Can a trainee perform endovascular aortic repair as effectively and safely as an experienced specialist?

OBJECTIVES: Endovascular aortic repair (EVAR) is a technically demanding procedure usually carried out by highly experienced surgeons. However, in this era of modern endovascular surgery with growing numbers of patients qualifying for the procedure, the need to enhance surgical training has emerged. Our aim was to compare the technical results of EVAR in patients operated on by trainees to that of those operated on by an endovascular expert. METHODS: Between 2016 and 2018, a total of 119 patients diagnosed with an abdominal aorta disease requiring EVAR were admitted to our clinic. Overall, we included 96 patients who underwent preoperative and postoperative computed tomography angiography and EVAR performed either by an endovascular expert (N = 51) or a trainee (N = 45). RESULTS: We detected no difference in the baseline characteristics, indication for EVAR and preoperative anatomy between patients operated on by trainees and our endovascular expert. We noted the same incidence of endoleak type Ia occurrence (n = 2 vs n = 2, P = 1.00), reintervention rate (n = 0 vs n = 0, P = 1.00) and in-hospital mortality (n = 0 vs n = 1, P = 1.00) for operations done by trainees and the expert, respectively. There was no difference in X-ray doses or time between the 2 groups. Despite longer median operation times [112 (first quartile: 84; third quartile: 129) vs 89 (75-104) min; P = 0.03] and in-hospital stays [10 (8-13) vs 8 (7-10) days, P = 0.007] of the patients operated on by trainees, the overall clinical success of EVAR was satisfactory in both groups. CONCLUSIONS: An EVAR planned and performed by a trainee need not raise the cumulative risk of the procedure. Trainees who have undergone both mind and hand skills training can therefore carry out EVAR under the supervision of an experienced specialist as effectively and safely as experts do.

Ultrasound in dialysis access: Opportunities and challenges.

Sonography is increasingly being used by nephrologists and the field of dialysis access is no exception. Advances in technology have allowed the addition of this universally available, portable, non-invasive tool to the nephrologist's armamentarium, which provides information on both morphology and physiology without the need for contrast or radiation. Ultrasound may be used across the spectrum of dialysis access, including central venous catheter placements, vascular mapping, regional anesthesia, creation, maintenance and assessment of hemodialysis access as well as assessment of the abdominal wall and peritoneal dialysis catheter placements. However, the lack of exposure in most training programs limits incorporation of routine use of ultrasounds in nephrology practice. As our specialty embarks on the ultrasound revolution, a two-pronged approach is essential to provide ample training opportunities while ensuring establishment of basic standards for training and competency.

The learning curve effect on outcomes with frozen elephant trunk technique for extensive thoracic aorta disease.

OBJECTIVE: The purpose of this study was to analyze the learning curve effect on hospital mortality, postoperative outcomes, freedom from reintervention in the aorta and long-term survival after frozen elephant trunk (FET) operation. METHODS: From July 2009 to June 2018, 79 patients underwent surgery with the FET technique. They had type A aortic dissection (acute 7.6%, chronic 33%), type B aortic dissection (acute 1.26%, chronic 34.2%), and complex thoracic aortic aneurysm (24%). 27.8% were reoperations and 43% received concomitant cardiac procedures. To compare the results, the sample was divided into group 1 (G1) (first half of the sample - operations from 2009 to 2014) and group 2 (G2) (first half of the sample - operations from 2015 to 2018). RESULTS: The in-hospital mortality was 20.25%, 30.7% for G1 and 10% for G2 (P = .02). The mean cardiopulmonary bypass time, myocardial ischemia time, and selective cerebral perfusion at 25°C time were 154 ± 31, 118 ± 32, and 59 ± 12 minutes, respectively, similar for both groups. Stroke and spinal cord injury occurred in four and two patients, with no difference between groups (P = .61 and P = .24). The necessity for secondary intervention on the downstream aorta for both groups was also similar (P = .136). Five of sixty-three surviving patients died during the follow-up period and the estimated survival rate was different between groups 49% vs 88% (P = .007). CONCLUSION: The learning curve with the FET procedure had a significant impact on hospital mortality and midterm survival over the follow-up period, albeit did not influence the freedom from reintervention on the downstream aorta.

