Determining who trains vascular surgery fellows in endovascular techniques
Article Outline
Objectives
Vascular surgery training has evolved from a single clinical year after general surgery training to a multi-year training program to encompass such entities as noninvasive vascular laboratory, office-based procedures, and endovascular techniques. Simultaneously, members of the vascular surgery community have had to undergo significant training to become facile with endovascular techniques. We surveyed vascular surgery trainees on the online Vascular Surgery In-Training Examination (VSITE) in 2008 and 2009 to assess who trained them in percutaneous techniques.
Methods
Vascular surgery trainees in the Independent (2-year) and Integrated (5-year) training programs were asked to participate in a survey upon completion of the VSITE in 2008 and 2009. Examinees were asked to select whether vascular surgeons, cardiologists, or interventional radiologists trained them in carotid angioplasty and stenting (CAS), thoracic endografts (TEVAR), endovascular abdominal aortic aneurysm repair (EVAR), renal artery intervention, iliac stenting, superficial femoral artery (SFA), and tibial artery percutaneous interventions.
Results
Survey response rate was 79.6% (191 of 240). Results of the survey are shown in Table I. In 2009, vascular surgeons provided more than 84% of the training to vascular surgery residents. Only six respondents had >50% of their percutaneous training with interventional radiology and two with cardiologists.
Conclusion
Vascular surgeons involved in resident education have been able to retrain themselves in endovascular techniques such that they are now able to provide greater than 80% of the endovascular experience to vascular surgery residents.
Vascular surgery training has undergone a number of changes over the past decade. Most notable was the introduction of endovascular abdominal aortic aneurysm repair in the 1990s. This technique spawned a new era of endovascular and percutaneous techniques that are now mandatory in all vascular surgery training programs. In 2002, the Residency Review Committee-Surgery established minimum program requirements for endovascular procedures. After consultation with the Association of Program Directors in Vascular Surgery (APDVS) and the Vascular Surgery Board (VSB) of the American Board of Surgery (ABS), the Society for Vascular Surgery (SVS), and American Heart Association (AHA) credentialing recommendations of 100 angiograms and 50 interventions and an additional requirement of 5 endovascular aortic aneurysm repairs (EVAR) were adopted as minimal requirements for a vascular fellowship program to be reaccredited.1 Although this document was meant to ensure acquisition of basic endovascular skills in vascular surgery training, the mere introduction of the requirement had a significant impact on training programs as noted by the ever-increasing numbers of endovascular procedures reported by vascular surgery graduates from 2003-2008. In 2002, the average number of endovascular diagnostic and therapeutic procedures performed were 33 and 48, respectively, both of which were below the newly established program requirements.2 Five years later (2007), the 50th percentile numbers for diagnostic and therapeutic endovascular procedures rose dramatically to 100 and 156, respectively, for vascular fellows completing their training in 2007.3
Simultaneously, vascular surgeons in the workforce were beginning to develop percutaneous skills at varying levels in varying different arrangements – many times with other specialists such as interventional radiology and interventional cardiology. Although skills may be acquired from many types of specialists, it is often desirable to learn techniques from those in one's area of specialty. Particularly in the area of vascular surgery, it is helpful for the endovascular instructor to have the perspective of open and endovascular surgery when figuring out which options may be best for which patients. Having both skill sets allows a viewpoint which may not be imparted by the pure interventionalist or the surgeon with only open surgery capabilities. There has been concern, however, that bias still exists among vascular surgeons against these less durable, less morbid, and more patient-preferred percutaneous therapies, and that this bias may be standing in the way of complete endovascular training.4, 5 With percutaneous skill levels variable at the faculty level, it was unclear in training programs how vascular surgery trainees were gaining the experience required. We sought to query vascular fellows around the nation with regard to who they were receiving their training from to gain a better understanding of endovascular training in vascular surgery programs.
Methods
An online Vascular Surgery In-Training Examination (VSITE) was developed in 2007 and first administered in 2008 by the VSB of the ABS and the APDVS to assess trainee knowledge. The VSITE continues to be given on an annual basis to all trainees in vascular surgery, with greater than 95% of training programs participating.
Vascular surgery residents in the Independent (2-year) and Integrated (5-year) training programs were asked to participate in a survey upon completion of the 2008 and 2009 VSITE. The 2008, survey consisted of 16 questions regarding demographics, interest in pursuing general surgery, and endovascular training with specific questions regarding who trained them in carotid angioplasty and stenting (CAS), thoracic endografting (TEVAR), EVAR, renal artery intervention, iliac artery angioplasty and stenting, and interventions in the superficial femoral and tibial arteries. In 2009, VSITE examinees were surveyed with questions on demographics and noting what percent of endovascular surgery training was received from vascular surgeons, cardiologists, or interventional radiologists. Results were tabulated on a Microsoft Excel spreadsheet and analyzed.
