Comparison of surgical operative experience of trainees and practicing vascular surgeons: A report from the Vascular Surgery Board of the American Board of Surgery

Impact of Integrated Vascular Surgery Residency on General Surgery Resident and Vascular Fellow Operative Volume: A National Analysis

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.

Venous ablation procedures by provider type, including advanced practice providers

OBJECTIVE

The necessary training and certification of providers performing venous ablation has become a topic of debate in recent years. As venous interventions have shifted away from the hospital, the diversity of provider backgrounds has increased. We aimed to characterize superficial venous ablation practice patterns associated with different provider types.

METHODS

We analyzed Medicare Fee-For-Service data from 2010 through 2018. Procedures were identified by their Current Procedural Terminology code and included radiofrequency ablation, endovenous laser ablation, chemical adhesive ablation (ie, VenaSeal; Medtronic, Inc), and mechanochemical ablation. These procedures were correlated with the practitioner type to identify provider-specific trends.

RESULTS

Between 2010 and 2018, the number of ablation procedures increased by 107% from 114,197 to 236,558 per year (P < .001). Most procedures were performed by surgeons without vascular board certification (28.7%; 95% confidence interval [CI], 28.7%-28.8%), followed by vascular surgeons (27.1%; 95% CI, 27.0%-27.2%). Traditionally noninterventional specialties, which exclude surgeons, cardiologists, and interventional radiologists, accounted for 14.1% (95% CI, 14.1%-14.2%), and APPs accounted for 3.5% (95% CI, 3.4%-3.5%) of all ablation procedures during the study period. The total number of ablations increased by 9.7% annually (95% CI, 9.7%-9.8%), whereas procedures performed by APPs increased by 62.0% annually (95% CI, 61.6%-62.4%). There were significant differences between specialties in the use of nonthermal ablation modalities: APPs had the highest affinity for nonthermal ablation (odds ratio [OR], 2.60; 95% CI, 2.51-2.69). Cardiologists were also more likely to use nonthermal ablation (OR, 1.62; 95% CI, 1.59-1.66). Similarly, the uptake of new nonthermal technology (ie, chemical adhesives) was greatest among APPs (OR, 3.57; 95% CI, 3.43-3.70) and cardiologists (OR, 1.86; 95% CI, 1.81-1.91). Vascular surgeons were less likely to use nonthermal modalities (OR, 0.95; 95% CI, 0.92-0.97), including new nonthermal technology in the first year of availability (OR, 0.93; 95% CI, 0.90-0.95).

CONCLUSIONS

The use of venous procedures has increased rapidly during the past decade, particularly as endovenous ablations have been performed by a wider practitioner base, including APPs and noninterventionalists. Practice patterns differ by provider type, with APPs and cardiologists skewing more toward nonthermal modalities, including more rapid uptake of new nonthermal technology. Provider-specific biases for specific ablation modalities might reflect differences in training, skill set, the need for capital equipment, clinical privileges, or reimbursement. These data could help to inform training paradigms, the allocation of resources, and evaluation of appropriateness in a real-world setting.

Concerning Trends in Vascular Surgery Trainee Operative Experience in Venous Disease

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.

A national analysis of vascular surgery resident operative experience in peripheral artery disease

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.

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

BACKGROUND

Since the introduction of endovascular aneurysm repair (EVAR) in 1992, the number of open AAA repair (OAR) cases continue to decline. The consequence of reduced OAR cases raises valid concerns related to patient safety and the future training of vascular surgeons that need to be appropriately addressed. Our objective is to analyze trends in OAR and EVAR cases and to assess their implications on the quality of vascular surgery training.

METHODS

We analyzed the Accreditation Council for Graduate Medical Education (ACGME) case log database for total clinical experience in OAR and EVAR for graduating vascular surgery fellows (VSFs) finishing 5 + 2 programs between 2002 and 2019 and vascular surgery integrated residents (VSRs) between 2013 and 2019. VSF case totals were calculated by combining average total cases of open and endovascular supra- and infrarenal AAA repair during fellowship years combined with total cases performed during their general surgery residency. VSR case totals included only the cases performed during the 5-year residency period. Isolated Iliac and thoracic aortic aneurysms were excluded from our analysis.

