Vascular Surgery Training Research Articles

Trends in operative case volumes of Canadian vascular surgery trainees

ObjectiveVascular surgery has evolved with increasing use of endovascular therapies and a decline in open surgery. The influence of these changes, in addition to a new vascular surgery training program introduced in 2012, on case volumes of vascular trainees is not known. We sought to evaluate trends in operative case volumes of Canadian vascular surgery trainees. MethodsA survey was administered to graduates of the Canadian Royal College-accredited Vascular Fellowships (VFs) and Integrated Vascular Surgery Residency (IVSR) programs (2007-2019) to record cases performed during their final 2 years of training. Procedures of interest were open abdominal aortic aneurysm (oAAA) repair, open thoracic/thoracoabdominal aortic (oTAA/TAAA) repair, lower extremity bypass (LEB), carotid endarterectomy (CEA), lower extremity endovascular intervention (LEEI), and endovascular abdominal, advanced, and thoracic aortic repair (EVAR, aEVAR, and TEVAR). Case volumes were analyzed overall, and by graduation year, type of training program, and resident demographics. ResultsA total of 60 participants (10% female) from all the 10 Canadian training institutions responded (response rate, 63%). There was a declining trend in overall procedures performed since the introduction of IVSR in 2012 (median, 427 [interquartile range (IQR), 304-496] in 2007-2012 vs median, 342 [IQR, 279-405] in 2013-2019; P = .055), driven by a significant decline in open vascular surgery cases (median, 273 [IQR, 221-339] in 2007-2012 vs median, 156 [IQR, 128-181] in 2013-2019; P = .001). Case volumes of oAAA, LEB, and CEA declined by 44%, 40%, and 45%, respectively. Compared with vascular fellows, IVSR residents logged ∼2.5 times more aEVARs (median, 8; IQR, 2-11 vs median, 19; IQR, 8-27; P = .001) and ∼1.5 times more LEEIs (median, 60; IQR, 40-99 vs median, 93; IQR, 69-120; P = .018). Trainees were most confident (range, 90%-100%) in performing oAAA, EVAR, LEB, LEEI, and CEA after training, and least confident in performing oTAA/TAAA and aEVAR (20% and 49% confidence, respectively). ConclusionsOperative case volumes of Canadian vascular surgery trainees since the introduction of IVSR program in 2012 have decreased, driven by declining exposure to open cases. However, trainees continue to receive adequate operative exposure to perform most standard vascular procedures confidently upon graduation.

The Impact of Endovascular Repair of Abdominal Aortic Aneurysms on Vascular Surgery Training in Open Aneurysm Repair

Since the introduction of endovascular abdominal aortic aneurysm (AAA) repair (EVAR) in 1999, open AAA repair (OAR) cases have been reduced dramatically. The consequence of reduced OAR cases has raised valid concerns regarding patient safety and future training of vascular surgeons, which need to be appropriately addressed. Our objective is to analyze trends in OAR and EVAR cases and assess the implications on the vascular surgery training.

Use of a Novel Simulator and Simulation-based Mastery Learning to Improve Femoral Arterial Access Skills

Femoral artery access (FAA) is a fundamental clinical skill across multiple specialties. Simulation-based mastery learning (SBML) is a rigorous form of competency-based education that improves procedural skills and clinical outcomes. We assessed the impact of a FAA SBML curriculum on procedural competency among cardiology fellows (CFs) and vascular surgery trainees (VSTs).

Radiation Exposure in Vascular Surgery Trainees

We evaluated the radiation safety practices among vascular surgery residents (postgraduate year [PGY] 4-7) enrolled in Accreditation Council for Graduate Medical Education vascular surgical residency programs across the United States.

Temporal Changes in Female Trainee Representation Within Differing Vascular Surgery Training Paradigms

Demographics of medical students have evolved over time and, in 2017, more than one-half of incoming medical students were female. It is unclear whether a similar evolution has been observed within the vascular surgery trainee pool and whether differences exist between vascular integrated residencies (VIRs) and vascular fellowships (VFs). The purpose of this study is to evaluate temporal changes in female representation among applicants and residents to VIRs and VFs.