Results
In 2008, 240 trainees (14% female and 86% male; 80% US medical graduates, 20% foreign medical graduates) from more than 95% (91 of 95) of the vascular surgery training programs took the VSITE. Thirty-six vascular surgery faculty took the examination as well. The survey was completed by 191 of 240 trainees for a response rate of 80%. More than 80% of surveyed vascular surgery trainees were trained by vascular surgeons on complex endovascular techniques such as CAS (82%), TEVAR (88%), renal artery angioplasty, and stenting (87%), and superficial femoral artery (SFA)/tibial (93%) interventions (Table I). Less than 10% of vascular surgery trainees were trained by cardiologists in CAS (8.9%), TEVAR (1.6%), renal artery angioplasty and stenting (5.2%), and SFA/tibial (4.7%) interventions (Table I). Interventional radiologists trained 15% of vascular trainees in CAS, 6.3% in TEVAR, 22% in renal artery angioplasty and stenting, and 19% in SFA/tibial interventions.
Table I. Percentage of endovascular training that trainees received in select percutaneous procedures from various specialists in 2008
| Vascular surgeons (No. trainees/total No. trainees) | Cardiologists (No. trainees/total No. trainees) | Interventional radiologists (No. trainees/total No. trainees) | |
|---|---|---|---|
| CAS | 82.2% (157/191) | 8.9%(17/191) | 14.6%(28/191) |
| TEVAR | 88.0%(168/191) | 1.6%(3/191) | 6.3%(12/191) |
| EVAR | 99.0%(189/191) | 2.1%(4/191) | 8.4%(16/191) |
| Renal stenting | 86.9%(166/191) | 5.2%(10/191) | 21.9%(42/191) |
| Iliac PTA/stent | 94.8%(181/191) | 4.2%(8/191) | 20.9%(40/191) |
| SFA/tibial PTA | 92.7%(177/191) | 4.7%(9/191) | 18.8%(36/191) |
In 2009, a total of 243 vascular surgery trainees took the VSITE examination including 224 Independent (2-year), 18 Integrated (5-year), and 1 Early Specialization Program (4 + 2) trainees. The survey was completed by 191 of 243 trainees for a response rate of 79%. Eighty-five percent of those surveyed stated that vascular surgeons provided more than 50% of their training in endovascular techniques (Table II). Of the Independent trainees, 87% had ≥50% of their endovascular training by vascular surgeons compared to 68% of Integrated. Only 2 Independent trainees (1.4%) surveyed had more than 50% of their percutaneous training by cardiology with zero in the Integrated group (Table III). Four Independent (2.5%) and 1 Integrated (7.7%) respondent had >50% of percutaneous training with Interventional Radiology (Table IV).
Table II. Percentage of endovascular training that trainees received from vascular surgeons in 2009
| Total | Independent program (“5+2”) | Integrated program (“0+5”) | ||||
|---|---|---|---|---|---|---|
| (n) | (%) | (n) | (%) | (n) | (%) | |
| A – 0% | 3 | 1.7 | 1 | .6 | 0 | 0 |
| B – 1% to 10% | 2 | 1.1 | 2 | 1.3 | 0 | 0 |
| C – 11% to 25% | 1 | .6 | 1 | .6 | 0 | 0 |
| D – 26% to 50% | 21 | 11.7 | 15 | 9.7 | 4 | 30.8 |
| E – 51% to 75% | 39 | 21.8 | 32 | 20.8 | 4 | 30.8 |
| F – 75% to 100% | 113 | 63.1 | 103 | 66.9 | 5 | 38.5 |
Table III. Percentage of endovascular training that vascular trainees received from cardiologists in 2009
| Independent program (“5+2”) | Integrated program (“0+5”) | |||
|---|---|---|---|---|
| (n) | (%) | (n) | (%) | |
| A – 0% | 123 | 80.4 | 4 | 30.8 |
| B – 1% to 10% | 19 | 12.4 | 4 | 30.8 |
| C – 11% to 25% | 6 | 3.9 | 5 | 38.5 |
| D – 26% to 50% | 3 | 2.0 | 13 | 100.0 |
| E – 51% to 75% | 1 | .7 | 0 | 0 |
| F – 75% to 100% | 1 | .7 | 0 | 0 |
Table IV. Percentage of endovascular training that vascular trainees received from Interventional Radiologists in 2009
| Independent program (“5+2”) | Integrated program (“0+5”) | |||
|---|---|---|---|---|
| (n) | (%) | (n) | (%) | |
| A – 0% | 99 | 64.3 | 2 | 15.4 |
| B – 1% to 10% | 34 | 22.1 | 6 | 46.2 |
| C – 11% to 25% | 13 | 8.4 | 4 | 30.8 |
| D – 26% to 50% | 4 | 2.6 | 0 | 0 |
| E – 51% to 75% | 3 | 1.9 | 1 | 7.7 |
| F – 75% to 100% | 1 | .6 | 0 | 0 |
Discussion
Vascular surgery training has undergone significant change in the past decade - most notably with the introduction of percutaneous endovascular techniques and the subsequent requirement of diagnostic and therapeutic procedures in all vascular surgery training programs beginning in 2002. Simultaneously, the vascular surgery workforce was being retrained in endovascular techniques. Concern has been raised that advanced endovascular techniques such as CAS, TEVAR, and SFA/tibial interventions have not been fully embraced and that potential bias exists against these techniques by vascular surgeons who do not believe they are as durable.3
