS procedures performed by these 134 specialists. Thirty-day stroke and death rate was 4.6%, and myocardial infarction was observed in 1.1% of patients. Serious adverse events have not been clustered at individual institutions, and no significant differences have been observed between vascular surgeons or neurosurgeons and other credentialed specialists. CONCLUSIONS Vascular surgeons with basic catheter and guide wire skills, particularly those who have incorporated diagnostic cerebral angiography into their practice, can be credentialed to perform CAS. Individuals or groups should devote a number of cases (n = 10-30 per surgeon) to CAS to accomplish this goal. Pending US Food and Drug Administration approval of devices and Center for Medicaid and Medicare Services reimbursement, institutional financial support for the performance of these procedures must be secured. The learning curve for CAS should not be considered so formidable as to discourage surgeons from adding these techniques of CAS to their procedural inventory.
Collapse
Affiliation(s)
- Robert W Hobson
- Department of Surgery, UMDNJ-NJ Medical School, Newark, NJ 07101, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Abstract
OBJECTIVE The purpose of this study was to analyze the use of operative training resources for vascular surgery residents (VSRs) and general surgery residents (GSRs) over the past 10 years in the United States, to address questions concerning adequate endovascular versus open surgical training and the potential to expand the number of VSRs to meet future workforce needs. METHODS National operative data from the Residency Review Committee for Surgery (RRC) were analyzed for all vascular surgery (VS) and general surgery (GS) training programs from 1994 to 2003. GSR experience in programs with and without associated VS programs was also compared. RESULTS Mean total VS volume per VSR increased from 220 operations in 1994 to 368 in 2003, owing to the addition of 140 endovascular procedures by 2003. GSR volume was more stable, with 117 mean total VS operations in 1994 and 122 in 2003. This volume was distributed as approximately 50% major open VS operations for both VSR and GSR. In addition, 39% of VSR experience was endovascular, whereas 32% of GSR experience was vascular access. The average VSR performed 2.7 times more major open VS operations than each GSR, but because of the 10-fold greater number of GSRs, VSRs performed only 20% of the total major operations available for VS training. Selective procedures, such as renal revascularization and open infrarenal abdominal aortic aneurysm repair decreased over time, while endovascular abdominal aortic aneurysm repair increased dramatically, accounting for 46% of aortic aneurysm repairs per VSR in 2003. The mean volume of total interventional procedures per VSR in 2003 was 152 diagnostic and 213 therapeutic. GSRs in programs with and without an associated VS program had very similar operative volumes. CONCLUSIONS Interventional procedures have increased VSR operative volume by 50% in recent years, with only a 12% decrease in major open operations. Nearly all VSRs currently meet RRC minimum requirements for open and endovascular procedures. Mean GSR operative volume has been stable, and far exceeds RRC minimum requirements. Based on the number of major open vascular operations available for training in 2003, the current number of VSR positions could be increased by 50% if GSR operative volume was decreased by 15%. However, increased interventional volume would also be required, for which there is competition with other specialties.
Collapse
Affiliation(s)
- Jack L Cronenwett
- Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.
| |
Collapse
|
45
|
Creager MA, Goldstone J, Hirshfeld JW, Kazmers A, Kent KC, Lorell BH, Olin JW, Rainer Pauly R, Rosenfield K, Roubin GS, Sicard GA, White CJ, Creager MA, Winters WL, Hirshfeld JW, Lorell BH, Merli G, Rodgers GP, Tracy CM, Weitz HH. ACC/ACP/SCAI/SVMB/SVS clinical competence statement on vascular medicine and catheter-based peripheral vascular interventions: a report of the American College of Cardiology/American Heart Association/American College of Physician Task Force on Clinical Competence (ACC/ACP/SCAI/SVMB/SVS Writing Committee to develop a clinical competence statement on peripheral vascular disease). J Am Coll Cardiol 2004; 44:941-57. [PMID: 15312891 DOI: 10.1016/j.jacc.2003.10.012] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
46
|