The Vascular Surgery in Training Examination Is Highly Predictive of Board Pass Rates

During each year of training, vascular surgery trainees participate in the Vascular Surgery In-Training Examination (VSITE). Although considered a low stakes formative examination, correlation of the examination to pass/fail performance on the American Board of Surgery Vascular Surgery Board qualifying and certifying examinations could provide program directors and trainees stratification of passing probability. The ability of the VSITE to predict future board certification was evaluated.

The State of Vascular Surgery Virtual Away Rotations in the Time of a Pandemic

The ensuing restrictions from the coronavirus disease 2019 pandemic have significantly hindered in-person fourth-year medical student away rotations. Adapting to this, vascular surgery training programs introduced virtual away rotations (VAR) for fourth-year medical students, in preparation for the residency match. This study aimed to characterize the current curricula of vascular surgery VAR.

Women Representation in Academic Vascular Surgery: Leadership, Education, and Research

There has been an increase in the proportion of registered women vascular surgeons in the past 5 years. It is unclear whether these changes have been reflected within leadership positions within vascular surgery. The purpose of our study was to quantify and highlight women representation within academic vascular surgery, specifically among editorial boards, the Society for Vascular Surgery (SVS), and in training program directors. Data on program directors and department or division leadership was determined by visiting the individual websites of all active vascular surgery residencies (n = 63) and fellowships (n = 116). Data on committee involvement was obtained from the SVS website (https://vascular.org/about/councils-and-committees). Demographics on editorial boards was determined from the top three vascular surgery-specific journals with the highest impact factors: Journal of Vascular Surgery, Journal of Vascular and Endovascular Surgery, and Annals of Vascular Surgery. Gender was assumed from the use of pronouns in surgeon biographies. The proportion of women vascular surgeons in the above leadership positions was compared with the demographics of the 2019 active physician's data available through the Association of American Medical Colleges using χ2 tests. Our analysis revealed significant disparities between men and women in vascular surgery leadership. Among active vascular surgeons, women account for 14.6% (575/3941) of the total workforce. Among the three highest impact vascular surgery journals, women comprised only 8.6% (25/291) of the editorial board, which was significantly lower than the proportion of active women vascular surgeons (P = .006). In contrast, 45.16% (14/31) of the SVS committee leadership positions were held by women (14/31), which was significantly higher than the proportion of active women surgeons (P < .001). Within vascular surgery training programs, women account for 14.52% (9/62 positions) of program directors in the integrated residency programs and 12.07% (14/116 positions) of program directors in fellowship programs (P = 1.0 and P = .487, respectively). Among division chiefs in the same academic institutions, women comprised only 4.81% (5/104 positions; P = .007) (Fig). Our results suggest that women are well-represented among SVS committee leadership but underrepresented among journal editorial boards and division leadership. Of note, our analysis may over-represent women in leadership as some individuals held multiple positions both within their institution and nationally. Leadership positions should evolve with the changing demographics of vascular surgeons, and additional research is needed to understand attitudes and barriers to a more balanced representation. In addition, gender was assumed based off pronoun usage, and self-reported data is needed to capture gender identity more accurately.

