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Trainee Impact on Postoperative Outcomes for Open and Endovascular Aortic Repair in the Vascular Quality Initiative
Joseph R Chitwood, Zdenek Novak, Emily L Spangler, Juliet Blakeslee-Carter, Adam W Beck
University of Alabama Birmingham, Birmingham, AL
Introduction:Previous research within the NSQIP has shown resident involvement in surgical care to be safe, with only small increases in minor infections and operative time among general surgical procedures. A VASQIP study on below-knee amputation demonstrated that trainee participation was associated with increased operative time, estimated blood loss (EBL), and higher transfusion requirements. However, to date there is no established body of evidence regarding surgical outcomes based on resident involvement in aortic procedures, whether open or endovascular.
The Vascular Quality Initiative (VQI) began collecting trainee-level data as a pilot in 2016, and since 2022 this has been a permanent field within the registry. This provides an opportunity to evaluate the effects of trainee participation on surgical outcomes in complex vascular operations. Given the widespread shift from open to endovascular aortic repair (EVAR), this dataset also allows for insight into case volumes across academic hospitals, non-academic teaching hospitals, and non-academic hospitals—an important consideration for vascular trainee exposure and the preparation of future vascular surgeons.
Methods:A retrospective review was performed of the VQI EVAR, TEVAR, and open aortic repair (OAR) registries between 2022-2024, when trainee data were routinely collected. All elective EVAR, complex EVAR (cEVAR; proximal landing zone >5), and open abdominal aortic aneurysm cases were included. Exclusion criteria were: emergent or urgent cases, open cases with operative times <40 minutes, EVAR/TEVAR cases <20 minutes, cases without academic affiliation or trainee presence recorded, and proximal thoracic TEVAR cases.
Primary exposure was resident participation (yes/no). Secondary exposure was hospital type: academic (part of an academic medical center), non-academic teaching (hosts residency program but not part of an academic center), or non-academic (no residency or medical school affiliation). Outcomes included operative time, EBL, transfusion volume, postoperative complications, return to the operating room (RTOR), length of stay (LOS), and mortality. Continuous variables were analyzed with two-sided t-tests or Mann-Whitney U tests; categorical variables with chi-square. Significance was defined as α<0.05. Analyses were performed in SPSS v30 (IBM Corp.).
Results:A total of 25,127 cases were reviewed (EVAR n=19063, cEVAR n=3450, OAR n=2614). Resident participation was associated with longer mean operative times across EVAR, cEVAR, and OAR at most hospital types. An exception was observed in EVAR at non-academic hospitals, where there was no significant difference in operative time with or without resident involvement [107 (66) vs 104 (59) minutes, p=0.3]. Interestingly, in cEVAR performed at non-academic hospitals, resident presence was associated with reduced operative times [80 (49) vs 113 (92) minutes, p=0.02]. In open repair, the longest operative times were observed at academic centers, and across all hospital types OAR cases involving residents required significantly longer operative times.
Estimated blood loss was significantly higher in cEVAR and OAR cases involving trainees across most hospital types, with the exception of non-academic hospitals where no significant difference was found [1450 (788-2075) vs 1300 (750-2500) mL, p=0.76]. In EVAR, EBL was higher only at non-academic teaching hospitals [75 (40-150) vs 50 (30-100) mL, p=0.03].
Resident involvement did not increase return to the operating room, in-hospital mortality, or overall postoperative complication rates. In fact, in open aortic repair, in-hospital mortality was lower in cases with resident participation (2.7% vs 4.3%, p<0.05), suggesting a protective effect. For EVAR, postoperative complications were slightly higher with resident involvement (4.7% vs 3.9%, p<0.05), though without differences in mortality or length of stay. Across both EVAR and OAR, postoperative and total length of stay were prolonged by approximately one day in cases involving residents.
Conclusions:This study provides novel insights into resident participation in aortic procedures across different hospital types within the VQI. While resident involvement is associated with modest increases in operative time, blood loss, and occasional postoperative complications, it does not translate into worse patient outcomes and may even be protective in open aortic repair.
Resident participation in aortic cases is ultimately safe and essential for training the next generation of vascular surgeons. As open case exposure continues to decline nationally with the expansion of endovascular techniques and the centralization of aortic care, structured opportunities for resident involvement are critical to ensure future patient access to high-quality aortic surgery.
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