Learning Curve Analysis to Determine Operative Requirements for Young Vascular Surgeons Learning Open Abdominal Aortic Aneurysm Repair.

BACKGROUND: Since endovascular aneurysm repair has become predominant, the issue of training young vascular surgeons in open abdominal aortic aneurysm (AAA) surgery has received significant attention. Through learning curve analysis, we aimed to determine the number of cases needed for young surgeons to achieve satisfactory open surgical skills.Methods and Results:A total of 562 consecutive patients who underwent open repair either by an attending surgeon (group A) or 6 young vascular surgeons (group Y) were included and assessed with regards to the preparation, clamp, and total operation times. Although some of the patients' characteristics were different, the surgical procedures were comparable between the 2 groups. There was a clear trend towards a decrease in each 10 successive cases in group Y. The operation times in group A were constant at 72±30 (preparation), 48±10 (clamp), and 231±59 min (total), which were achieved by young vascular surgeons in 10, 30, and 10 cases, respectively. In the cumulative sum analysis, 25-27 cases were necessary for young vascular surgeons to enhance their surgical skills. The complication rate in group Y was no higher than that in group A. CONCLUSIONS: Young vascular surgeons can safely learn open AAA repair without increasing operation time or complications. Approximately 30 cases would be necessary to gain satisfactory surgical skills.

Simulation training streamlines the real-life performance in endovascular repair of ruptured abdominal aortic aneurysms.

OBJECTIVE: Difficulties in distributing endovascular experience among all operating room (OR) personnel prevented full-scale use of endovascular aneurysm repair (EVAR) in emergencies. To streamline the procedure of EVAR for ruptured aneurysm (rEVAR) and to provide this method even to unstable patients, we initiated regular simulation training sessions. METHODS: This is an observational study of 29 simulation sessions performed between January 2015 and December 2017. We analyzed the development of time from OR door to aortic balloon occlusion during simulations and OR door to needle times in real-life rEVARs as well as the outcome of the 185 ruptured abdominal aortic aneurysm (rAAA) patients who arrived at the university hospital between January 2013 and December 2017. A questionnaire was sent for simulation attendants before and after the simulation session. RESULTS: In the first simulations, the door to occlusion time was 20 to 35 minutes. After adding a hemodynamic collapse to the simulation protocol, the time decreased to 10 to 13 minutes in the 10 recent simulations, including a 5-minute cardiopulmonary resuscitation (P = .01). The electronic questionnaire performed for attendees before and after the simulation session showed significant improvement in both confidence and knowledge of the OR staff regarding rEVAR procedure. In the real-life rEVARs, 75 of the 185 patients with rAAAs underwent EVAR. Among rEVAR patients, the median OR door to needle time was 65 minutes before and 16 minutes after the onset of simulations (P = .000). The overall 30-day mortality among all rAAA patients was 44.8% and 30.6% accordingly (P = .046). When patients who were turned down from the emergency surgery were excluded, the 30-day operative mortality was 39.2% and 25.1% during the periods, respectively (P = .051). The 30-day mortality was 16.2% after rEVAR and 40.6% after open surgery (P = .001). CONCLUSIONS: Simulation training for rEVAR significantly improves the treatment process in real-life patients and may enhance the outcome of rAAA patients.

Continuous Flow Perfused Cadaver Model for Endovascular Training, Research, and Development.

