Surgical Specialty Impacts Quality of Operative Training in Carotid Endarterectomy

Abstract

Carotid endarterectomy (CEA) is currently performed by multiple surgical specialties. The impact of surgical specialty and operative volume on post-CEA outcomes has been well described. However, it is unclear whether trainees of different surgical specialties have similar quality of operative training. Data from Accreditation Council for Graduate Medical Education annual reports were collected and compared between graduating vascular surgery (VS) residents, VS fellows, and neurological surgery (NS) residents. Only cases reported as chief/senior/lead resident, surgeon junior, or surgeon fellow were included in analysis. Linear regression analysis was utilized to evaluate trends in case-mix and volume. From 2013 to 2022, total CEA case volume was higher among VS residents and fellows, compared to NS residents (52.8±0.8 vs. 44.3±1.4 vs. 12.9±0.6, P<0.0001). Additionally, VS residents and fellows performed other carotid operations including transfemoral or transcarotid artery stenting (11.1±0.9 vs. 11.2±0.8 vs. 0), carotid body tumor resection (0.7±0.1 vs. 0.7±0.0 vs. 0), and extracranial cervical bypass (6.7±0.3 vs. 6.3±0.3 vs. 0) that were not reported by the NS resident cohort (P<0.0001 each). On linear regression analysis, total CEA procedures did not change for VS residents (R2=0.03, P=0.62), decreased for VS fellows (-1.29 cases/yr, R2=0.75, P<0.0001), and decreased among NS residents (-0.41 cases/yr, R2=0.44, P=0.01) over the study period. Although residents of multiple surgical specialties are trained in CEA, vascular training offers significantly greater numbers and diversity of extracranial carotid cases. It also appears that CEA volume is decreasing among neurosurgical trainees. In light of recent reports on the volume-outcome effect in carotid surgery, these data may have implications for future practice patterns in the domain of extracranial carotid artery disease.