Training for Multiple Arterial Grafting: A Thoracic Surgery Resident Survey.

BACKGROUND: Utilization of multiple arterial grafting (MAG) in the United States is less than 10%. Trainee experience with MAG has not previously been examined. METHODS: A total of 497 thoracic surgery residents in accredited training programs in March 2019 and 115 who completed residency in 2018 were electronically surveyed regarding their experience with MAG using a radial artery (RA) graft or bilateral internal mammary artery (BIMA) grafts with a skeletonized mammary (SM). RESULTS: Eighty-four (14%) trainees responded: 54% had completed 2+ years of training and 87% declared their focus as cardiac, undecided, or both cardiac and thoracic (CUB). Of all 84 respondents, 76% (n = 64 of 84) had no experience with RA harvest. A total of 35% (n = 29 of 84) had no experience with SM harvest. The majority, 68% (n = 57 of 84), used BIMA grafting in 0% to 5% of cases. A total of 61% (n = 51 of 84) used RA conduit in 0% to 5% of cases. Among trainees with 2+ years of experience, 56% (n = 25 of 45) had performed more than 6 SM takedowns, 18% (n = 8 of 45) had no experience. In trainees with 2+ years, 20% (n = 9 of 45) performed more than 5 RA harvests, while 80% (n = 36 of 45) had no experience. Examining integrated 6-year residents with greater than 3 years of experience, only 33% (n = 5 of 15) performed more than 5% RA grafting. A total of 90% of CUB trainees wanted to perform MAG in practice and 75% felt prepared to do so. CONCLUSIONS: Despite substantial variation in MAG training, respondents expressed an overwhelming interest in performing MAG. These data and the reality of MAG utilization in the United States indicate that a more rigorous, standardized approach to MAG training may be required.

Vein Graft Interposition: A Training Model Using Gradually Thawed Cryopreserved Vessels.

INTRODUCTION: Microsurgical interposition of vein grafts is an extraordinarily filigree surgical technique, which requires both sound theoretical knowledge and solid manual skills. Although there are a large number of training models, the majority of these are either relatively expensive, technically complex, or employ synthetic materials with poor resemblance to human tissue. The authors' model allows training of ex vivo vein graft interposition on gradually thawed cryopreserved vessels and it, therefore, is cost-efficient and readily available when needed. Furthermore, it respects the 3R-principle (Reduce-Refine-Replace), as it is based on rat cadaveric vessels. METHODS: Three trainees with basic microsurgical experience, but without prior performance of vein graft interpositioning, were chosen to perform 20 femoral vein graft (5 mm) interpositions into femoral artery defects. The patency and leakage rate served as qualitative variable and operation time as a quantitative variable for efficiency control. RESULTS: For the first half of trials, the trainees had a patency failure rate of 50% and for the second half a rate of 13.3%. The leakage rate noticeably decreased from 44.4% in the first half of trials to 10% in the second half. Although the trainees needed 60 minutes on average for their first 10 trials, they improved to 51 minutes for their last 10 anastomoses. CONCLUSION: The authors' microsurgical model offers a simple, low-cost simulation training, specifically designed for learning of vein graft interposition into arterial defects. The model is associated with a high learning curve, based on an objective control of the anastomoses by assessment of the patency, leakage, and operation time.

Vascular fellow and resident experience performing infrapopliteal revascularization with endovascular procedures and vein bypass during training.

OBJECTIVE: Endovascular aneurysm repair has led to a significant reduction in vascular trainee experience in the surgical treatment of aortic aneurysms. We sought to evaluate whether the vascular training paradigm or the "endovascular first" approach to lower extremity vascular disease has had a similar effect on trainee experience with infrapopliteal endovascular therapy and vein bypass. METHODS: Deidentified data were provided by the Vascular Surgery Board on the number of procedures performed by each 2014 fellowship and residency (0 + 5) graduate during training. Data were analyzed using parametric and nonparametric methods, where appropriate. RESULTS: Of 125 trainees (109 fellows, 16 residents), 33 (27%) performed 10 or fewer infrapopliteal vein bypasses and 37 (29%) performed 10 or fewer infrapopliteal endovascular procedures during their training. Eleven trainees (9%) performed 10 or fewer of both procedures. There was a positive correlation between number of infrapopliteal vein bypass and endovascular procedures performed (r = 0.19; P = .03). There was no difference between fellows and residents in the mean number of bypass operations performed during training (17.3 vs 19.1; P = .50; range, 0-53). However, residents performed more infrapopliteal endovascular procedures than fellows did (median, 29 vs 16; P = .03; range, 0-128). CONCLUSIONS: More than one in four graduates of both training paradigms finish with a low number of infrapopliteal bypasses and endovascular interventions. The number of these procedures needed for proficiency is not known. Vascular surgery training programs should critically evaluate the number of infrapopliteal procedures required to achieve proficiency.

Assessment of open operative vascular surgical experience among general surgery residents.

