A single-institution experience: the integrated vascular surgery residency's effect on fellowship and general surgery resident case volume and diversity.

BACKGROUND: To determine whether the formation of an integrated vascular surgery residency (0 + 5) has negatively impacted the case volume and diversity of the vascular surgery fellows (5 + 2) and chief general surgeons at the same institution. METHODS: Operative data from the vascular integrated (0 + 5), independent (5 + 2), and general surgery residencies at a single institution were retrospectively reviewed and analyzed to determine vascular surgery case volumes from 2006-2012. National operative data (Residency Review Committee) were used for comparison of diversity and volume. Standard statistical methods were applied. RESULTS: During this period, the 5 + 2 fellows at our institution performed on average 741 (range, 554-1002) primary cases and 1091 (range, 844-1479) combined primary and secondary cases for the 2-year fellowship. Our integrated residency began in July 2007. Our fellows' primary case volumes remained relatively stable between 2006 and 2011, with a 4% increase in the number of cases, although their total (primary and secondary) case volumes fell 15%; by comparison, the equivalent national 50th percentile rates rose 16% during this time frame. Our institution's general surgery residents performed an average of 116 (range, 56-221) vascular cases individually during their 5-year residency from 2005-2011. From 2006-2011, the total case volume fell only 5%, while the national 50th percentile rate fell 24%. Across all years, however, resident and fellow volumes both continue to be above Accreditation Council for Graduate Medical Education minimum requirements, and the major vascular case volume at our institution in all groups studied remained statistically greater than or equal to the national 50th percentile of cases. Our first integrated resident to graduate finished in June 2012 with 931 total vascular cases and 249 general surgery cases for a total operative experience of 1180 cases during the 5-year residency. Finally, after an 8-year period (2003-2010) in which none of our general surgery residents pursued vascular training, 1 resident in each of the 2011, 2012, and 2013 graduating years has now done so. CONCLUSIONS: At our institution, the introduction of a 0 + 5 vascular residency has correlated with a modest drop (15%) in overall case volume for the 5 + 2 fellows, but the number of primary cases have actually increased slightly and they continue to meet or exceed Accreditation Council for Graduate Medical Education requirements and national 50th percentile rates. General surgery residents' vascular volumes, by contrast, have remained stable, and interest in vascular surgery by residents has increased. Our integrated vascular residents are projected to exceed the fellows' 50th percentile case volume and diversity targets during their residency experience.

Endovascular foreign body retrieval.

OBJECTIVE: The number of endovascular procedures performed is increasing exponentially as technology improves. A serious complication of endovascular therapy is loss of a foreign body in the vasculature. We reviewed our experience and evaluated the cause, management, and outcomes of intravascular foreign body (IVFB) misplacement. METHODS: We completed a retrospective review of patients who underwent endovascular retrieval of IVFBs between 2005 and 2010. Patients were identified by current procedural terminology code or by our hospital's risk management team. Patients undergoing routine endovascular retrieval of temporary vena cava filters were excluded. RESULTS: Twenty-seven IVFBs were identified in 26 patients. Twenty patients were asymptomatic (76.9%). Six patients were symptomatic (22.2%) with either pain (n = 4) or abnormal physical findings (n = 2). There were 13 (48.1%) catheter fragments, six (22.2%) guidewires, five (18.5%) inferior vena cava (IVC) filter (embolisms), two (7.4%) stents, and one (3.7%) sheath fragment. There were five (15.6%) embolizations of an IVFB into the right heart, three (9.4%) into a pulmonary artery, eight (25%) into the vena cava, eight (25%) into peripheral veins, five (15.6%) into peripheral arteries, one (3.1%) into a coronary artery, one (3.1%) into a hepatic vein, and one (3.1%) into adjacent soft tissue. The mechanism of endovascular loss was device fracture in 16 (59.3%) cases, loss of control in six cases (22.2%), migration in four (14.8%) cases, and incorrect device deployment in one case (3.7%). The probable cause of foreign body loss was technical error in eight (29.6%) cases. In three cases, IVFB retrieval was not attempted. The misplacement and retrieval were completed during the same procedure in 13 (48%) cases. Twenty-four endovascular retrievals were performed. Fifteen (62.5%) procedures used a snare to remove the IVFB and two (8.2%) used balloon catheters. Three IVFBs could not be removed and two cases were converted to open procedures. Technical success was achieved in 19/24 cases (79.2%). There were no immediate complications related to the retrieval of the IVFB; however, there was a single late complication of pulmonary embolism after failed endovascular retrieval (1/24, 4.2%). Thirty-day survival was 100%. CONCLUSIONS: Intravascular foreign bodies are a serious complication of endovascular therapy that can be minimized with proper device selection and deployment. When an intravascular foreign body is identified, endovascular retrieval should be attempted due to its high success rate and minimal morbidity.