Sidhu RS, Tompa D, Jang R, Grober ED, Johnston KW, Reznick RK, Hamstra SJ. Interpretation of three-dimensional structure from two-dimensional endovascular images: implications for educators in vascular surgery. J Vasc Surg 2004; 39:1305-11. [PMID: 15192573 DOI: 10.1016/j.jvs.2004.02.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE Endovascular therapy has had a major effect on vascular surgery; surgeons perform tasks in three dimensions (3D) while viewing two-dimensional (2D) displays. This fundamental change in how surgeons perform operations has educational implications related to learning curves and patient safety. We studied the effects of experience, training, and visual-spatial ability on 3D perception of 2D angiographic images of abdominal aortic aneurysms (AAA). METHODS A novel computer-based method was developed to produce 3D depth maps based on subjects' interpretations of 2D images. Seven experts (certified vascular surgeons) and 20 novices (medical or surgical trainees) were presented with a 2D AAA angiographic image. With software specifically designed for this study, a depth map representing each subject's 3D interpretation of the 2D angiogram was produced. The novices were then randomized into a control group and a treatment group, who received a 5-minute AAA anatomy educational session. All subjects repeated the exercise on a second AAA image. Finally, all novices were given tests of visual-spatial ability, including the Surface Development Test and the Mental Rotations Test. Comparisons between experts and novices were made with depth map comparison, a subject's perception of overall object contour. RESULTS The depth maps were significantly different (depth map comparison, P <.001) between the expert and both novice groups for the first image. After the educational intervention, the control group and the treatment group exhibited significantly different depth maps (depth map comparison, P <.001), with treatment group depth maps more similar to those of the expert group. There were no significant correlations between the visual-spatial tests and the novice depth map comparison with the expert group. CONCLUSIONS This is the first study to examine perception of endovascular images in an educational context. Perception of overall surface contour of 3D structures from 2D angiographic images is affected by experience and training. With application of methods of vision science to an important problem in surgery, this research represents a first step in understanding the nature of visual perceptual processes involved in execution of an increasingly common clinical task. These results have implications for understanding and studying the endovascular learning curve. CLINICAL RELEVANCE This research represents a unique collaboration in an effort to understand and solve one of the greatest problems facing surgical educators and surgeons. This research uses applied tools in vision science to understand the perceptual constraints involved in minimally invasive surgery. Specifically, we examined the mental three-dimensional maps experts use when viewing two-dimensional displays. Furthermore, we compared experts with novices in an effort to assist surgical trainees.
Collapse
Affiliation(s)
- R S Sidhu
- Division of Vascular Surgery, Department of Surgery, Wilson Centre for Research in Education, 1 Eaton S., Room 1-565, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada.
| | | | | | | | | | | | | |
Collapse
|
47
|
Forbes TL, DeRose G, Kribs SW, Harris KA. Cumulative sum failure analysis of the learning curve with endovascular abdominal aortic aneurysm repair. J Vasc Surg 2004; 39:102-8. [PMID: 14718826 DOI: 10.1016/s0741-5214(03)00922-4] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the importance of experience and the learning curve with endovascular abdominal aortic aneurysm (AAA) repair. METHODS A retrospective analysis was performed of all elective endovascular AAA repairs attempted by an individual surgeon and radiologist over a 4-year period. The primary outcome variable was achievement and 30-day maintenance of initial clinical success as defined by the Society for Vascular Surgery/American Association of Vascular Surgery reporting standards. Following standard statistical analysis, the cumulative sum (CUSUM) method was used to analyze the learning curve, with a predetermined acceptable failure rate of 10% and calculated 80% alert and 95% alarm lines. RESULTS Ninety-six elective endovascular AAA repairs were attempted by this team between 1998 and 2002 (mean age 74 +/- 0.8 years; mean aneurysm diameter 5.98 +/- 0.8 cm). Initial clinical success was achieved and maintained in 85 of 96 patients (88.5%). Although results were acceptable throughout the study period, improved results with respect to the target failure rate (10%) were not achieved until 60 patients were treated. The learning or CUSUM curves did not differ for different device manufacturers, with improved results being achieved following 20 implantations of each device. The results did differ when comparing aortouniiliac grafts (n = 27) and bifurcated grafts (n = 64). Results with bifurcated grafts remained consistent throughout the study period, whereas with aortouniiliac grafts, results improved after only a few procedures in comparison with the target failure rate. CONCLUSION Success rates with endovascular aneurysm repair will improve with an individual's experience. The CUSUM method is a valuable tool in the evaluation of this learning curve, which has credentialing and training implications. Although acceptable results were obtained throughout the study period, this analysis indicates that 60 endovascular aneurysm repairs, or 20 with an individual device, are necessary before optimal rates of initial clinical success can be achieved. These results can be achieved more readily with aortouniiliac grafts than with bifurcated grafts.
