Open vascular surgery procedures: how will we learn to do them and will they have the same quality?

Abstract

Theprogressiontowardendovascularproceduresforprimary treatment of vascular disease, from repair ofabdominalaorticaneurysms(AAA)toendotherapyforallaneurysmalandocclusivevasculardisease,hasgradu-allyoccurredoverthepast15years.Onlyfinanciallimi-tations placed by government agencies and insurancecompanieshaveslowedtheprogressiontowardprimaryendovascular therapy for all vascular diseases. In theUSA, carotid stenting and renal angioplasty are twoareas where limitations have recently been proposed orplaced on the use of endovascular therapy. Patients aredemanding endovascular approaches, and since physi-cians are better reimbursed for endovascular therapythan open surgery, many physicians, as well as patients,areembracingprimaryendovascularapproaches,inspiteof limited long-term data comparing endovascular andopen approaches in many vascular beds. With theincreased use of endovascular approaches, open vascu-lar procedures are performed less frequently and areoften reserved for patients with the most complex vas-cular problems. For example, endovascular repair ofAAA is commonly performed in patients with infrare-nal aneurysms with a long neck, while open surgicalrepair is usually reserved for pararenal and juxtarenalaneurysms which require suprarenal aortic clamping.Somevascularsurgeonshavereducedoperativerisksbylimiting their practices to specific procedures and refer-ringcomplexcasestoothervascularsurgeons,butthereis still a reduced volume of open procedures in manysurgical practices that previously had a large open sur-gical experience.Historically,operativemortalityhasbeenreducedtovery low levels by performing a high volume of casesand focusing practices exclusively on vascular surgery.With the reduced number of cases and the increasedcomplexityof theremainingopencases,whowillbeper-forming these open procedures in the future, and howwill the next generation of open vascular surgeons betrained? Many vascular surgeons who are involved intrainingprogramsareconcernedaboutthisproblem.Theremainingopencasesinmostacademictrainingcentersare often complex and therefore not optimal for train-ing;if trainingisperformedonthesecases,theremaybeasignificantrisktothepatient.Whataretheoptionsforfuturevascularcarethatwillkeeptheoutcomesof opencases as good as they are today and competitive withendovascularprocedures,intermsof outcomes,astheirfrequency decreases?Thereareseveralpossiblescenarios:1)theresultsofopen procedures, which will be performed less fre-quently, will worsen, leading to a more rapid movetoward an all endovascular approach to most vasculardiseases; 2) higher risk open vascular surgery proce-dures will be regionalized to a small group of surgeonswho perform these procedures in high volume; 3) there