Vascular surgeons--do they make a difference in peripheral vascular disease?

Physician impact on use of fluoroscopy during endovascular procedures to improve radiation safety

OBJECTIVE

To determine whether differences exist in fluoroscopy time and radiation exposure during lower extremity endovascular procedures performed by fellowship trained vascular surgeons vs general surgeons, to minimize radiation exposure to operating room staff.

METHODS

A retrospective review of all lower extremity endovascular procedures was performed from August 1, 2014, to January 29, 2016. The procedures were performed by the surgical department's four surgeons with endovascular privileges: two vascular surgeons and two general surgeons. Only procedures involving lower extremity arterial angiograms with balloon angioplasty, stenting, or atherectomy were included. The operative records were reviewed for each case. The total fluoroscopy time and total radiation dose for each procedure were recorded. Procedures were grouped according to the number of endovascular interventions as one to two interventions, three to four interventions, and five or more interventions performed. Statistical analysis was performed with a P value of less than .05 considered significant.

RESULTS

About 271 lower extremity endovascular procedures were performed during the study period by 4 surgeons. The average age of the patient population was 70 years. The total number of procedures performed over the study period were 112, 45, 91, and 25 for surgeons 1 through 4, respectively. On average, 3.24 interventions were performed during each procedure. Vascular surgeons were found to have shorter fluoroscopy time for procedures involving one to two (7.8 vs 30.1; P < .01), three to four (9.3 vs 34.2; P < .01), and five or more (11.5 vs 51.9; P < .01) interventions. Vascular surgeons were also found to have less radiation exposure compared with general surgeons in procedures with one to two (1.69 vs 3.53; P = .001) and five or more (2.3 vs 5.4; P = .003) interventions. There was no significant difference in radiation exposure between vascular and general surgeons for procedures with three to four interventions (5.86 vs 5.59; P = .95).

CONCLUSIONS

In this small series at our institution, lower extremity endovascular procedures performed by specialty trained vascular surgeons were associated with both decreased operative fluoroscopy time and decreased radiation exposure when compared with general surgeons.

A systematic review of the impact of volume of surgery and specialization on patient outcome

BACKGROUND AND METHODS

Volume of surgery and specialization may affect patient outcome. Articles examining the effects of one or more of three variables (hospital volume of surgery, surgeon volume and specialization) on outcome (measured by length of hospital stay, mortality and complication rate) were analysed. Reviews, opinion articles and observational studies were excluded. The methodological quality of each study was assessed, a correlation between the variables analysed and the outcome accepted if it was significant.

RESULTS

The search identified 55,391 articles published between 1957 and 2002; 1075 were relevant to the study, of which 163 (9,904,850 patients) fulfilled the entry criteria. These 163 examined 42 different surgical procedures, spanning 13 surgical specialities. None were randomized and 40 investigated more than one variable. Hospital volume was reported in 127 studies; high-volume hospitals had significantly better outcomes in 74.2 per cent of studies, but this effect was limited in prospective studies (40 per cent). Surgeon volume was reported in 58 studies; high-volume surgeons had significantly better outcomes in 74 per cent of studies. Specialization was reported in 22 studies; specialist surgeons had significantly better outcomes than general surgeons in 91 per cent of studies. The benefit of high surgeon volume and specialization varied in magnitude between specialities.

CONCLUSION

High surgeon volume and specialization are associated with improved patient outcome, while high hospital volume is of limited benefit.

Vascular surgery won a battle but is losing the war: a call to arms for every vascular surgeon

This paper describes the present status of the initiative to obtain American Board of Medical Specialties (ABMS) approval of an independent American Board of Vascular Surgery (ABVS). The need for such a board arises from the evolution of vascular surgery into a distinct, well-defined specialty that deals with all aspects of vascular disease, including knowledge of its natural history, all methods of noninvasive and invasive diagnosis, conservative and medical treatment, open operative treatment, endovascular treatment, and periprocedural care. Because of the greater skill requirements and increased complexity of vascular surgery, its paradigms of training must be changed. Longer periods of vascular training are required with a reciprocal 2- to 3-year shortening of training in general surgery. This cannot be done without an independent ABVS. The effort to obtain ABVS approval has elicited opposition from the American Board of Surgery (ABS) and from some vascular surgery leaders associated with it, making the ABVS a contentious issue. A successful effort was made to reach consensus within vascular surgery, and the ABVS application was submitted to the ABMS. As a result of an ABS campaign that combined pressure and dire warnings, this application encountered intense opposition within the ABMS and its Liaison Committee for Specialty Boards (LCSB). Institutional and professional self-interest, rather than quality of patient care, appeared to be the overriding considerations in the ABS argument. Measures to overcome this ABS opposition and obstructionism are proposed. They require unity, action, and tangible support from all vascular surgeons. If this call to arms goes unheeded, vascular surgery will not continue to be the self-sufficient specialty it has become and, most importantly, patient care will suffer.