Training in Modern Lower Extremity Revascularization: an Analysis of the Operative Experience of Surgical Trainees over Twenty Years
Alexander H Shannon1, Bernadette J Goudreau1, Derek de Gris1, Ian O Cook1, J. Michael Cullen1, Zachary M Tyerman1, Gilbert R Upchurch, Jr.2, William P Robinson, III1
1University of Virginia, Charlottesville, VA;2University of Florida, Gainesville, FL
Vascular Surgery practice and training has changed dramatically over the last 20 years,1 most notably the increased emphasis on endovascular procedures and the advent of integrated vascular programs. The impact of these changes on general surgery resident vascular experience is unclear. Traditionally, vascular training consists of 5 years of general surgery residency followed by 2 years of dedicated vascular fellowship. The integrated vascular surgery track, developed in 2006, eliminates the need for board certification in general surgery prior to obtaining certification in vascular surgery. It is a 5 year training program with a predominantly vascular focus supplemented by general surgery exposure.2,3 Per 2017 Accreditation Council for Graduate Medical Education (ACGME) data, there are 54 accredited integrated vascular surgery tracks and 106 accredited vascular surgery fellowships in the United States.4
Trends in therapy and in trainee case volume for abdominal aortic aneurysm (AAA) repair over the past two decades, including a dramatic decline in the volume of open AAA repair, has been well documented.5-7 This is a source of considerable concern. However, the trends in training in lower extremity revascularization over the last twenty years and the volume of both open and endovascular revascularization performed by general surgery residents (GSR), vascular fellows (VF), and integrated vascular residents (IVR) has not been well described. The differentiation of vascular surgery training into fellowships and integrated paths as well as the expansion of endovascular practice may influence trends in general surgery trainee vascular surgery experience. Even with specialization of training, general surgeons are still performing vascular procedures including lower extremity (LE) revascularizations.8
Thus, the objective of this study was to evaluate national trends in training in LE revascularization of general surgery residents (GSR), vascular fellows (VF), and integrated vascular residents (IVR) over the past 20 years. We hypothesized that GSR LE revascularizations are down trending and that with further evaluation, patterns among VF and IVR may help to further define these changes.
ACGME vascular surgery case logs were queried from 1999-2017. National GSR, VF, and IVR averages for each year were collected for the following case types: LE peripheral open cases, LE peripheral endovascular cases, and total overall LE vascular cases. Changes in operative volume over time were quantitatively analyzed using linear regression and comparison of best-fit line to a slope of zero (indicating no change).
The average number of LE revascularization procedures performed by all surgical trainees increased from 1999-2017 (p < 0.0001). GSR demonstrate a statistically significant decrease in total LE cases (p = 0.0004), while vascular fellows experienced an increase in these case numbers (p = 0.0317). Though data collection was limited to 2012-2017, average number of cases per IVR has remained stable (p = 0.08) (Figure 1A-D). When comparing open vs. endovascular cases, GSR show a statistically significant downward trend in open LE cases from 21.4 to 15.8 in the most recent recorded year (p = 0.0002) with a stable number of endovascular cases (4.5 to 5.3, p= 0.0743). VF are upward trending in open (93.5 to 101.3, p = 0.0045) as well
as endovascular cases (80.3 to 98.3, p = 0.0334). IVR do not demonstrate statistically significant differences in case volume when evaluating open (112.8 to 128.5, p= 0.124) vs. endovascular (90.1 to 107.7, p =0.0787) procedures.
In this time trend analysis of ACGME case logs, we found a decline in overall GSR LE revascularizations from 1999-2017. During this same time period, VF have experienced significant increases in LE revascularizations with IVR demonstrating a stable trend in total LE revascularization numbers, though the data for IVR is limited as the first reported year of case averages was 2012. When evaluating the case experience at a more granular level, the open case experience for GSR is declining while that of VF increasing and IVR remains unchanged. When evaluating endovascular procedures logged, the experience for GSR and IVR remains stable with an increase noted for VF, suggesting that the decline in total LE revascularizations performed by GSR is more likely related to a shift in open cases from GSR to VF and a lack of increase in GSR endovascular cases as seen with VF.
Vascular surgery continues to evolve, requiring reassessment of traditional training methods as well as defining the role IVR in modern residency/fellowship structures.9 Concerns have been raised regarding IVR surgical autonomy and independence at the conclusion of training given the abbreviated course.10 Consequently, case requirements for vascular surgery have increased for both fellows and integrated residents in recent years.11 The first assessment of operative logs comparing traditional vascular fellows vs. trainees in the integrated track performed by Batista et al analyzed ACGME case logs from 2013 and determined both traditional and integrated tracks have equivalent open vascular training but integrated programs demonstrate a superior overall endovascular exposure (albeit in minor procedures).12 Similarly, a retrospective review of vascular case logs from 2012-2014 demonstrated comparable overall vascular surgery experience between VF and IVR, although IVR reported higher number of major vascular cases.13 Additionally, both VF and IVR report positive experiences in both training and employment search, helping to address the shortage of well-trained vascular surgeons.14,15
Our data reveal a concerning downward trend in GSR vascular experience over the past two decades. A study by Malangoni et al, comparing GSR case logs from 2005 to those from 2010, demonstrated that although there was an overall 21% increase in operative volume of graduating surgical residents, the greatest decline in GSR cases was in vascular surgery.16 The reasons for these troubling trends are unclear. The assumption that GSR cases are simply lost to VF or IVR is not supported in the current literature.17 A single center study demonstrated introduction of IVR correlated with a modest drop in VF case volume, but GSR cases remained stable.18 Additionally, a review of 8 years of ACGME case logs determined that specialty specific training programs, like IVR, has not degraded the GSR operative experience.19
An alternative explanation may involve a drive for VF to ensure operative proficiency in open cases as the field moves toward more endovascular intervention. Additionally, the unchanged endovascular experience of GSR suggests that these trainees are not performing cases reflective of modern day vascular intervention. In recent years, there has been an increase in utilization and implementation of endovascular procedures with prior studies showing endovascular procedures decrease GSR open vascular surgical volume.5,7,20,21 In order for GSR vascular exposure to improve and be relevant in modern surgical practice, a push for adequate
open as well as endovascular case volume is necessary. Currently, there is no ACGME minimum requirement for endovascular cases in general surgery training. Regardless of future subspecialty pursuit, a fundamental endovascular knowledge base is essential for a general surgeon as they will encounter an increasing number of patients who will need or have previously undergone endovascular intervention.
Limitations of this study include its observational nature and inability to control for unmeasured variables as well as changes to case logging methods over time.
In this 20 year review of ACGME case data, GSR overall LE revascularization experience has significantly declined, with a steep decline in open case volume and a low endovascular case volume that has not increased over time. VF demonstrates an upward trend in overall, open, and endovascular cases. IVR case experience in all areas has remained stable since 2012, the first year of reported data. These trends suggest shifts in open LE revascularizations from GSR cases to VF without a corresponding shift in endovascular LE experience to GSR. These findings indicate that the decreasing number of lower extremity revascularizations must be utilized strategically for the benefit of multiple groups of surgical trainees. Furthermore, there is an unrealized opportunity for GSR to gain a more robust endovascular LE experience. Strategic changes to the general surgery curriculum and ACGME vascular requirements may aid in providing a vascular experience to GSR that is more reflective of modern-day vascular practice.
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