Representation of women in vascular surgery science and societies

ObjectiveMedical schools and surgical residencies have seen an increase in the proportion of female matriculants, with 30% of current vascular surgery trainees being women over the past decade. There is widespread focus on increasing diversity in medicine and surgery in an effort to provide optimal quality of patient care and the advancement of science. The presence of gender diversity and opportunities to identify with women in leadership positions positively correlates with women choosing to enter traditionally male-dominated fields. The purpose of this study was to evaluate the representation of women in regional and national vascular surgical societies over the last 20 years. MethodsA retrospective review of the meeting programs of vascular surgery societies was performed. Data were collected on abstract presenters, moderators, committee members and chairs, and officers (president, president-elect, vice president, secretary, and treasurer). The data were divided into early (1999-2009) and late (2010-2019) time periods. ResultsFive regional and five national societies' data were analyzed, including 139 meetings. The mean percentage of female abstract presenters increased significantly from 10.9% in the early period to 20.6% in the late period (P < .001). Female senior authors increased slightly from 8.7% to 11.5%, but this change was not statistically significant (P = .22). Female meeting moderators increased significantly from 7.8% to 17.2% (P < .001), as well as female committee members increased from 10.9% to 20.3% (P = .003). Female committee chairs increased slightly from 10.9% to 16.9%, but this difference was not statistically significant (P = .13). Female society officers increased considerably from 6.4% to 14.8%. (P = .002). Significant variation was noted between societies, with five societies (three regional and two national) having less than 10% women at the officer level in 2019. There was a wide variation noted between societies in the percentage of female abstract presenters (range, 7.6%-34.9%), senior authors (3.9%-17.9%), and meeting moderators (5.4%-40.7%). ConclusionsOver the past two decades, there has been a significant increase in the representation of women in vascular surgery societies among those presenting scientific work, serving as meeting moderators, and serving as committee members. However, the representation of women among committee chairs, senior authors, and society leadership has not kept up pace with the increase noted at other levels. Efforts to recruit women into the field of vascular surgery as well as to support the professional development of female vascular surgeons are facilitated by the presence of women in leadership roles. Increasing the representation of women in vascular society leadership positions may be a key strategy in promoting gender diversity in the vascular surgery field.

Trends in General Surgery Operative Experience Obtained by Integrated Vascular Surgery Residents

When the integrated vascular surgery training pathway was introduced, training was comprised of nearly equal amounts of core general surgery and vascular surgery experience. However, specific requirements for case numbers or types were not defined. Over time, the time spent on core general surgery requirements has been reduced, most recently in 2018, from 24 to 18 months. We sought to determine trends in general surgery case volume and type over the past 10 years for vascular surgery residents. We conducted a retrospective review of the Accreditation Council for Graduate Medical Education case log data for integrated vascular surgery graduates from 2012-2018. We evaluated trends in mean numbers of cases, categorized as general surgery open (GS-open), general surgery laparoscopic (GS-laparoscopic), vascular surgery open (VS-open), and vascular surgery endovascular (VS-endo). Cases were also categorized by anatomic region as head/neck, thoracic, or abdominal. The mean number of total head/neck, thoracic, or abdominal cases logged by graduating integrated vascular surgery trainees was 263.5. This total, as well as the proportion of general surgery cases (35%-38%, p = 0.99) has remained constant over time. The type of general surgery cases has changed significantly, with an upward trend in the mean number of GS-open cases and downward trend in mean GS-laparoscopic cases (GS-open p = 0.006, GS-laparoscopic p = 0.048). Among head/neck and thoracic subgroups, no significant changes were observed, while in the abdominal subgroup, there has been a significant increase in GS-open over time (p = 0.005). Additionally, the number of open vascular abdominal aortic cases has remained stable, with an average of 36.82 per graduating trainee per year. In the 10 years since the introduction of integrated vascular surgery programs, total case volume and proportion of general surgery cases have remained remarkably stable. The type of general surgery cases has shifted though, with a decrease in GS-laparoscopic cases, replaced primarily by open abdominal cases. These changes likely reflect integrated vascular residents actively seeking out these opportunities during their core rotations and a willingness by general surgery partners to provide these opportunities. At the program level, these data may help guide program directors' choices about the specific core rotations they incorporate into their curriculum. At the national level, this information may contribute to future discussions regarding the optimal number of core general surgery rotation requirements.

