Advanced Endovascular Training for Vascular Residents: What More Do We Need?

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.

Towards an Action Recognition Framework for Endovascular Surgery

Objective knowledge about instrument manoeuvres in endovascular surgery is essential for evaluating surgical skills and developing advanced technologies for cathlab routines. To the recent day, endovascular navigation has been exclusively assessed in laboratory scenarios. By contrast, information contained in available fluoroscopy data from clinical cases has been disregarded. In this work, we pioneer a learning-based framework for motion activity recognition in fluoroscopy sequences. The architecture is composed of two networks for instrument segmentation and action recognition. In this preliminary study, we demonstrate feasibility of recognising instrument manoeuvres automatically in our ex vivo datasets.Clinical relevance-The proposed framework contributes to image-based and automated assessment of endovascular tasks. This facilitates robotic control development, surgical education, and smart clinical documentation.

Standards for endovascular neurosurgical training and certification of the society of korean endovascular neurosurgeons 2013

The need for standard endovascular neurosurgical (ENS) training programs and certification in Korea cannot be overlooked due to the increasing number of ENS specialists and the expanding ENS field. The Society of Korean Endovascular Neurosurgeons (SKEN) Certification Committee has prepared training programs and certification since 2010, and the first certificates were issued in 2013. A task force team (TFT) was organized in August 2010 to develop training programs and certification. TFT members researched programs and systems in other countries to develop a program that best suited Korea. After 2 years, a rough draft of the ENS training and certification regulations were prepared, and the standard training program title was decided. The SKEN Certification Committee made an official announcement about the certification program in March 2013. The final certification regulations comprised three major parts: certified endovascular neurosurgeons (EN), certified ENS institutions, and certified ENS training institutions. Applications have been evaluated and the results were announced in June 2013 as follows: 126 members received EN certification and 55 hospitals became ENS-certified institutions. The SKEN has established standard ENS training programs together with a certification system, and it is expected that they will advance the field of ENS to enhance public health and safety in Korea.

Impact of an intensive 2-day endovascular training course on technical performance of trainees

BACKGROUND

The objective of this study was to evaluate the effect of a 2-day international endovascular training course on the performance of trainees as compared with a control group, assessed in a bench model-based task using an objective structured evaluation protocol.

METHODS

A total of 50 trainees, 28 course participants of 2 consecutive identical courses and a control group of 22 participants with a similar level of experience without course attendance, underwent baseline and final assessment (simulated arterial access task). The evaluation form consisted of a global assessment (GA), task-specific checklist percentage score (CL), and global rating scale percentage score (GR), with both percentage scores ranging from 0% (worst performance) to 100% (best performance).

RESULTS

Course participants were more likely to pass the GA at final testing than the control group (odds ratio=59; 95% confidence interval [CI] 9.5-656; P<0.001). The estimated difference in percentage score at final testing between course participants and the control group was 26% (95% CI 18-34; P<0.001) for the CL and 29% (95% CI 19-40; P<0.001) for the GR.

CONCLUSIONS

A 2-day structured endovascular training course significantly improves endovascular performance in a simulated environment. These results are important for the design of endovascular training curricula with the ultimate goal of contributing to patient safety.

Endovascular training of vascular surgeons in the USA

Current trends in vascular surgery in the USA are driven by increased demand for endovascular procedures. Traditionally-trained vascular surgeons have adapted to these trends by acquiring endovascular skills; vascular surgery fellowships were standardized to 2-years to incorporate endovascular training. However, the traditional "5 + 2" training paradigm appears to be less appealing to the current generation of surgical students, resulting in fellowship positions going unfilled, and potentially predicting a shortage of vascular surgeons. Recognition of this trend has led to the adoption of alternative training pathways, in particular the integrated "0 + 5" pathway, to supplement the traditional "5 + 2" independent pathway. The integrated pathway has several perceived advantages for vascular surgery trainees including early teaching of endovascular skills. However, it has challenges that include maintaining open operative skills and changing strategies to attract candidates from among the pool of medical students instead of the pool of general surgery residents. Simulators, both open and endovascular, are playing an increasingly important role in training programs as well as for outreach programs to medical students. Recruitment strategies for future generations of vascular surgeons in the USA may need to consider residents' lifestyle preferences as well as outreach to traditionally underrepresented groups such as women and minorities.

Determining who trains vascular surgery fellows in endovascular techniques

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.

Sonographic follow-up of the access site after arterial angiography: Impact on the detected complication rate

OBJECTIVE

This study prospectively evaluated the impact of sonographic follow-up on the detection rate of access site complications in arterial angiography and determined parameters associated with major complications of the access site after arterial angiography.

METHODS

Sonographic follow-up (mean +/- SD, 1.46 +/- 1.11 days after) of the access site (transfemoral, n = 896; and transbrachial, n = 44) was obtained prospectively in 940 arterial angiographies and included evaluations for hematoma, pseudoaneurysm, arteriovenous fistula, arterial dissection, and venous/arterial thrombosis. Clotting parameters, anticoagulation therapy, and several patient and procedure characteristics were recorded. Univariate and multivariate logistic regression analyses were performed.

RESULTS

Sonography depicted major access site complications in 39 of 940 angiographies (4.2%). Major access site complications (major local hematoma, n = 13; retroperitoneal hematoma, n = 1; pseudoaneurysm, n = 18; arterial dissection, n = 1; arteriovenous fistula, n = 1; arterial thrombosis, n = 2; and venous thrombosis, n = 3) required conservative (n = 32 [3.4%]) or surgical (n = 7 [0.7%]) treatment. Independent factors significantly associated with major access site complications were age older than 60.33 years and sheath size greater than 5F (P < .05).

CONCLUSIONS

Major access site complications were detected in 4.2% of cases and were significantly associated with age and sheath size.