BACKGROUND: Endovascular simulation employing computer, animal, and static models are common and useful adjuncts for teaching endovascular procedures and developing novel, complex endovascular techniques. Unfortunately, these models lack realistic haptic feedback and thus do not faithfully replicate many of the technical challenges associated with clinical endovascular procedures (e.g., arterial calcification, rigidity, and stenosis). We sought to develop a realistic and reproducible perfused cadaver model for endovascular training, device development, and research. METHODS: Fresh frozen, elderly (age 50-80 years) male cadavers were thawed and prepared for open dissection. The entire arterial tree (ascending aorta to femoral arteries) was dissected free and major branch vessels exposed. Sheaths were placed to allow outflow from selected vessels. A Dacron conduit was sewn to the ascending aorta to generate arterial inflow, which was provided by a centrifugal pump. Aortic aneurysms were created in the descending thoracic and abdominal aorta. Digital subtraction arteriography and various endovascular interventions were performed, including stent grafts and EndoAnchors deployment. RESULTS: Continuous antegrade flow was achieved in the thoracic, abdominal, iliac, and femoral segments. Open and percutaneous access at the femoral region was obtained with realistic back-bleeding and tactile feedback. Adequate, fluoroscopically documented flow was observed in both cannulated major and noncannulated smaller branches. We performed angiography with standard techniques via a pigtail catheter and contrast injector throughout the arterial system. Abdominal and thoracic endografts were deployed with appropriate angiographic guidance and realistic haptic feedback for both guidewire and stent grafts. Additional applications, including selective cannulation, aorto-iliac occlusive disease interventions, and anchor placement, were also successfully simulated. Finally, the model was used as a platform to test investigational devices. CONCLUSIONS: Our pressurized cadaver flow model successfully replicated multiple aspects of advanced endovascular procedures with haptic feedback. This novel human cadaver model allows for training and device development under clinically realistic conditions.

A modular vascular access training program for higher surgical trainees.

INTRODUCTION: Access surgery is delivered by vascular/transplant surgeons with a division that is defined by historic practice. This has resulted in an inconsistent training pattern. We aimed to design a focused, modular training program (The Brighton Vascular Access Fellowship) providing trainees with a reproducible level of exposure and competence. METHODS: The programme was 16 days over 8 weeks on a one-to-one basis with candidates expected to be performing procedures as first surgeon with ongoing, formative assessment. The outpatient setting took the format of a one-stop clinic to involve planning and the follow-up. Assessment was through caseload exposure and conventional statistical analyses to obtain median values (as proxy measures of training exposure consistency). Assessment of confidence and capability was through an electronically distributed qualitative survey tool. RESULTS: A total of 14 candidates completed the programme by June 2017. Operative exposure was obtained for 11 (79%) with a total of 471 cases of which 286 were conducted as first surgeon. There was a median of 32 cases by each candidate with 25 of the cases performed as first surgeon. Qualitative assessment revealed that 13 of 14 (93%) were either practicing independently or no longer required the trainer to scrub in for the operation. A total of 13 of 14 (93%) strongly agreed that they felt comfortable with offering a basic access service. CONCLUSIONS: Focused modular training might be one of the answers to the current era of restricted and sometimes inconsistent training in some aspects of surgery. This model is reproducible and may be applicable in other aspects of training.

The effect of an educational program for vascular access care on nurses' knowledge at dialysis centers in Khartoum State, Sudan.

End-stage renal disease is a worldwide problem that requires highly skilled nursing care. Hemodialysis (HD) is a corner-stone procedure in the management of most patients who require renal replacement therapy. Adequate vascular access is essential for the successful use of HD. Appropriate knowledge in taking care of vascular access is essential for minimizing complications and accurately recognizing vascular access-related problems. This study was to evaluate the effect of an educational program for vascular access care on nurses' knowledge at nine dialysis centers in Khartoum State. This was a Quasi experimental study (pre-and post-test for the same group). Sixty-one nurses working in these HD centers were chosen by simple random sampling method. A structured face-to-face interview questionnaire based on the Kidney Dialysis Outcome Quality Initiative (K/DOQI) clinical practice guidelines for vascular access care was used. Instrument validity was determined through content validity by a panel of experts. Reliability of the instrument was tested by a pilot study to test the knowledge scores for 15 nurses. The Pearson correlation coefficient obtained was (r = 0.82). Data collection was taken before and after the educational intervention. A follow-up test was performed three month later, using the same data collection tools. Twenty-two individual variables assessing the knowledge levels in aspects related to the six K/DOQI guidelines showed improvement in all scores of the nurses' knowledge after the educational intervention; and the differences from the preeducational scores were statistically significant (P < 0.001). The study showed that a structured educational program based on the K/DOQI clinical practice guidelines had a significant impact on the dialysis nurses knowledge in caring for vascular access in HD patients. The knowledge level attained was maintained for at least three months after the educational intervention.