Feasibility and Evaluation of Surgical Simulation with Developed Crisis Scenarios: A Comparison of Performance by Vascular Surgery Training Paradigms

Surgical simulation is an integral component of training and has become increasingly vital in the evaluation and assessment of surgical trainees. Simulation proficiency determination has been traditionally based on accuracy and time to completion of various simulated tasks, but we were interested in assessing clinical judgment during a simulated crisis scenario. This study assessed the feasibility of creating a crisis simulator station for vascular surgery and evaluated the performance of vascular surgery integrated residents (0+5) and vascular surgery fellows (5+2) during a technical testing with an integrated crisis scenario. A Modified Delphi method was used to create vascular surgery crisis simulation stations containing a clinical scenario in conjunction with either an open or endovascular simulator. Senior level vascular surgery trainees from both integrated residencies (0+5) and traditional vascular surgery fellowships (5+2) were then evaluated on two simulation stations: 1) Elective carotid endarterectomy (CEA) where the crisis is a postoperative stroke and 2) Endovascular aneurysm repair (EVAR) for a ruptured abdominal aortic aneurysm (rAAA). Each simulation had a crisis scenario incorporated into the procedure. Assessment was completed using a performance assessment tool containing a Likert scale. Total score was calculated as a percentage. Scores were also sub-divided in the following four categories: Situation Recognition and Decision-making, Procedural Flow, Technical Skills, and Interpretation and Use of Imaging Skills. Student's t-test was used for analysis. 40 senior-level trainees were evaluated (27 fellows and 13 integrated residents) completing 80 simulations. The CEA crisis simulation yielded similar results between both groups (0+5 vs. 5+2, p = 1.00). The 0+5 residents in vascular surgery were graded to be more proficient in the EVAR for rAAA crisis simulation and demonstrated significant differences in Total Score (p = 0.04), Procedural Flow (p=0.03), and Interpretation and Use of Imaging Skills (p = 0.02). The creation of crisis-based simulation for trainees in vascular surgery is feasible and actionable. Integrated 0+5 residents performed similarly to 5+2 fellows on an open carotid endarterectomy (CEA) crisis simulation, but 0+5 residents scored significantly higher compared to traditional 5+2 fellows in an endovascular rAAA crisis simulation. Crisis simulation may offer better educational experiences and improved value compared to routine simulation. Further studies using different procedural models and clinical scenarios are needed to assess the validity of crisis simulation in vascular surgery and to better understand the performance disparities found between these training paradigms.

The Changing Demographics of Surgical Trainees in General and Vascular Surgery: National Trends over the Past Decade

Recent initiatives have targeted the issue of gender and ethnic/racial disparities in general surgery and vascular surgery. However, the prevalence of these disparities in general and vascular surgical training programs is unknown. A retrospective analysis was conducted using data from three separate sources, including the US Graduate Medical Education annual report, Electronic Residency Application Service database, and National Resident Matching Program annual report. Demographic information regarding gender distribution and ethnic/racial identity was collected from 328 general surgery residency programs, 59 vascular surgery residency programs, and 100 vascular surgery fellowship programs across the US. The primary outcomes of this study were to evaluate national trends in gender and ethnic diversity in general surgery and vascular surgery training programs, including both traditional fellowship and integrated residency paradigms. From 2011-2020, general surgery residency programs showed a positive trend towards both female applicants (from 31.9%-41.5%) and trainees (from 36.2%-43.1%) (p < 0.0001 each). The proportion of minority trainees decreased, primarily among Black (from 7.2%-5.4%) and Asian trainees (from 21.5%-19.2%) (p < 0.0001 each). Concurrently, the number of vascular integrated residency programs grew from 27 to 59, resulting in a fivefold increase in trainees (from 64-335). Despite this growth, there was no change in the proportion of women applicants or trainees for both vascular integrated residency (24.9% applicants; 36.2% trainees) and fellowship programs (27.4% applicants; 25.9% trainees) over the study period (p = 0.11, 0.89, 0.43, and 0.13 respectively). Moreover, there was no significant change in proportion of minority trainees in both vascular integrated residency and fellowship programs. While general surgery programs have expanded in proportion of both female applicants and trainees, racial diversity has decreased. Gender and racial diversity in vascular training has not changed. Future initiatives in general and vascular surgery should focus on recruitment and promotion of proficient women and minority trainees.

