The Diversity of Surgical Trainees Index identifies racial and ethnic disparities among surgical specialties.

OBJECTIVE: Racial and ethnic disparities have been well-described among surgical specialties; however, variations in underrepresented in medicine (URiM) representation between these specialties have not previously been quantified. METHODS: Data collected from Accreditation Council for Graduate Medical Education (ACGME) annual reports were used to derive the Diversity of Surgical Trainee Index (DoSTI) metric, which was calculated as the proportion of URiM residents and fellow physicians within a given surgical specialty, relative to the overall proportion of URiM trainees within all surgical and non-surgical ACGME-accredited programs in the same academic year. RESULTS: From 2013 to 2022, a total of 108,193 ACGME-accredited residency programs trained 1,296,204 residents and fellows in the United States. Of these, 14.1% (n = 182,680) of trainees self-identified as URiM over the study period. The mean DoSTI among all surgical specialties was 0.80 (standard error, 0.01) compared with all ACGME-accredited programs. High DoSTI specialties incorporated significantly higher proportions of Hispanic (8.7% vs 6.3%) and Black (5.2% vs 2.5%) trainees compared with low DoSTI specialties (P < .0001 each). General surgery (1.06 ± 0.01), plastic surgery (traditional) (1.12 ± 0.06), vascular surgery (integrated) (0.96 ± 0.03), and vascular surgery (traditional) (0.94 ± 0.06) had the highest DoSTI indices (P < .05 each vs composite). On linear regression analysis, only ophthalmology (+0.01/year; R2 = 0.41; P = .019), orthopedic surgery (+0.01/year; R2 = 0.33; P = .047), otolaryngology (+0.02/year; R2 = 0.86; P < .001), and pediatric surgery (+0.06/year; R2 = 0.33; P = .048) demonstrated an annual increase in DoSTI. CONCLUSIONS: The DoSTI is a novel metric used to quantify the degree of URiM representation among surgical specialties. DoSTI has revealed specialty-specific variations in racial/ethnic minority representation among surgical training programs. This metric may be used to improve provider awareness, identify high performing DoSTI specialties to highlight their best practices, and ultimately, recruit a more diverse surgical workforce.

Feasibility and Intermediate Results of Transcarotid Revascularization with a Prosthetic Conduit.

BACKGROUND: Transcarotid artery revascularization (TCAR) is a hybrid technique with excellent initial outcomes. The technical success and safety of TCAR is heavily dependent on an anatomically suitable common carotid artery (CCA). Many patients do not meet anatomic criteria and therefore are not eligible for this therapy. We sought to extend the eligibility of TCAR to patients with unfavorable CCA anatomy via the adoption of a prosthetic arterial conduit. METHODS: A single-center retrospective study of patients with critical carotid artery stenosis who underwent TCAR via a prosthetic conduit between June 2019 and October 2021 was performed. All patients in the study were considered high-risk for carotid endarterectomy based on anatomic features, such as restenosis post-carotid endarterectomy and neck radiation. Unfavorable CCA anatomy was defined as a clavicle to carotid bifurcation distance <5 cm, a CCA diameter <6 mm, and/or significant atherosclerotic disease at the intended arterial access site. The primary outcome of interest was technical success. Secondary outcomes included perioperative complications, intermediate and long-term patency, intermediate and long-term stroke and/or mortality and in-hospital length of stay. Follow-up ranged from 1 to 29 months. RESULTS: Eight patients underwent 10 TCAR procedures via a prosthetic conduit. A total of 2 procedures (20%) were performed on female patients and 8 procedures (75%) were performed on male patients. The mean age was 65 years old (standard deviation 11 years). Technical success was 100%. The 30-day ipsilateral stroke rate was 0%. The 30-day patency was 90%. There was no re-exploration for hemorrhage and 30 day mortality was 0%. CONCLUSIONS: TCAR is an excellent option for carotid artery revascularization. Unfavorable CCA anatomy has limited its applicability. TCAR via a prosthetic conduit has the potential to expand eligibility for this promising therapy.

Risk factors and consequences of wound complications following sartorius flap reconstruction.

