Certification of Basic Skills in Endovascular Aortic Repair Through a Modular Simulation Course With Real Time Performance Assessment.

OBJECTIVE: Endovascular aortic repair (EVAR) is being used increasingly for the treatment of infrarenal abdominal aortic aneurysms. Improvement in educational strategies is required to teach future vascular surgeons EVAR skills, but a comprehensive, pre-defined e-learning and simulation curriculum remains to be developed and tested. EndoVascular Aortic Repair Assessment of Technical Expertise (EVARATE), an assessment tool for simulation based education (SBE) in EVAR, has previously been designed to assess EVAR skills, and a pass limit defining mastery level has been set. However, EVARATE was developed for anonymous video ratings in a research setting, and its feasibility for real time ratings in a standardised SBE programme in EVAR is unproven. This study aimed to test the effect of a newly developed simulation based modular course in EVAR. In addition, the applicability of EVARATE for real time performance assessments was investigated. METHODS: The European Society of Vascular Surgery (ESVS) and Copenhagen Certification Programme in EVAR (ENHANCE-EVAR) was tested in a prospective cohort study. ENHANCE-EVAR is a modular SBE programme in EVAR consisting of e-learning and hands-on SBE. Participants were rated with the EVARATE tool by experienced EVAR surgeons. RESULTS: Twenty-four physicians completed the study. The mean improvement in EVARATE score during the course was +11.8 (95% confidence interval 9.8 - 13.7) points (p < .001). Twenty-two participants (92%) passed with a mean number of 2.8 ± 0.7 test attempts to reach the pass limit. Cronbach's alpha coefficient was 0.91, corresponding to excellent reliability of the EVARATE scale. Differences between instructors' EVARATE ratings were insignificant (p = .16), with a maximum variation between instructors of ± 1.3 points. CONCLUSION: ENHANCE-EVAR, a comprehensive certifying EVAR course, was proven to be effective. EndoVascular Aortic Repair Assessment of Technical Expertise (EVARATE) is a trustworthy tool for assessing performance within an authentic educational setting, enabling real time feedback.

A National Needs Assessment in Simulation Based Training in Vascular Surgery.

OBJECTIVES: The aim of this research was to ascertain the highest need areas for vascular simulation, in order to tailor training for the highest impact. DESIGN, PARTICIPANTS AND SETTING: A needs assessment was conducted according to best practices using the Delphi method. All consultant vascular surgeons/trainers in the training jurisdiction (n=33) were approached through an independent intermediary to contribute and generate a prioritized list of procedures for training. The research team were blinded to participant identities. Three rounds were conducted according to the Delphi process and scored according to the Copenhagen Needs Assessment Formula (CAMES-NAF). RESULTS: A final list of 34 vascular procedures was selected and prioritized by surgical trainers. Principles of arterial repair and endarterectomy/patching were considered the highest priority. Complex major interventions such as open abdominal aortic aneurysm (AAA) repair, carotid endarterectomy, and endovascular aortic repair (EVAR) consistently ranked higher than rarer, such as first rib resection and more basic procedures, such as foam injection for varicose veins. Major lower limb amputations typically ranked lower overall compared to arterial interventions. Surgical trainers generally agreed with the ranking according to the CAMES-NAF. There was some disagreement for a select few procedures such as iliac stenting (which rose 13 places) and open radial artery exposure (which fell 6 places) on subsequent iterations. CONCLUSIONS: Core operative principles and common major operative cases should remain the priority for vascular technical skills training. Other procedures which may be less invasive, but have the potential for major complications should also not be overlooked. In designing simulators the main focus should center on specific skill acquisition for commonly performed major procedures and management of the recognized potential complications. Lower limb amputations are considered adequately taught in clinical practice, or are too challenging to simulate in simulator models apart from cadaveric models.

Starting a Vascular Surgery Fellowship at a Rural Healthcare Center.