Invited commentary

Dr Hekman and coauthors have presented important data from the 2018 Annual Training Survey of the Association of Program Directors in Vascular Surgery. Their data follow the 2016 to 2018 survey data, which found that >60% of active vascular surgery integrated resident and fellows experienced one or more symptoms of distress on a weekly basis.1 The authors identify modifiable risk factors for burnout among vascular surgery trainees, including the clinical learning environment (specifically feeling appropriately challenged, appropriately integrating learning and clinical productivity, and a supportive learning environment), longitudinal mentorship, and specific coping strategies.

Factors influencing medical student choices in the integrated vascular surgery match: Implications for future post-pandemic residency matches

ObjectiveIntegrated vascular surgery residency is among the most competitive specialties, but little is known about the applicant perspective. The coronavirus disease 2019 outbreak impacted the 2021 integrated vascular surgery residency match because of travel restrictions. We sought to better understand pre-pandemic applicant recruitment strategies, logistics of away rotations, and the residency interview process to identify areas for improvement in the application process. MethodsAn anonymous survey was sent to matched students in 2020, inquiring about motivations for pursuing vascular surgery (VS), logistic of away rotations and interviews, and factors influencing students' rank lists. ResultsSeventy of the 73 matched students completed the survey (95.9% response rate). The median age was 27 (range, 25-41); 32.9% were female, 91.4% were U.S. medical students, and 77.1% were from institutions with a VS training program. Factors most strongly influencing the decision to choose VS as a career were interest in open vascular procedures, endovascular procedures, perceived job satisfaction, emerging technologies, and influence of a mentor. The prospect of the job market, future salary, and competitiveness of the application process had the least impact. Of the matched students, 82.9% completed an away rotation (median, 2; range, 1-4), with 51.7% of students paying a total cost of more than $2500. Fifty percent of students matched either at their home institution or where they had performed an away rotation. Students reported application submissions to a median of 50 programs (range, 1-70) and interviewed at 17 (range, 1-28), with 40% of students paying a total of more than $4000 for interview costs. The most significant factors affecting students' rank lists included program culture, open aortic surgical volume, geography, and complex endovascular procedure volume. Tours of facilities, resident salary, and male/female distribution had the least importance. ConclusionsSuccessfully matched applicants in 2020 prioritized operative case volume and program collegiality when ranking programs. Despite their high cost, away rotations played an important role in the Match, suggesting that time spent at potential institutions allowed ideal assessment of factors for students. The high average number of away rotations and in-person interviews performed in 2019-2020 was limited for the 2021 Match due to coronavirus disease 2019 restrictions. Programs will have to continue developing creative alternatives or additions to away rotations and the application processes to assure continued success in future post-pandemic Match cycles.

Open Abdominal Aortic Aneurysm Surgery Among Vascular Surgery Trainees: On the Verge of Extinction?

Objective: In the past decade, treatment of abdominal aortic aneurysm (AAA) has shifted dramatically from open aneurysm repair (OAR) to an endovascular approach (EVAR). The decreasing number OARs has raised concerns regarding future vascular surgeons’ competence to perform this complex and high risk procedure. The main goal of this study was to evaluate AAA repair trends among vascular surgery residents over the last 15 years on a national level.

Vascular surgery trainee retention in the UK: how many leave and why? A survey of trainee and Training Programme Directors\u2019 perceptions

BackgroundIt is currently not known how many trainees leave vascular surgery, and their reasons for doing so are unclear. This paper is the first to publish the number of UK trainees leaving the training programme and interrogates their reasons for doing so.MethodsAn email survey was distributed to current and recent Training Programme Directors (TPDs) to quantify the number of trainees resigning between 2013 and 2019. Trainees resigning a National Training Number (NTN) were surveyed regarding their reasons for doing so.ResultsSince 2013, 23 UK vascular surgery trainees have resigned NTNs, representing 15.4% of the 149 NTNs awarded between 2013 and our analysis. Reasons for leaving, as relayed by TPDs, included availability of an academic career, geography, health and many other reasons classified as “work-life balance” factors. Data from the trainees surveyed also highlighted work-life balance but also identified pressures within the training system and NHS.ConclusionsUK data of this sort has not previously been available. The authors’ primary recommendation is that prospective data collection on trainee retention is carried out, with structured exit interviews with trainees who decide to leave. Our secondary recommendations include improvements to the inter-deanery transfer process and early realistic exposure to vascular surgery for junior doctors to improve trainee retention rates in vascular surgery.

