Losing Exposure: Diminishing Revascularization Experience in General Surgery Residency

Abstract

With the rising popularity of endovascular procedures, there is concern that vascular surgery trainees receive increasingly limited experience with open lower extremity revascularization procedures. The purpose of the study was to evaluate trends in open lower extremity revascularization procedures performed by general surgery residents and vascular surgery fellows over time. These trends were assessed alongside resident participation in endovascular revascularization procedures over time. The Accreditation Council for Graduate Medical Education case logs of general surgery residents and vascular surgery fellows were reviewed from 2005-2006 to 2014-2015. The mean numbers of open aortoiliac and infrainguinal revascularization cases per surgeon were compared by academic year. Case logs for endovascular revascularization procedures were available beginning in 2007-2008. Nonparametric tests for trend were performed to evaluate changes over time. General surgery residents' experience in open aortoiliac and infrainguinal revascularization decreased during the study period (P = .003) from 14.7 to 8.4 mean cases per resident as displayed in the Fig, but it remained relatively constant for vascular fellows (45.3 to 46.5 mean cases per fellow; P = .138). Conversely, endovascular aortoiliac and infrainguinal revascularization experience has increased, although not statistically significant, since reporting began in 2009 (from 2.6 to 3.6 mean cases per general surgery resident; P = .078). Among vascular fellows, reported since 2007, experience with endovascular aortoiliac and infrainguinal revascularization has increased but did not represent a consistent trend, from 53.2 to 69.1 (P = .267). General surgery residents are experiencing a decreasing exposure to open lower extremity revascularization procedures, most significantly bypass using saphenous vein, which remains the “gold standard.” This decrease might be attributed to a multitude of changing variables, including the expansion of fellowship involvement or integrated vascular residency programs and the continued emerging sophistication of the endovascular approaches, despite the gold standard of care. On the basis of these trends, one could argue that general surgery residents graduating today are less fit to treat individuals with peripheral arterial occlusive disease because of their limited experience in performing open procedures. Furthermore, progressively diminishing experience with the art of open surgical repair may deter residents from pursuing a career in vascular surgery.