Long-term Outcomes of a Telementoring Program for Distant Teaching of Endovascular Aneurysm Repair.

PURPOSE: To prospectively evaluate the long-term outcomes after a telementoring program for distant teaching of endovascular aneurysm repair (EVAR) and the degree of EVAR procedure assimilation into routine practice. METHODS: A telementoring protocol using stepwise introduction of EVAR was implemented between a university care center and a remote vascular health care site; from March 1999 to October 2003, 49 EVAR patients (mean age 72 years; 48 men) were treated during telementoring at the remote center. After the telementoring period, 86 patients (mean age 71 years; 77 men) underwent EVAR procedures carried out at the secondary care center from November 2003 to July 2011. The long-term outcomes were compared between the EVAR procedures performed during telementoring with the procedures performed independently thereafter. RESULTS: No significant difference was appreciated between telementored and not telementored procedures either in 30-day mortality (4.1% vs 2.3%, p=0.621) or in the initial technical success (93.9% vs 97.7%, p=0.353). The telementored group showed no significant difference in overall aneurysm-related mortality (6.1% vs 2.3%, p=0.353) or in the overall complication rates (p=0.985). The reintervention rate was significantly lower among the unmentored procedures (11.6% vs 32.7%, p=0.004). In particular, significantly fewer patients underwent late endovascular procedures (1.2% vs 12.2%, p=0.009) and late percutaneous interventions (7.0% vs 20.4%, p=0.027) after telementoring ceased. CONCLUSION: The telementoring program followed here allowed excellent EVAR skill assimilation into the routine practice of a remote health care site. Telementoring is a feasible strategy to support skill introduction in remote medical facilities.

A simulator for training in endovascular aneurysm repair: The use of three dimensional printers.

OBJECTIVES: To develop an endovascular aneurysm repair (EVAR) simulation system using three dimensional (3D) printed aneurysms, and to evaluate the impact of patient specific training prior to EVAR on the surgical performance of vascular surgery residents in a university hospital in Brazil. METHODS: This was a prospective, controlled, single centre study. During 2015, the aneurysms of patients undergoing elective EVAR at São Paulo University Medical School were 3D printed and used in training sessions with vascular surgery residents. The 3D printers Stratasys-Connex 350, Formlabs-Form1+, and Makerbot were tested. Ten residents were enrolled in the control group (five residents and 30 patients in 2014) or the training group (five residents and 25 patients in 2015). The control group performed the surgery under the supervision of a senior vascular surgeon (routine procedure, without simulator training). The training group practised the surgery in a patient specific simulator prior to the routine procedure. Objective parameters were analysed, and a subjective questionnaire addressing training utility and realism was answered. RESULTS: Patient specific training reduced fluoroscopy time by 30% (mean 48 min, 95% confidence interval [CI] 40-58 vs. 33 min, 95% CI 26-42 [p < .01]), total procedure time by 29% (mean 292 min [95% CI 235-336] vs. 207 [95% CI 173-247]; p < .01), and volume of contrast used by 25% (mean 87 mL [95% CI 73-103] vs. 65 mL [95% CI 52-81]; p = .02). The residents considered the training useful and realistic, and reported that it increased their self confidence. The 3D printers Form1+ (using flexible resin) and Makerbot (using silicone) provided the best performance based on simulator quality and cost. CONCLUSION: An EVAR simulation system using 3D printed aneurysms was feasible. The best results were obtained with the 3D printers Form1+ (using flexible resin) and Makerbot (using silicone). Patient specific training prior to EVAR at a university hospital in Brazil improved residents' surgical performance (based on fluoroscopy time, surgery time, and volume of contrast used) and increased their self confidence.

Role of Simulation in Endovascular Aneurysm Repair (EVAR) Training: A Preliminary Study.