Lower extremity arterial interventions in England.

The increasing prevalence of diabetes mellitus and advances in endovascular therapies continue to have an impact on the epidemiology and management of lower extremity arterial disease. This study describes trends in lower extremity revascularisation and major lower limb amputation in NHS England over the past two decades (2000-2019). Numbers of lower extremity endovascular interventions, open surgical procedures and major lower limb amputations performed in NHS England between 2000 and 2019 were extracted from publicly available hospital admitted patient care activity reports. Trends in intervention were assessed with linear regression models and chi-square tests for trend. Over this period, 527,131 revascularisations and 92,053 amputations were performed. The mean age of patients was 67.5 years (standard deviation 1.6 years) and 65.3% were male. The number of lower limb revascularisation procedures increased by 402.4 units/year (95% confidence interval, CI, 290.1-514.6, p < 0.001). The number of endovascular interventions rose by 43.5% (10,912 in 2000 vs 15,657 in 2019; β = 359.5.0, 95% CI 279.3-439.8, p < 0.001) compared with no significant increase in the number of open surgical procedures (8,483 in 2000 vs 7,872 in 2019; β = 42.8, 95% CI -8.3 to 94.0, p = 0.095). The number of major lower limb amputations has decreased by 9.4% (5,418 in 2000 vs 4,907 in 2019; β = -31.0; 95% CI -49.6 to -12.5, R2 = 0.42, p = 0.003). There has been a significant increase in the rate of lower limb revascularisation procedures associated with decreased numbers of major lower limb amputations over the past two decades. These changes in overall trends may affect both service provision and vascular surgery training planning.

Feasibility and acceptability of virtual mock oral examinations for senior vascular surgery trainees and implications for the certifying exam

ObjectivesThe COVID-19 pandemic resulted in the cancellation of in-person testing across the country. We sought to understand the feasibility of conducting virtual oral examinations as well as solicit opinions of vascular surgery program directors (PD) regarding the use of virtual platforms to conduct both low stakes mock oral examinations with their trainees and potentially “real” high stakes certifying examinations (CE) moving forward. MethodsForty-four senior vascular surgery trainees from 17 institutions took part in a virtual mock oral examination conducted by 38 practicing vascular surgeons via Zoom. Each examination lasted 30 minutes with four clinical scenarios. An anonymous survey pertaining to the conduct of the examination and opinions on feasibility of using virtual examinations for the vascular surgery CE was sent to all examiners and examinees. A similar survey was sent to all vascular surgery program directors. ResultsThe overall pass rate was 82% (36/44 participants) with no correlation with training paradigm. 32/44 (73%) of trainees, 29/38 (76%) of examiners and 49/103 (48%) of PDs completed the surveys. Examinees and examiners thought the experience was beneficial and PDs also thought the experience would be beneficial for their trainees. While the majority of trainees and examiners believed they were able to communicate and express (or evaluate) knowledge and confidence as easily virtually as in person, PDs were less likely to agree confidence could be assessed virtually. The majority of respondents thought the CE of the Vascular Surgery Board of the American Board of Surgery could be offered virtually, although no groups thought virtual exams were superior to in person exams. While cost benefit was perceived in virtual examinations, the security of the examination was a concern. ConclusionsPerforming virtual mock oral examinations for vascular surgery trainees is feasible. Both vascular surgery trainees as well as PDs feel that virtual CEs should be considered by the Vascular Surgery Board.