INTRODUCTION: In the United States, there is an anticipated critical shortage of vascular surgeons in the coming decades. The shortage is expected to be particularly pronounced in rural areas. Our institution serves a rural and underserved population in which the incidence and prevalence of cardiovascular disease continues to rise. Our institution maintains a general surgery residency and has all the required Accreditation Council for Graduate Medical Education (ACGME) rotations and educational infrastructure to support a vascular surgery fellowship. This study aims to analyze the vascular caseload at our institution to determine if we and other institutions with similar surgical volumes can support the creation of a 2-year vascular fellowship. METHODS: A single-site retrospective review of the number and type of vascular cases conducted at our institution between July 2016 and June 2021 was performed. The procedures were grouped into the following ACGME-defined categories: abdominal, cerebrovascular, complex, endovascular aneurysm repair, endovascular diagnostic or therapeutic, and peripheral. The total number and annual average for each category was obtained. Using the annual average, a 2-year estimate was calculated and compared to the ACGME minimum for each category. Our 2-year estimate was then compared to the national average for graduating vascular surgery fellows in order to generate a z-score for each category. RESULTS: In the specified period, 6100 total surgical procedures were performed by three vascular surgeons at our institution. Two thousand five hundred and seventy-eight of the 6100 procedures met at least one of the ACGME-defined category requirements. Our center greatly exceeded the requirements for each category except for abdominal. This is consistent with trends observed in most centers across the nation, which are seeing a decline in open repairs across all categories, especially in open abdominal repairs. Our center's vascular case volume shows no significant difference the national average in each ACGME category (P ≥ 0.05 for all). CONCLUSIONS: Despite our center's large vascular caseload and need for more vascular providers, there were not enough open abdominal cases performed to support the training of a vascular fellow. Given the continued decline in open aortic volume across the country, we anticipate that rural centers similar to our own will have difficulty establishing programs to train and recruit vascular surgeons. Flexibility in the abdominal category requirement or creation of open aortic fellowships may be necessary for smaller rural centers to train vascular surgeons and meet the future needs of the specialty.

Reliable and valid assessment of procedural skills in resuscitative endovascular balloon occlusion of the aorta.

BACKGROUND: Valid and reliable assessment of skills is essential for improved and evidence-based training concepts. In a recent study, we presented a novel tool to assess procedural skills in resuscitative endovascular balloon occlusion of the aorta (REBOA), REBOA-RATE, based on international expert consensus. Although expert consensus is a strong foundation, the performance of REBOA-RATE has not been explored. The study aimed to examine the reliability and validity of REBOA-RATE. METHODS: This was an experimental simulation-based study. We enrolled doctors with three levels of expertise to perform two REBOA procedures in a simulated scenario of out-of-hospital cardiac arrest. Procedures were video-recorded, and videos were blinded and randomized. Three clinical experts independently rated all procedures using REBOA-RATE. Data were analyzed using Messick's framework for validity evidence, including generalizability analysis of reliability and determination of a pass/fail standard. RESULTS: Forty-two doctors were enrolled: 16 novices, 13 anesthesiologists, and 13 endovascular experts. They all performed two procedures, yielding 84 procedures and 252 ratings. The REBOA-RATE assessment tool showed high internal consistency (Cronbach's α = 0.95) and excellent interrater reliability (intraclass correlation coefficient, 0.97). Assessment using one rater and three procedures could ensure overall reliability suitable for high-stakes testing (G-coefficient >0.80). Mean scores (SD) for the three groups in the second procedure were as follows: novices, 32% (24%); anesthesiologists, 55% (29%); endovascular experts, 93% (4%) (p < 0.001). The pass/fail standard was set at 81%, which all experts but no novices passed. CONCLUSION: Data strongly support the reliability and validity of REBOA-RATE, which successfully discriminated between all experience levels. The REBOA-RATE assessment tool requires minimal instruction, and one rater is sufficient for reliable assessment. Together, these are strong arguments for the use of REBOA-RATE to assess REBOA skills, allowing for competency-based training and certification concepts. LEVEL OF EVIDENCE: Diagnostic test, no or poor gold standard, level V.

Education Research: Challenges Faced by Neurology Trainees in a Neuro-Intervention Career Track.