RESULTS

The average number of OAR cases per trainee has decreased by 60% (from 36.9 to 14.7) with a rate of 1.4 cases per year (P < 0.001) for VSF. Meanwhile, EVAR average cases have increased by 102% (from 22 to 44.4). However, there were 2 different trends exhibited with EVAR over the study period. Between 2002 and 2007, EVAR cases tended to increase by 5.9 cases per year (P < 0.001). Whereas, between 2007 and 2019, there was a slightly decreased trend in EVAR cases by 0.3 cases per year (P = 0.01). For VSR, while no significant trend was observed in the mean number of OAR cases (Coef. -0.3, P = 0.2) due to the limited time frame, the proportion of open cases was significantly lower compared to endovascular cases. Additionally, there were 2 different trends exhibited with EVAR over the study period. Between 2013 and 2015, EVAR cases tended to increase by 1.7 cases per year (P = 0.1). Whereas, between 2015 and 2019, there was a slightly decreased trend in EVAR cases by 0.2 cases per year (P = 0.007).

CONCLUSIONS

A significant reduction in average OAR cases and an increase in EVAR cases were observed over the study period. Vascular surgery training programs may need to introduce further training programs in open surgical repair to ensure vascular surgery trainees have the required technical skills and expertize to perform such a high-risk procedure safely and independently.

Evaluating the venous experience in vascular surgery training

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.

The endovascular performance spectrum of vascular surgery departments in Germany: Results of an online survey among senior department physicians

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.

Vascular access creation and maintenance in the USA

Exponential growth and increasing longevity of end-stage renal disease (ESRD) has resulted in significant ongoing changes in vascular access (VA) planning and management in the United States. There is a positive trend showing an increase in arteriovenous fistula (AVF) prevalence both in incident and prevalent patients and a decrease in tunneled dialysis catheters (TDCs) in prevalent patients. Current surgical training seems to provide adequate exposure to VA and an ample opportunity to develop skills required for safe surgical placement of VA. The prevalent differences in practice patterns suggest a need for standardization of VA care. There is a need for a structured curriculum in VA, which is a critical component in making sound decisions in access planning and management.

Considerations for patients undergoing endovascular abdominal aortic aneurysm repair

Endovascular aneurysm repair has taken over open surgery as the primary strategy for treatment of patients with abdominal and thoracic aneurysms. The minimally invasive nature of these techniques requires alterations in preoperative workup, intraoperative management, and familiarity with unique complications that can occur. Familiarity from the anesthetic standpoint of endovascular techniques, including treatment of patients with fenestrated, chimney, snorkel, and periscope grafts, is necessary for the contemporary cardiac anesthesiologist.

A model of cardiopulmonary bypass staged training integrating technical and non-technical skills dedicated to cardiac trainees

OBJECTIVES

To develop a standardized simulation-based curriculum to teach medical knowledge and technical, communication and critical thinking skills necessary to initiate and wean from cardiopulmonary bypass (CPB) to junior cardiac trainees (CTs) in France. Performance on post-curricular tests was compared between CTs who participated in the new curriculum to those who did not.

METHODS

The simulation-based curriculum was developed by content and education experts. Simulations sequentially taught the skills necessary for initiating and weaning from CPB as well as managing crises by adding fidelity and complexity to scenarios. Nine CTs were randomly assigned to the new curriculum (n=5) or the traditional curriculum (n=4). Skills were assessed using tests of medical knowledge and technical, communication (GRS) and critical thinking (SCT) skills. A two-sample Wilcoxon rank-sum test compared average scores between the two groups. Alpha of 0.05 was set to indicate statistically significant differences.

RESULTS

The resutls revealed that CTs in the new curriculum significantly outperformed CTs in the traditional curriculum on technical (18.2 vs 14.8, p=0.05) and communication (3.5 vs 2.2, p=0.013) skills. There was no significant difference between CTs in the new curriculum in the Script Concordance Test (16.5 vs 14.8, p=0.141) and knowledge tests (26.9 vs 24.6, p=0.14) compared to CTs in the traditional curriculum.

CONCLUSION

Our new curriculum teaches communication and technical skills necessary for CPB. The results of this pilot study are encouraging and relevant. They give grounds for future research with a larger panel of trainees. Based on the current distribution of scores, a sample size of 12 CTs per group should yield significant results for all tests.

Application of Porter’s Five Forces Model and generic strategies for vascular surgery: should be stuck in the middle?

There are many stakeholders in the vascular marketplace from clinicians to hospitals, third party payers, medical device manufacturers and the government. Economic stress, threats of policy reform and changing health-care delivery are adding to the challenges faced by vascular surgeons. Use of Porter's Five Forces analysis to identify the sources of competition, the strength and likelihood of that competition existing, and barriers to competition that affect vascular surgery will help our specialty understand both the strength of our current competition and the strength of a position that our specialty will need to move to. By understanding the nature of the Porter's Five Forces as it applies to vascular surgery, and by appreciating their relative importance, our society would be in a stronger position to defend itself against threats and perhaps influence the forces with a long-term strategy. Porter's generic strategies attempt to create effective links for business with customers and suppliers and create barriers to new entrants and substitute products. It brings an initial perspective that is convenient to adapt to vascular surgery in order to reveal opportunities.Vascular surgery is uniquely situated to pursue both a differentiation and high value leadership strategy.