Examining the Development of Operative Autonomy in Vascular Surgery Training and When Trainees and Program Directors Agree and Disagree

Lack of autonomy in the operating room (OR) during general surgery residency is a major contributing factor to low confidence operating independently after graduation. Although attempts to address decreased autonomy and development of entrustment in the OR are being made in general surgery programs, this issue has not been examined thoroughly in vascular surgery. We sought to determine barriers and opportunities for developing operative autonomy during vascular surgery training by surveying program directors (PDs) and trainees (integrated residents and fellows) in U.S. vascular surgery training programs. An anonymous electronic survey was sent via email to all PDs (n = 155) and trainees (n = 516) in United States vascular surgery training programs. Demographics, academic characteristics, and responses regarding factors impacting the development of entrustment were collected. Thirty-five PDs and 100 trainees completed the survey (22.5% and 19.4% response rate, respectively). Sixty percent of trainees were integrated residents and 40% were fellows. Twenty percent of PDs and 33% of trainees were female, and 5% of all PDs and trainees were from underrepresented minorities. The single most positive factor affecting the development of autonomy according to trainees and PDs is familiarity of the faculty with the trainee. Both PDs and trainees thought the trainee's preparation for the case positively affected development of autonomy; however, more PDs believed that involvement with preoperative preparation in particular (marking the patient, consenting the patient, filling out a history and physical, prepping and draping the patient) was important (P < 0.05). PDs believed that duty-hour limitations negatively affected the trainee's ability to develop autonomy in the OR, whereas more trainees believed that hospital or OR efficiency policies played a negative role (P < 0.05). Finally, compared with trainees, PDs believed that the appropriate amount of time for safe struggle before the attending should take over the case was when OR efficiency was compromised or at any moment the trainee is unsure of themselves (P < 0.05); trainees believed that the attending should take over the case after the limit of their skill set or troubleshooting ability was reached (P < 0.05). Familiarity of the attending physician with the trainee is an important positive factor for development of entrustment and autonomy in vascular surgery trainees. Duty-hour limitations and belief of the need for hospital efficiency may negatively impact operative independence of trainees. An open discussion about balancing OR efficiency and trainees' safe struggle is essential to address the growth of independent operative skills in vascular surgery trainees.

Self-Perceived Comfort Performing Vascular Surgery Procedures among Senior Vascular Surgery Trainees and Recent Graduates

In the last two decades, vascular surgery training evolved from exclusively learning open skills to learning endovascular skills in addition to a functional reduction in training duration with 0+5 residency programs. The implications for this on trainee evolution to independence are unknown. We aimed to assess self-perceived comfort performing open and endovascular procedures and to identify predictors of high comfort among senior vascular surgery trainees and recent graduates. Junior and senior 0+5 vascular surgery residents, traditional fellows, and attendings in their first 4 years of practice were asked to complete a survey assessing the number of vascular procedures performed to date, comfort performing these procedures on a Likert scale, and validated scales of self-efficacy and grit. Groups were then matched by training level and age. Logistic regression identified independent predictors of the top quartile of self-perceived comfort performing procedures. Surveys were completed by 92 trainees and 71 attending surgeons in their first 4 years of practice. After matching, completing ≥7 open juxtarenal aortic repairs (OR = 4.73, 95% CI = 1.59-14.07) and a higher self-efficacy score (OR = 3.24, 95% CI = 1.20-8.76), were independent predictors of top quartile comfort performing open vascular procedures. 0+5 residency training inversely correlated with top quartile comfort performing open vascular operations (OR = 0.12, 95% CI = 0.03-0.47). Completing ≥7 complex EVARs (OR = 3.94, 95% CI = 1.61-9.59) and a higher self-efficacy personality score (OR = 2.76, 95% CI = 1.09-7.02) were predictors of top quartile comfort performing endovascular procedures. In this nationally representative survey, both trainees and junior attendings completed a paucity of complex open vascular cases, which corresponded to reduced comfort performing these procedures. Furthermore, 0+5 residency training was associated with lower self-perceived comfort performing open vascular surgery, a trend that persisted through the first years of practice. Endovascular comfort did not show a similar correlation.