OBJECTIVE: The widespread adoption of endovascular therapy (EVT) for emergent large vessel occlusion has led to increased nationwide demand for neurointerventionalists, heightened interest among neurology residents to pursue neurointervention as a career, and increased importance of neurointervention exposure for all neurologists who care for patients with acute ischemic stroke. Exposure to neurointervention and its career path are not well-defined for neurology trainees. METHODS: The Society for Vascular and Interventional Neurology (SVIN) Education Committee conducted a multicenter electronic survey directed towards neurology residents and vascular neurology (VN), neurocritical care (NCC), and neurointervention fellows in June 2018. A total of 250 programs were invited to participate; 76 trainees completed the survey. RESULTS: Respondents self-identified as 22% postgraduate year (PGY)2, 40% PGY3/4, 30% VN fellows, and 8% neurointervention or NCC fellows. Eighty-seven percent of trainees had more than 2 months exposure to VN during residency, 41% to NCC, and only 3% to neurointervention. Sixty-eight percent of respondents had no exposure to neurointervention during residency. Whereas 72% believed that a background in neurology was good preparation for neurointervention, only 41% agreed that fellowship training pathway in neurointervention is well-structured for neurology residents when compared to other subspecialties. CONCLUSION: In this survey, respondents identified lack of exposure to neurointervention and a well-defined training pathway as obstacles towards pursuing neurointervention as a career. These obstacles must be addressed for the continued development of neurointervention as a subspecialty of neurology.

Machine learning-based operation skills assessment with vascular difficulty index for vascular intervention surgery.

An accurate assessment of surgical operation skills is essential for improving the vascular intervention surgical outcome and the performance of endovascular surgery robots. In existing studies, subjective and objective assessments of surgical operation skills use a variety of indicators, such as the operation speed and operation smoothness. However, the vascular conditions of particular patients have not been considered in the assessment, leading to deviations in the evaluation. Therefore, in this paper, an operation skills assessment method including the vascular difficulty level index for catheter insertion at the aortic arch in endovascular surgery is proposed. First, the model describing the difficulty of the vascular anatomical structure is established with characteristics of different aortic arch branches based on machine learning. Afterwards, the vascular difficulty level is set as an objective index combined with operating characteristics extracted from the operations performed by surgeons to evaluate the surgical operation skills at the aortic arch using machine learning. The accuracy of the assessment improves from 86.67 to 96.67% after inclusion of the vascular difficulty as an evaluation indicator to more objectively and accurately evaluate skills. The method described in this paper can be adopted to train novice surgeons in endovascular surgery, and for studies of vascular interventional surgery robots. Graphical abstract Operation skill assessment with vascular difficulty for vascular interventional surgery.

The decline of open abdominal aortic aneurysm surgery among individual training programs and vascular surgery trainees.

OBJECTIVE: In the past decade, treatment of abdominal aortic aneurysm (AAA) has dramatically shifted from open repair to an endovascular approach. The decreasing number of open AAA repairs (OAR) has raised concerns regarding future vascular surgeons' competence to perform this complex and high-risk procedure. Prior work has documented decreasing open aortic volume among surgical residents. However, these studies report average national case volume with a limited understanding of the variation in OAR exposure among training programs and trainees. We sought to evaluate the current open AAA repair trends among individual accredited vascular surgery training programs and vascular surgery residents to better evaluate trainees' exposure to OAR. METHODS: We identified elderly Medicare beneficiaries undergoing OAR and endovascular aneurysm repair (EVAR) between 2010 and 2014. Accredited vascular surgery training program hospitals were identified. OAR and EVAR volume was aggregated at the program level and the number of senior vascular surgery trainees per year at each program was captured. The training program all-payer total AAA repair volume was calculated based on the national proportion of patients undergoing AAA covered by Medicare in the Vascular Quality Initiative. Temporal trends in program and vascular surgery trainee OAR and EVAR volume were calculated. RESULTS: A total of 119,408 (77%) EVAR and 35,042 (23%) were identified in the Medicare database between 2010 and 2014. Of these, 21% were performed among the 111 training programs, including 22,227 (73%) EVAR and 8416 (27%) OAR. The total OAR volume among training programs decreased by 38% during the study period, from a median of 29.1 to 18.2 OAR. In 2014, 25% of programs performed fewer than 10 OARs annually. Among senior vascular surgery trainees, the median number of OAR decreased from 10.0 in 2010 to 6.4 in 2014 and approximately one-half of senior trainees had exposure to fewer than five OAR in 2014. CONCLUSIONS: Exposure to OAR among vascular surgery training programs has dramatically decreased, with nearly one-half of senior trainees performing fewer than five OAR in 2014. The variable and diminishing OAR exposure among vascular surgery training program highlights growing concerns surrounding competence in complex open repairs and suggest that only a small proportion of current trainees have ample opportunity to develop confidence and proficiency in this high-risk operation.