OBJECTIVE: Groin wound complications are common following vascular surgery and can lead to significant patient morbidity. Sartorius muscle flap coverage may help to prevent vascular graft infection in the setting of wound dehiscence or infection. However, risk factors and consequences of wound complications following sartorius flap reconstruction remain incompletely investigated. METHODS: We retrospectively queried all patients who underwent sartorius flap reconstruction at a tertiary academic medical center. Data collected included patient demographics, medical comorbidities, surgical indication, index vascular procedure, and postoperative outcomes. The primary outcome was wound complication following sartorius flap procedure, which was defined as groin wound infection, dehiscence, or lymphocutaneous fistula. RESULTS: From 2012 to 2022, a total of 113 patients underwent sartorius flap reconstruction. Of these, 66 (58.4%) were performed after the development of a prior groin complication, and 47 (41.6%) were prophylactic. A total of 88 patients (77.9%) had a prosthetic bypass graft adjacent to the flap. Twenty-nine patients (25.7%) suffered a wound complication following sartorius flap reconstruction, including 14 (12.4%) with wound dehiscence, 13 (11.5%) with wound infection, and two (1.8%) with lymphocutaneous fistula. Patients with wound complications had a higher body mass index (28.8 vs 26.4 kg/m2; P =.03) and more frequently active smokers (86.2% vs 66.7%; P = .04). Additionally, patients with wound complications had a higher unplanned 30-day hospital readmission rates (72.4% vs 15.5%; P < .001), reintervention rates (75.9% vs 8.3%; P < .001), and re-do flap reconstruction rates (13.8% vs 2.4%; P = .02). On multivariable analysis, higher body mass index was independently associated with post-flap wound complications (adjusted odds ratio [aOR], 1.01; 95% confidence interval [CI], 1.001-1.03; P = .037). Consequently, wound complications were associated with both surgical reintervention (aOR, 35.4; 95% CI, 9.9-126.3; P < .001) and unplanned hospital readmission (aOR, 17.8; 95% CI, 5.9-54.1; P < .001). CONCLUSIONS: Sartorius flap reconstruction is an effective adjunct in facilitating wound healing of groin wounds. However, wound complications are common following sartorius flap reconstruction and may be associated with reintervention and unplanned hospital readmission. These data support the judicious and thoughtful utilization of sartorius flap procedures among high-risk patients.

Concerning Trends in Vascular Surgery Trainee Operative Experience in Venous Disease.

BACKGROUND: Comprehensive vascular care includes both arterial and venous disease management. However, operative training in venous disease is often significantly overshadowed by arterial procedures, despite the public health burden of acute and chronic venous disease. The purpose of this study is to evaluate the case-mix and volume of venous procedures performed by graduating integrated vascular surgery residents and fellows in the United States. METHODS: Accreditation Council for Graduate Medical Education national operative log reports were compiled for graduating integrated VSR (vascular surgery residency) and traditional vascular surgery fellowship (VSF) trainees from academic years 2013 to 2022. Only cases categorized as "surgeon fellow", "surgeon chief", or "surgeon junior" were included. Linear regression analysis was utilized to evaluate trends in case-mix and volume. RESULTS: Over the 10-year study period, total vascular cases increased for both VSR (mean 870.5 ± 9.3 cases, annual change +9.5 cases/year, R2 = 0.77, P < 0.001) and VSF (mean 682.1 ± 6.9 cases, annual change +6.7 cases/year, R2 = 0.85, P < 0.001) trainees. Concurrently, the proportion of venous cases in the VSR group decreased from 12.5% to 7.3% (annual change -3.7 cases/year, R2 = 0.72, P < 0.001). VSR trainees experienced an annual decrease in 4 of the top 5 venous case types performed, including venous angioplasty/stenting (-1.6 cases/year, P = 0.002), vena cava filter placement (-0.9 cases/year, P = 0.002), endoluminal ablation (-0.2 cases/year, P = 0.47), diagnostic venography (-1.7 cases/year, P < 0.001), and varicose vein treatment (-1.0 cases/year, P < 0.001). Venous cases proportions also decreased in the VSF group from 8.4% to 6.2% (annual change -2.2 cases/year, R2 = 0.54, P = 0.002). VSF trainees experienced an annual decrease in 4 of the top 5 venous case types, including venous angioplasty/stenting (-1.5 cases/year, P = 0.003), diagnostic venography (-1.2 cases/year, P < 0.001), vena cava filter placement (-0.2 cases/year, P = 0.44), endoluminal ablation (-0.6 cases/year, P < 0.001), and varicose vein treatment (-0.1 cases/year, P = 0.04). Both VSR and VSF trainee groups graduated with fewer than 5 cases for each of the following venous procedures-percutaneous mechanical thrombectomy, venous thrombolysis, open venous reconstruction, sclerotherapy, venous embolectomy, portal-systemic shunting, venous ulceration treatment, and arteriovenous malformation treatment. CONCLUSIONS: Current vascular residents and fellows have limited exposure to venous procedures, in part due to a proportional decline in venous cases. More robust venous operative experience is needed during surgical training. Further studies are needed to understand whether this discrepancy in venous and arterial training impacts career progression and patient outcomes.