The results of the surveys administered to 2008 and 2009 vascular surgery trainees reveals that more than 80% of trainees receive advanced endovascular training in CAS, TEVAR, renal angioplasty and stenting, and SFA/tibial interventions from vascular surgeons. This commentary by trainees infers that the vascular surgery faculty, at least in training programs, are up-to-date in areas of both basic and complex endovascular techniques. Although this cannot be generalized to vascular surgery practices not involved in training programs, experience dictates that many of those in community-based practice are equally on the cutting edge. Nonetheless, these results suggest that vascular surgeons in training programs have embraced the technology and that presumed vascular surgeon bias does not seem to be standing in the way of trainees gaining experience in advanced endovascular procedures.
Slightly lower percentages, 68%, of Integrated trainees were receiving the majority of their endovascular training from vascular surgeons when compared with 87% of Independent trainees. This is likely inherent to the infancy of this training paradigm given the low number of residents to survey and that many of the residents will have spent limited time at this stage of their residency, with vascular surgeons for advanced endovascular techniques. Rotations with Interventional Radiology and Cardiology and exposure to their endovascular techniques are not uncommon in the early years of an Integrated program. As this training pathway ages, the percentage of trainees trained in advanced endovascular techniques would be expected to increase.
There are inherent weaknesses to our survey. Heterogeneity with regard to skill level in endovascular techniques can certainly exist among faculty groups in vascular training programs where there may be a designated vascular surgeon who concentrates more on endovascular techniques than his or her partner. Our survey was not designed to capture this bias based on the questions that were asked. This practice arrangement would still adequately cover the goal of having vascular surgeons train vascular residents in all levels of endovascular techniques; however, as time goes on a more homogenous look may evolve in the group. Additionally, our survey did not have 100% participation. The online examination was to be designed so that the examination would not be considered complete until the survey was answered; however, the software design did allow some trainees to submit their examination without completing the survey. This problem occurred again in 2009 and will be addressed through the use of a new software company in 2010. Nonetheless, our survey still captured the opinions of more than 75% of trainees. Additionally, the survey was slightly different in 2008 compared to 2009, making comparison difficult. In 2008, questions were directed at asking trainees who trained them in specific endovascular techniques, while in 2009, we asked what percentage of their endovascular training came from vascular surgeons, interventional radiologists, or interventional cardiologists. Approaching the question in two different ways seems to have brought about a similar response from trainees, namely that greater than 80% of endovascular experience comes from vascular surgeons, although a consistent survey question going forward in the future will help track trends in training.
Conclusion
Vascular surgeons involved in resident education have been able to educate themselves in endovascular techniques in such a way as to provide greater than 80% of the endovascular experience to vascular surgery residents in training programs. Ongoing evaluation of vascular surgery trainees regarding their education in vascular surgery will continue to help strengthen our training programs and provide opportunities for improvement.
Author contributions
References
- . Endovascular interventions training and credentialing for vascular surgeons. J Vasc Surg. 1999;29:177–186
- Accreditation Council for Graduate Medical Education Program National Data for Vascular Fellowship programs for 2001-2002, Report B.
- Accreditation Council for Graduate Medical Education Vascular Surgery Program National Statistics Report for 2007-2008.
- . Advanced endovascular training for vascular residents: what more do we need?. Semin Vasc Surg. 2006;19:194–199
- . Incorporation of endovascular training into a vascular fellowship program. Am J Surg. 1995;170:168–173
Competition of interest: none.
The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a competition of interest.
PII: S0741-5214(09)02257-5
doi:10.1016/j.jvs.2009.10.109
© 2010 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