Trends in a changing vascular practice environment for members of the Society for Vascular Surgery

OBJECTIVE

To survey the Society for Vascular Surgery (SVS) membership with regard to practice trends related to work effort, employment status, practice ownership, endovascular cases, and anticipated changes in practice in the near future.

METHODS

A survey questionnaire was developed to gather information about member demographics and practice, hours worked, full-time (FT) or part-time status, employment status, practice ownership, competition for referrals, proportion of endovascular vs open procedures, and anticipated changes in practice in the next 3 years. We used SurveyMonkey and distributed the survey to all active vascular surgeon (VS) members of the SVS.

RESULTS

The response rate was 207 of 2230 (10.7%). Two thirds were in private practice, and 21% were in solo practice. Twenty-four percent were employed by hospitals/health systems. Those VS under the age of 50 years were more likely to exclusively practice vascular surgery compared with VS over the age of 50 years (P = .0003). Sixty-eight of the physicians (32.7%) were between 50 and 59 years old, 186 (90.3%) were men, 192 (92.8%) worked FT (>36 hours of patient care per week), and almost two thirds worked >60 hours per week. Those in physician-owned practices worked >40 hours of patient care per week more often than did FT employed VS (P = .012). Younger VS (age <50 years) more frequently reported >50% of their workload being endovascular compared with older VS (age ≥50 years; P < .001). Eighty percent of FT VS planned to continue their current practice over the next 3 years. Of the 43.6% indicating loss of referrals, 82% pointed to cardiologists as the competition.

CONCLUSIONS

The current workforce is predominately male and works FT; one-third is between the ages of 50 and 59 years. Younger VS (age <50 years) are more likely to exclusively practice VS and have a higher caseload of endovascular procedures. Those in physician-owned practices are more likely to put in >40 hours of patient care per week than are FT employed VS. Longitudinal surveys of SVS members are imperative to help tailor educational, training, and practice management offerings, guide governmental activities, advocate for issues important to members, improve branding initiatives, and sponsor workforce analyses.

The impact of endovascular procedures on fellowship training in lower extremity revascularization

OBJECTIVE

The introduction of endovascular aneurysm repair has resulted in a decline in open abdominal aortic aneurysm repairs performed by vascular residents. The purpose of this study was to evaluate if a similar trend has occurred with open lower extremity revascularization procedures, with increased endovascular procedures producing a decrease in the number of open lower extremity revascularizations. Furthermore, this study evaluates the effect of endovascular procedure volume on the frequency of subtypes of open lower extremity procedures performed.

METHODS

The total number of vascular procedures, lower extremity bypasses, and endovascular interventions from 2000 to 2010 were analyzed from case logs of vascular residents as reported by the Accreditation Council for Graduate Medical Education.

RESULTS

The average number of cases performed by vascular residents has increased by 150% from 463.9 in 2000 to 1168 in 2009, due to the increased number of endovascular procedures. The average number of endovascular revascularizations has increased by 317% from 40.5 performed in 2000 to 168.9 in 2009. Femoral-popliteal bypasses have increased in frequency by 27% whereas the number of infrapopliteal bypass has remained unchanged. The largest difference is seen in femoral endarterectomies with a 234% increase from 3.2 per resident in 2001 to 10.7 per resident in 2010. Comparison of the proportion of femoral-popliteal and tibioperoneal interventions performed by angioplasty or bypass after 2007 revealed that endovascular interventions comprise 50% of procedures in the femoral-popliteal distribution, whereas 65% of infrapopliteal interventions are still performed using open techniques.

CONCLUSIONS

The number of procedures performed during vascular residency has dramatically increased over the last decade secondary to the increased number of endovascular procedures. The average vascular surgery resident's open operative experience has been stable over the last 10 years, despite the increasing endovascular case volume. Residents perform femoral endarterectomy with increasing frequency, perhaps representing an increasing volume of hybrid procedures. Gaps in information available for evaluating resident training remain a significant obstacle. Moving forward, revision of the current reporting system to a format that more accurately reflects resident experience would be beneficial.

Qualitative Impact of the Endovascular Era on Vascular Surgeons’ Comfort Level and Enjoyment With Open and Endovascular AAA Repairs

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.