Prosthetic Conduit Use Does Not Adversely Impact Outcomes after Open Repair of Popliteal Artery Aneurysms.

BACKGROUND: Single segment, greater saphenous vein (GSV) conduit is considered the optimal bypass conduit among patients undergoing bypass surgery for peripheral artery disease (PAD). While this data has been extrapolated to patients undergoing bypass for popliteal artery aneurysms (PAAs), the pathophysiology of PAA is inherently different when compared to PAD, and the impact of conduit type on long-term outcomes after open repair of PAA remains unclear. METHODS: A multicenter database of five regional hospitals was retrospectively reviewed for all patients with PAA undergoing open surgical repair. Data were collected on demographic information, operative details, medications, and postoperative outcomes. Kaplan-Meier curves were used to compare freedom from major adverse limb events (MALE) following GSV versus prosthetic bypass. Cox proportional hazards model was used to identify patient-level characteristics associated with MALE, which was defined as major ipsilateral limb amputation or reintervention for graft patency. RESULTS: From 1999 to 2020, a total of 101 patients with PAA underwent open exclusion and bypass surgery. Median follow-up period was 4.2 years (interquartile range, 1.3-7.4 years), and complete data were available for 99 (98.0%) patients. The majority of patients were male (99.0%) and Caucasian (93.9%). Only 11.1% of procedures were emergent, with the remainder (88.9%) being elective. All patients underwent medial exposure with a below-knee popliteal bypass target (100%). Bypass conduits included GSV (69.7%), prosthetic conduit (28.3%), and 2 (2.0%) alternative conduits (one spliced arm vein, one cryopreserved vein). Patients undergoing prosthetic bypass were older (72 vs. 66 years, P = 0.001) and had similar rates of medical comorbidities. Compared with the GSV group, patients with prosthetic conduits were more frequently placed on postoperative anticoagulation (60.7% vs. 23.2%, P < 0.001). Conduit type did not impact postoperative complication rates (P = NS each). MALE rates were low overall (19.2% at 2 years), and similar when stratified by conduit type (log rank P = 0.47). On multivariable analysis, emergent bypass was associated with MALE (hazard ratio [HR] 5.73, 95% confidence interval [CI] 2.07-15.85, P < 0.001). Prosthetic conduit usage (HR 1.00, 95% CI, 0.40-2.51, P = 0.99) and postoperative anticoagulation (HR 1.02, 95% CI 0.42-2.50, P = 0.97) were not associated with MALE. CONCLUSIONS: Open repair of PAA is associated with excellent long-term outcomes. Prosthetic bypass is a comparable alternative to autogenous conduit for below-knee popliteal bypass targets, and lack of suitable GSV should not prohibit open surgical repair when indicated.

A national analysis of vascular surgery resident operative experience in peripheral artery disease.

