Vascular Surgery Trainees' Experience with Open Lower Extremity Revascularization in an Era of Endovascular-First Therapy

Abstract

The impact of the adoption of endovascular-first therapies for lower extremity revascularization on vascular trainees’ experience with open bypass is not known. We sought to determine trends in open versus endovascular lower extremity revascularization case volumes among graduating vascular fellows (5+2) and integrated vascular residents (0+5). We reviewed the Accreditation Council for Graduate Medical Education 2012-2021 case log data for graduating vascular surgery fellows (5+2) and integrated residents (0+5). We retrieved the mean number of femoropopliteal and infrapopliteal revascularization procedures carried out by each trainee group, both open and endovascular. The means were plotted against time. A Mann Kendall test was conducted to detect trends in the average number of cases performed by vascular graduates. Between 2012 and 2021, integrated vascular residents graduated with an average of 21.9 femoropopliteal and 22.5 infrapopliteal bypasses which were 4.4 ± 1.4 and 3.0 ± 1.9 more than vascular surgery fellows, respectively. For both trainee groups, the mean number of open procedures—femoropopliteal or infrapopliteal—was consistent over the course of the years with no statistically significant trend observed (Figs 1 and 2). Integrated vascular residents graduated with an average of 47.9 femoropopliteal and 22.7 infrapopliteal endovascular procedures, which were 6.2 ± 2.9 and 3.1 ± 1.7 more than vascular surgery fellows, respectively. We observed a statistically significant increase in the mean number of femoropopliteal and infrapopliteal endovascular procedures in this time period –in both trainee groups. The mean number of femoropopliteal endovascular cases increased by 105.5% (31.1 to 63.9; P < .001) for integrated residents and 110.3% (26.2 to 55.1; P < .001) for vascular fellows. Likewise, the mean number of infrapopliteal endovascular cases increased by 120.3% (14.3 to 31.5; P < .001) for integrated residents and 94.1% (13.6 to 26.4; P < .001) for vascular fellows. The overall case volume of femoropopliteal and infrapopliteal procedures, combining open and endovascular techniques, increased for both trainee groups, which is mainly due a significant increase in peripheral vascular intervention volume. The total case volume of lower extremity revascularization has increased for all vascular trainees but graduates of integrated residency programs have a more robust experience. Despite a significant rise in endovascular case volume, however, the average number of open bypass procedures performed by graduating vascular surgery trainees is not affected and has remained stable.Fig 2Trends in open infrapopliteal bypass revascularization.View Large Image Figure ViewerDownload Hi-res image Download (PPT)