BACKGROUND: General surgeons have traditionally performed open vascular operations. However, endovascular interventions, vascular residencies, and work-hour limitations may have had an impact on open vascular surgery training among general surgery residents. We evaluated the temporal trend of open vascular operations performed by general surgery residents to assess any changes that have occurred. METHODS: The Accreditation Council for Graduate Medical Education's database was used to evaluate graduating general surgery residents' cases from 1999 to 2013. Mean and median case volumes were analyzed for carotid endarterectomy, open aortoiliac aneurysm repair, and lower extremity bypass. Significance of temporal trends were identified using the R(2) test. RESULTS: The average number of carotid endarterectomies performed by general surgery residents decreased from 23.1 ± 14 (11.6 ± 9 chief, 11.4 + 10 junior) cases per resident in 1999 to 10.7 ± 9 (3.4 ± 5 chief, 7.3 ± 6 junior) in 2012 (R(2) = 0.98). Similarly, elective open aortoiliac aneurysm repairs decreased from 7.4 ± 5 (4 ± 4 chief, 3.4 ± 4 junior) in 1999 to 1.3 ± 2 (0.4 ± 1 chief, 0.8 ± 1 junior) in 2012 (R(2) = 0.98). The number of lower extremity bypasses decreased from 21 ± 12 (9.5 ± 7 chief, 11.8 ± 9 junior) in 1999 to 7.6 ± 2.6 (2.4 ± 1.3 chief, 5.2 + 1.8 junior) in 2012 (R(2) = 0.94). Infrapopliteal bypasses decreased from 8.1 ± 3.8 (3.5 ± 2.2 chief, 4.5 ± 2.9 junior) in 2001 to 3 ± 2.2 (1 ± 1.6 chief, 2 ± 1.6 junior) in 2012 (R(2) = 0.94). CONCLUSIONS: General surgery resident exposure to open vascular surgery has significantly decreased. Current and future graduates may not have adequate exposure to open vascular operations to be safely credentialed to perform these procedures in future practice without advanced vascular surgical training.

Rat posterior facial vein interpositional graft: a more relevant training model.

Microvascular training models for vein grafting most often use the rat epigastric vein interpositioned to the femoral artery. We describe the rat posterior facial vein as an alternative vein graft model; it has at least a 2:1 diametric ratio to the femoral artery and a tougher connective tissue, making it more similar to clinical vein grafting for reconstructive microsurgery. A series of 24 grafts interpositioned to the femoral artery were done using 11-12 sutures per end-to-end anastomosis and yielded early patency rates of 96% at 20 min and 92% at 2 and 4 weeks for subsets of 12 grafts. As a training model the diametric disparity provides unique challenges with clinical relevance, for which a number of different techniques for matching arterial to venous circumferences can be done.

Assessment of surgical residents in a vascular anastomosis laboratory.

BACKGROUND: We designed a simple, low-cost workshop to teach surgical residents the basic skills of vascular anastomosis. We studied our ability to identify objective procedural and end-product metrics that could be used to measure improvement in vascular anastomotic skill before and after training. MATERIALS AND METHODS: Ten postgraduate year 2 residents without previous vascular surgery experience and four attending surgeons (expert) performed end-to-side anastomosis using a synthetic graft. The residents were taught the basic skills of vascular anastomosis during three didactic workshops. The objective metrics included volume leakage after saline perfusion (leak) and the time needed to complete the anastomosis. Penalty points were assigned for broken sutures, air knots, locking sutures, and failure to maintain an outside-in to inside-out technique. The leak, time, and penalties before and after training were compared. RESULTS: The mean leak was 70.4 ± 13.7 mL and the mean completion time was 18.7 ± 3 min for the pretraining group versus 45.3 ± 10.6 mL (P < 0.01) and 8.5 ± 1 min (P < 0.001), respectively, for the attending group. After training, significant improvement was seen in resident leak (46.7 ± 6.8 mL; P < 0.001) and completion time (14.4 ± 3 min; P < 0.01). Leak was similar between the post-training and expert groups (46.7 ± 6.8 mL and 45.3 ± 10.6 mL, respectively; P = 0.77); however, a significant difference for the completion time remained (14.4 ± 3.0 min and 8.5 ± 1 min, respectively; P < 0.01). The mean number of technical errors improved from 2.7 in the pretraining group to zero for the post-training group after completing the workshop. CONCLUSIONS: We have reported an easy to implement workshop for teaching surgical residents the basic skills of performing vascular anastomosis.

Surgical trainee participation during infrainguinal bypass grafting procedures is associated with increased early postoperative graft failure.

OBJECTIVE: This study was conducted to determine the potential effect of surgical trainee participation during infrainguinal bypass procedures on postoperative graft patency rates. METHODS: Data from the National Surgical Quality Improvement Program (NSQIP) Participant User Files from 2005 through 2009 were retrospectively reviewed, using propensity score matching, to identify all patients undergoing infrainguinal bypass grafting procedures, excluding those who had prior operation ≤30 days of the index procedure. A separate analysis was performed on a subset of procedures from the entire NSQIP sample that was matched on propensity for intraoperative surgical trainee participation. The primary predictor variable was intraoperative surgical trainee participation. The main outcome measure was the 30-day postoperative graft failure rate. RESULTS: For the entire sample of 14,723 NSQIP patients undergoing infrainguinal bypass grafting, 30-day graft failure rates were significantly higher when a surgical trainee participated (5.8%) vs without participation (3.9%; P < .0001). For the cohort of 9234 patients matched on their propensity for intraoperative trainee participation, this difference in graft failure rate remained significant (5.0% with participation vs 4.0% without participation; P = .02). CONCLUSIONS: Surgical trainee participation is an independent risk factor for technical failure after infrainguinal bypass grafting. Prospective evaluation is needed to determine the cause of this increase in graft failure rates for procedures that involve surgical trainees.