Concerning Trends in Vascular Surgery Trainee Operative Experience in Venous Disease

Abstract

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 venousdisease.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. 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. 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. 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.