Accredited Endovascular Surgical Neuroradiology Programs: Current Specialty Composition and Academic Impact Using the h Index.

BACKGROUND: Concerns exist that neurosurgery might fail to lead the field of endovascular surgical neuroradiology (ESN), as other specialties are allowed to train and practice ESN. This study aimed to assess the current breakdown of specialties and their relative academic productivity in accredited ESN fellowship programs. METHODS: A list of fellowship programs was obtained from the Accreditation Council for Graduate Medical Education and Committee on Advanced Subspecialty Training directories. Primary specialty (i.e., residency) training for each faculty member in these programs was determined using information provided by the programs. A bibliometric search was performed for each member using Web of Science (Clarivate Analytics, Philadelphia, Pennsylvania, USA). Cumulative and ESN-specific h indices were calculated; h indices were compared between each specialty group and between international medical graduates and US medical graduates, regardless of specialty training. RESULTS: Thirty-one ESN fellowship programs with 88 faculty members were included. Neurosurgeons constituted 61.4% (n = 54) of the total ESN faculty, followed by radiologists with 30.7% (n = 27), and neurologists with 7.9% (n = 7). The mean ESN-specific h index for neurosurgery-trained ESN faculty was 16.2 ± 14.6 compared with 14.4 ± 10.9 for radiologists and 13.0 ± 12.6 for neurologists (P = 0.76). There were 12 IMGs and 76 USMGs. The mean ESN-specific h index was greater for IMGs than USMGs, 24.7 ± 14.3 versus 14.0 ± 12.7 (P = 0.008), respectively. CONCLUSIONS: Neurosurgery is leading the ESN field in numbers; however, the h index is not significantly different among ESN faculty based on primary training. The number of IMGs is relatively small, yet IMGs have significantly higher mean h indices.

A Binational Need Assessment to Define the Level of Endovascular Expertise Required by Vascular Surgical Trainees.

BACKGROUND: There has been a shift toward competency-based surgical education programs to improve trainee performance and achieve better patient outcomes. Endovascular procedures comprise a significant volume of vascular surgery, but the current methods for assessing the endovascular competence of vascular trainees in Australia and New Zealand are suboptimal. The objective of this study was to perform a need assessment to define the scope of endovascular expertise required by vascular surgical trainees to later aid in the development of novel surgical training assessment tools. METHODS: A modified Delphi method was used to achieve expert consensus. Fifty-three key stakeholders in vascular surgical education and training (SET) in Australia and New Zealand were invited to take part in the 2-stage survey. Experts were asked which procedures they considered to be requisite for vascular surgery trainees and at which SET level competence should be achieved. The results were reiterated to the expert panel in the second stage, and consensus considered achieved if over 75% of experts were in agreement. RESULTS: In the first stage 25 experts reached consensus that competence in 18 of the 26 procedures should be requisite for SET trainees. Twenty-two experts responded to the second stage and consensus was achieved for 12 out of 14 of the procedural items with mean percentage of experts in agreement being 90%. CONCLUSIONS: A need assessment using a modified Delphi method has achieved consensus among experts in vascular surgery regarding the endovascular procedures considered to be requisite for vascular surgery trainees in Australia and New Zealand.

Neuroendovascular Fellowship Training: Self-Assessment of a Program Accredited by the Committee on Advanced Subspecialty Training.