Collapse
Affiliation(s)
- Thomas L Forbes
- Division of Vascular Surgery, London Health Sciences Center, University of Western Ontario, 375 South Street N380, London, Ontario, Canada N6A 4G5.
| | | | | | | |
Collapse
|
48
|
Abstract
Although early on vascular surgeons rebuked the concept that carotid stenting could stand up against the gold standard of carotid endarterectomy, this minimally invasive treatment for carotid bifurcation disease has been shown to have surprisingly low rates of periprocedural complications and is clearly favored by patients, for whom avoidance of surgery reigns paramount. Unfortunately, reluctance to embrace this and other emerging endovascular technologies, as well as a variety of other factors to be discussed, has left vascular surgeons poorly positioned to participate in the delivery of these therapies to their patients. With estimates of up to 75% of carotid stenoses being suitable for treatment by this new modality, and with carotid endarterectomy being the most commonly performed vascular operation in the United States today, this is a significant problem for our specialty and one badly in need of a solution. An understanding of the myriad of underlying interrelated problems helps to provide insight into possible solutions.
Collapse
Affiliation(s)
- Kim J Hodgson
- Southern Illinois University, Springfield 62794-9638, USA
| |
Collapse
|
49
|
Green RM, Waldman D. Five-year results of a merger between vascular surgeons and interventional radiologists in a university medical center. J Vasc Surg 2003; 38:1213-9. [PMID: 14681616 DOI: 10.1016/j.jvs.2003.07.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES We examined economic and practice trends after 5 years of a merger between vascular surgeons and interventional radiologists. METHODS In 1998 a merger between the Division of Vascular Surgery and the Section of Interventional Radiology at the University of Rochester established the Center for Vascular Disease (CVD). Business activity was administered from the offices of the vascular surgeons. RESULTS In 1998 the CVD included five vascular surgeons and three interventional radiologists, who generated a total income of $5,789,311 US dollars (34% from vascular surgeons, 24% from interventional radiologists, 42% from vascular laboratories). Vascular surgeon participation in endoluminal therapy was limited to repair of abdominal aortic aneurysms (AAAs). Income was derived from 1011 major vascular procedures, 10,510 catheter-based procedures in 3286 patients, and 1 inpatient and 3 outpatient vascular laboratory tests. In 2002 there were six vascular surgeons (five, full-time equivalent) and four interventional radiologists, and total income was $6,550,463 US dollars despite significant reductions in unit value reimbursement over the 5 years, a 4% reduction in the number of major vascular procedures, and a 13% reduction in income from vascular laboratories. In 2002 the number of endoluminal procedures increased to 16,026 in 7131 patients, and contributions to CVD income increased from 24% in 1998 to 31% in 2002. Three of the six vascular surgeons performed endoluminal procedures in 634 patients in 2002, compared with none in 1998. CONCLUSIONS Gross revenues increased in a declining reimbursement and conventional practice environment, because of the increased number of endoluminal procedures, in part provided by vascular surgeons. The implications of these data should be considered by those responsible for training vascular surgeons.
Collapse
Affiliation(s)
- Richard M Green
- Division of Vascular Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642, USA.
| | | |
Collapse
|
50
|
Abstract
BACKGROUND Despite satisfactory results for surgery performed by trainees, vascular surgeons need to improve training methods to ensure that aspiring surgeons are adequately trained with less clinical exposure during fewer dedicated years of training. OBJECTIVES To review the wide range of workshop, laboratory and seminar-room based methods available to train for the diverse range of skills required for distal arterial revascularisation. Training methods include anastomotic suturing skills with bench-top training apparatus, working with realistic plastic models and prosthetic conduits, cadaveric dissections and virtual-reality simulations. Many of these also provide excellent opportunities for objective assessment of technical skills and trainees' progress. DESIGN AND METHODS A review of the literature on surgical education, surgical skills training and assessment. An evaluation of some of the apparatus, facilities, training curricula and courses, currently available to European trainees, is carried out. CONCLUSIONS Many methods are now available to allow focused training for particular skills in non-clinical settings. Objective tools are also available that allow assessment of trainees at many levels or practicing surgeons. These technical skills assessment methods are important for trainees and surgeons who, in the future, will increasingly need to demonstrate competence in vascular surgery.
Collapse
Affiliation(s)
- M J Jackson
- Regional Vascular Unit, St Mary's Hospital, London, UK
| | | | | |
Collapse
|