BACKGROUND: Endovascular and hybrid interventions have played an increasingly prominent role in the treatment of peripheral arterial disease (PAD) in the past decade. This shift has prompted concerns about the adequacy of open surgical training for current surgical residents. Moreover, the recent Best Surgical Therapy in Patients With Critical Limb Ischemia trial has further emphasized the importance of open surgical techniques in the treatment of peripheral arterial disease. The purpose of this study was to examine national temporal trends in peripheral operative volume among integrated vascular surgery residents. METHODS: Data was obtained from the Accreditation Council for Graduate Medical Education national data reports for integrated vascular surgery residents. Case volumes for surgeon chief or surgeon junior cases were collected from academic years 2012 to 2013 and 2021 to 2022. Trends in case-mix and volume were evaluated using linear regression analysis. RESULTS: The mean total vascular operative volume increased from 851.2 to 914.3 cases among graduating chief residents, with an annual growth of 8.5 ± 1.7 cases/year (R2 = 0.77; P < .0001). Major vascular case volume also increased at a rate of 5.7 ± 1.2 cases/year (R2 = 0.74; P < .001). Among operative categories, peripheral cases were the most frequent (n = 232.2 [26.6%]) and demonstrated the greatest annual growth (+8.0 ± 0.8 cases/year, R2 = 0.93; P < .001). No changes were seen in volume of open peripheral cases, including suprainguinal bypass (+0.1 ± 0.2 cases/year; R2 = 0.08; P = .40) or femoropopliteal bypass procedures (-0.1 ± 0.2 cases/year; R2 = 0.17; P = .20). Infrapopliteal bypass (+0.4 ± 0.1 cases/year; R2 = 0.48; P = .006), iliac/femoral endarterectomy (+1.3 ± 0.2 cases/year; R2 = 0.82; P < .001), and leg thromboembolectomy (+0.4 ± 0.1 cases/year; R2 = 0.64; P < .001) all demonstrated annual growth. For endovascular peripheral cases, aortoiliac revascularization (+3.4 ± 0.3 cases/year; R2 = 0.94; P < .001), femoropopliteal revascularization (+5.4 ± 0.2 cases/year; R2 = 0.98; P < .001), and tibioperoneal revascularization (+2.0 ± 0.2 cases/year; R2 = 0.92; P < .001) all increased in volume. Lower extremity amputations, including above-knee amputation (+0.6 ± 0.2 cases/year; R2 = 0.65; P < .001) and below-knee amputation (+0.9 ± 0.2 cases/year; R2 = 0.72; P < .001) also demonstrated an increase in volume. CONCLUSIONS: Current graduating residents have higher open and endovascular case volumes for peripheral artery disease on a national level, despite the increasing popularity of endovascular techniques. Further studies are needed to identify how these trends may impact current vascular surgery milestones. These trends may also influence the rising interest in competency-based training programs.

A Qualitative Appraisal of Neurotology Fellowship Websites.

OBJECTIVE: To assess the accessibility and breadth of online information regarding neurotology fellowship programs by appraising individual fellowship websites as well as two popular online databases. METHODS: The American Neurotology Society Program Information Page (ANSPIP), the American Medical Association's Fellowship and Residency Electronic Interactive Database (FREIDA), and three online search engines (Google, Yahoo, Bing) were assessed for accessibility to individual fellowship websites. Each program's ANSPIP data sheet and fellowship-specific website were then evaluated for the presence of 18 characteristics of interest to the neurotology fellowship applicant. RESULTS: All three search engines yielded 23 (96%) Accreditation Council for Graduate Medical Education (ACGME)-accredited neurotology fellowship websites. Searching "Neurotology fellowships" in Google, Yahoo, and Bing required exploring up to nine pages of search results to identify all of the ACGME-accredited program-specific websites. Direct links to program websites were found on 12 (55%) and 3 (13%) of the ANSPIP and FREIDA fellowship pages, respectively. Of the 18 characteristics of interest, the ANSPIP data sheet and individual program websites on average delineated 8.0 and 7.8 characteristics, respectively. Ninety-one percent of fellowship websites included program coordinator information, general program description, and breadth of surgical exposure. In contrast, work/life balance, postfellowship placement, and current fellow(s) were least commonly displayed (4%, 9%, 13% respectively). One-hundred percent of ANSPIP data sheets included program coordinator information, number of fellows, and affiliated hospital(s), whereas none of the pages included selection criteria, application requirements, description of location, or work/life balance. CONCLUSION: Although most neurotology fellowship programs have websites or ANSPIP data sheets, many of them lack information that has been previously demonstrated to be valued by applicants. Furthermore, incongruence of information between these sources may lead to confusion, applicant stress, and reflect poorly on fellowship programs. Perhaps a standardized list of ACGME-required data points to be posted on websites would facilitate the application process.