The University at Buffalo's neuroendovascular fellowship is one of the longest running fellowship programs in North America. The burgeoning neurointerventional workforce and the rapid growth in the neurointerventional space on the heels of groundbreaking clinical trials prompted us to assess the fellowship's academic impact and its graduates' perceptions and productivity. An anonymized web-based survey was sent to all former neuroendovascular fellows with specific questions pertaining to current practice, research and funding, and perceptions about the fellowship's impact on their skills, competitiveness, and compensation. Additionally, the h-index was calculated to assess the academic productivity of each graduated fellow. Among 50 former fellows, 42 (84%) completed the survey. The fellows came from various countries, ethnic backgrounds, and specialties including neurosurgery (n = 39, 93%), neurology (n = 2, 5%), and neuroradiology (n = 1, 2%). Twenty (48%) respondents were currently chairs or directors of their practice. Most (n = 30, 71%) spent at least 10% of their time on research activities, with 27 (64%) receiving research funding. The median h-index of all 50 former fellows was 14. The biggest gains from the fellowship were reported to be improvement in endovascular skills (median = 10 on a scale of 0-10 [highest]) and increase in competitiveness for jobs in vascular neurosurgery (median = 10), followed by increase in academic productivity (median = 8), and knowledge of vascular disease (median = 8). In an era with open calls for moratoriums on endovascular fellowships, concerns over market saturation, and pleas to improve training, fellowship programs perhaps merit a more objective assessment. The effectiveness of a fellowship program may best be measured by the academic impact and leadership roles of former fellows.

Design of a cost-effective, hemodynamically adjustable model for resuscitative endovascular balloon occlusion of the aorta (REBOA) simulation.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct technique for salvaging patients with noncompressible torso hemorrhage. Current REBOA training paradigms require large animals, virtual reality simulators, or human cadavers for acquisition of skills. These training strategies are expensive and resource intensive, which may prevent widespread dissemination of REBOA. We have developed a low-cost, near-physiologic, pulsatile REBOA simulator by connecting an anatomic vascular circuit constructed out of latex and polyvinyl chloride tubing to a commercially available pump. This pulsatile simulator is capable of generating cardiac outputs ranging from 1.7 to 6.8 L/min with corresponding arterial blood pressures of 54 to 226/14 to 121 mmHg. The simulator accommodates a 12 French introducer sheath and a CODA balloon catheter. Upon balloon inflation, the arterial waveform distal to the occlusion flattens, distal pulsation within the simulator is lost, and systolic blood pressures proximal to the balloon catheter increase by up to 62 mmHg. Further development and validation of this simulator will allow for refinement, reduction, and replacement of large animal models, costly virtual reality simulators, and perfused cadavers for training purposes. This will ultimately facilitate the low-cost, high-fidelity REBOA simulation needed for the widespread dissemination of this life-saving technique.

Perspectives on endovascular training in traditional 5+2 vascular surgery fellowship training programs.

This study aimed to compare expectations and experiences of fellows to those of faculty in vascular surgery fellowship programs with regard to endovascular training. Anonymous surveys were sent to fellows (n = 235) and program directors (n = 147), with 79 fellows and 65 faculty members responding. Fellows noted higher expectations of their endovascular skills prior to starting fellowship than the faculty group reported expecting. Faculty assessed fellows' pre-training endovascular skills at a significantly lower level than the fellows' self-assessment. Fellows were significantly less satisfied with the structured aspects of endovascular training than the faculty believed them to be. Only 3% of fellows vs. 32% of faculty felt that the presence of an endovascular simulator affected how residents ranked fellowship programs during the match. In conclusion, incoming fellows in vascular surgery fellowship programs have high expectations of themselves, but may overestimate their actual pre-training endovascular skills. Fellows desire more structured endovascular training, which is not recognized by faculty. Endovascular simulators are valued, but may not be a significant draw in the match process.

National Simulation-Based Training of Fellows: The Vascular Surgery Example.

Vascular surgery has evolved dramatically as a specialty, with new training paradigms and an ever-developing, technically demanding field. The ability to evaluate trainees on their fundamental skills is an important step in ensuring some uniformity in trainees' basic technical abilities. This article describes the development and implementation of the fundamentals of vascular and endovascular surgery, including lessons applied from the Fundamentals of Laparoscopic Surgery and Fundamentals of Endoscopic Surgery programs.

Implication of the recent positive endovascular intervention trials for organizing acute stroke care: European perspective.

