Sapan Desai (Department of Vascular Surgery, Southern Illinois University, USA) and colleagues report in the Journal of Vascular Surgery that the ongoing decrease in open aneurysm repair that has occurred as a result of the increase in endovascular aortic aneurysm repair (EVAR) may mean that next-generation vascular surgeons do not gain sufficient experience in open repair during training and, therefore, may be ill prepared to perform the procedure.
Desai et al comment that data from the US Accreditation Council for Graduate Medical Education (ACGME) procedure database indicate that between 2001 and 2007, the number of EVAR procedures increased by 298.8% while the number of open procedures decreased by 17%, which they say has “raised concerns” that the volume of open repair procedures now being performed may “no longer be conducive for adequate vascular trainee education”. The authors add: “A total of 30 open abdominal cases are required for graduating vascular surgery fellows and integrated residents, and because of this continued decline in the open abdominal experience, the current vascular surgery training paradigm should be re-evaluated to ensure that the next generation of vascular surgeons is appropriately trained to respond to all forms of vascular disease.” Therefore, the purpose of Desai et al’s study was to forecast, using US national historic trends, future open aneurysm repair volume and its effect on vascular surgery training.
Through a retrospective analysis of data from the National Inpatient Sample, the authors identified how many open aneurysm repair procedures had been performed every year in the USA between 1998 and 2011. They confirmed previous findings that there had been a rapid decrease in open repair (from a peak of 42, 872 cases in 2000 to 10,039 in 2011) in line with a rapid increase in EVAR (from 2,358 cases in 2000 to 35,028 cases in 2011) during this time period. Of the 10,039 open repairs performed in 2011, 6,055 (60.3%) were performed at teaching institutions. Desai et al noted: “In the 2011 ACGME National Resident Report, there were 124 vascular surgery trainees at 96 training programmes who completed an average of 21.7 cases. Vascular surgeons were therefore present for 2,691 cases (44.4%).” Using these data, they calculated that—overall—there would be 6,805, 3,863, and 2,200 open repairs performed in 2015, 2020, and 2025 respectively and of these, 3,809, 2,162, and 1,231 (respectively) would be performed at teaching institutions. Desai et al comment: “If there is no change in resident utilisation, it is expected that just 1,693 of those cases [open repairs] will be completed by vascular surgery trainees in 2015. With the advent of the 0+5 vascular training paradigm, there were 163 vascular training positions in 2013. Overall, the increase in vascular surgery trainees, coupled with our model’s prediction of a lower number of open aneurysm repairs, indicates that vascular fellows will complete about 10 open aneurysm repairs in 2015 and about five open aneurysm repairs in 2020.”
The authors write that, based on their results, there is a “paramount need” to ensure that the next generation of vascular surgeons are adequately prepared to perform both open and endovascular repairs. They add that vascular surgeons potentially not having sufficient experience to perform open repair is an “issue” because “EVAR is associated with endoleaks that can result in increase in aneurysm size and rupture in the wrong patient, and knowledge of open repair is hence important.”
Desai et al suggest that the exposure of vascular trainees to open repair could be increased by regionalising care to centres of excellence, the use of high-fidelity simulation systems, the creation of dedicated open repair vascular fellowships, or a combination of these approaches. They add: “Increased trainee utilisation can also offset the decreasing exposure to open aneurysm repair; for example, trainees in a 0+5 programme who make a special effort to scrub open aneurysm repair cases can also offset this decline by virtue of more years of training.”
Desai told Vascular News: “The skillset required to prepare vascular surgeons for open abdominal cases is becoming more precious with the passage of time. Fewer open abdominal cases are completed today than ever before. Further, integrated vascular surgery residents may be at particular risk as the open experience they may obtain in the latter two to three years of general surgery residency is no longer available to them. Several options exist to help ensure that the next generation of vascular surgeons is able to competently repair an abdominal aortic aneurysm via an open approach: a dedicated open surgery fellowship, rotations at hospitals that have high open volume (such as in Canada or India), or the creation of centres of excellence for open repair.”