Timely recanalization leads to improved patient outcomes in acute ischemic stroke. Recent trial results demonstrated a strong benefit for endovascular therapies over standard medical care in patients with acute ischemic stroke and a major intracranial artery occlusion≤6 hours or even beyond from symptom onset and independent of patients' age. Previous studies have shown the benefit of intravenous thrombolysis that had gradually, albeit slowly, reshaped acute stroke care worldwide. Now, given the superior benefits of endovascular intervention, the whole structure of acute stroke care needs to be reorganized to meet patient needs and to deliver evidence-based treatments effectively. However, a blueprint for success with novel stroke treatments should be composed of numerous elements and requires efforts from various parties. Regarding the endovascular therapies, the strengths of Europe include highly organized democratic society structures, high rate of urbanization, well-developed revenue-based healthcare systems, and high income levels, whereas the obstacles include the east-west disparity in wealth, the ongoing economic crisis hindering spread of fairly costly new treatments, and the quickly aging population putting more demands on health care in general. Regional and national plans for covering whole population with 24/7 adequate acute stroke care are necessary in close cooperation of professionals and decision-makers. Europe-wide new training programs for expert physicians in stroke care should be initiated shortly. European Stroke Organisation has a unique role in providing expertise, consultation, guidelines, and versatile training in meeting new demands in stroke care. This article discusses the current situation, prospects, and challenges in Europe offering personal views on potential solutions.

Preparedness of neurosurgery graduates for neuroendovascular fellowship: a national survey of fellowship programs.

OBJECT: Endovascular interventions have become an essential part of a neurosurgeon's practice. Whether endovascular procedures have been effectively integrated into residency curricula, however, remains uncertain. The purpose of this study was to assess the preparedness of US neurosurgery graduate trainees for neuroendovascular fellowship. METHODS: A multidomain, global assessment survey was sent to all directors/faculty of neuroendovascular fellowship programs involved in training of US neurosurgery graduates. Surveyees were asked to assess trainees as they entered fellowship. RESULTS: The response rate was 78% (25/32). Of respondent program directors, 38% reported that new fellows did not know the history and imaging of the patient and 50% were unable to formulate an appropriate treatment plan. As many as 79% of fellows were unfamiliar with endovascular devices and 75% were unfamiliar with angiographic equipment. Furthermore, 58% of fellows were unable to perform femoral access, 54% were unable to perform femoral closure, 79% were unable to catheterize a major vessel, 86% were unable to perform a 4-vessel angiogram, and 100% were unable to catheterize an aneurysm. Additionally, program directors reported that over 50% of fellows could not recognize neurovascular anatomy and 54% could not recognize/classify vascular abnormalities. There was an overall agreement that fellows demonstrated professionalism and interest in research and had good communication/clinical skills. CONCLUSIONS: The results of this study suggest potential gaps in the training of neurosurgery residents with regard to endovascular neurosurgery. In an era of minimally invasive therapies, changes in residency curricula may be needed to keep pace with the ever-changing field of neurosurgery.

Developing a complex endovascular fenestrated and branched aortic program.

In 2008, the top priority in our division's 5-year strategic plan was "to become an internationally recognized center of excellence for the endovascular treatment of complex aortic pathology extending from the aortic valve to the external iliac artery." Five components were identified as "most critical" to achieve this strategic priority: (1) training at centers of excellence in complex endovascular repair; (2) industry partnership to improve access to developing technologies; (3) a fully integrated team approach with one leader involved in all steps of all cases; (4) prospective data collection; and (5) development and implementation of a physician-sponsored investigational device exemption for juxtarenal, pararenal, and thoracoabdominal aneurysms. We have now performed 49 repairs (16 commercially manufactured devices, 33 physician-modified devices) for 3 common iliac, 20 juxtarenal, 9 pararenal, and 17 thoracoabdominal aneurysms, using 142 fenestrations, branches, and scallops. All patients had complete 30-day follow-up for calculation of 30-day events. Kaplan-Meier analysis was used to calculate 1-year events. In 5 years, we developed a successful complex endovascular aortic program that uses fenestrated/branched repair techniques. A focused team strategic planning approach to program development is an effective way for vascular surgery divisions to gain experience and expertise with new complex technologies while ensuring acceptable patient outcomes.