BACKGROUND: Endovascular aneurysm repair (EVAR) requires a high-level of technical-competency to avoid device-related complications. Virtual reality simulation-based training (SBT) may offer an alternative method of psychomotor skill acquisition; however, its role in EVAR training is undefined. This study aimed to: a) benchmark competency levels using EVAR SBT, and b) investigate the impact of supervised SBT on trainee performance. METHODS: EVAR procedure-related metrics were benchmarked by six experienced consultants using a Simbionix Angiomentor EVAR simulator. Sixteen vascular surgical trainees performing a comparable EVAR before and after structured SBT (>4 teaching sessions) were assessed utilising a modified Likert-scale score. These were benchmarked for comparison against the standard set by the consultant body. RESULTS: Median procedural-time for consultants was 43.5 min (IQR 7.5). A significant improvement in trainee procedural-time following SBT was observed (median procedural time 77 min [IQR 20.75] vs. 56 min [IQR: 7.00], p < .0001). The mean (SD) trainee Likert score pre- and post-SBT improved (16.6 [SD 1.455] vs. 28.63 [SD 2.986], p < .0001). Fewer endoleaks were observed (p = .0063) and trainees chose an appropriately sized device more often after SBT. CONCLUSION: This study suggests that EVAR-SBT should be considered as an adjunct to standard psychomotor skill teaching techniques for EVAR within the vascular surgery training curricula.

Progressive shortfall in open aneurysm experience for vascular surgery trainees with the impact of fenestrated and branched endovascular technology.

BACKGROUND: In 2014, we published a series of articles in the Journal of Vascular Surgery that detailed the decrease in volume of open aneurysm repair (OAR) completed for abdominal aortic aneurysm (AAA) by vascular surgery trainees. At that time, only data points from 2000 through 2011 were available, and reliable predictions could only be made through 2015. Lack of data on endovascular aneurysm repair (EVAR) using fenestrated (FEVAR) and branched (BrEVAR) endografts also affected our findings. Despite these limitations, our predictions for OAR completed by vascular trainees were accurate for 2012 to 2014. This report uses updated data points through 2014 in conjunction with data on FEVAR and BrEVAR obtained from industry to predict trends in OAR and how it will affect vascular surgery training through 2020. METHODS: An S-curve modified logistic function was used to model the effect of introducing new technologies (EVAR, FEVAR, BrEVAR) on the standard management of AAA with OAR starting in the year 2000, similar to the technique that we have previously described. Weighted samples and data from the United States Census Bureau were used in conjunction with volume estimates derived from the National Inpatient Sample, State Inpatient Databases, and industry sources to determine trends in OAR and EVAR. The number of cases completed at teaching hospitals was calculated using the National Inpatient Sample, and Accreditation Council for Graduate Medical Education case logs were used to forecast the number of cases completed by vascular surgery trainees through 2020. Sensitivity analysis and trend analysis were completed. RESULTS: Approximately 45,000 AAA repairs are completed annually in the United States, but only 15% of these are now completed using OAR compared with >50% just a decade ago. Further, with the accelerating adoption of FEVAR and BrEVAR, and expanding indications for standard EVAR, our model predicts that <3000 OARs will be completed annually by 2020. Because only a subset of these cases are completed at teaching institutions, our model predicts that a vascular surgery trainee in a fellowship program will complete only one to two OARs, whereas trainees in a 0+5 program may complete two to three OARs. CONCLUSIONS: Our initial prediction in the 2014 report was that vascular trainees would complete approximately five OARs by 2020. After incorporating new data on BrEVAR, FEVAR, and the accelerating pace of EVAR use between 2012 and 2014, it now appears that vascular trainees will complete one to three OARs during their training.

Operative Autonomy among Senior Surgical Trainees during Infrainguinal Bypass Operations Is Not Associated with Worse Long-term Patient Outcomes.

BACKGROUND: In an era of rapidly evolving surgical training, intraoperative teaching remains paramount to the education of surgical trainees. The impact of surgical trainees' level of expertise on outcomes after infrainguinal bypass surgery, a technically demanding operation, remains unknown. The purpose of this study was to explore the effects of surgical residents' experience on outcomes after infrainguinal bypass surgery. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database, we identified patients who underwent infrainguinal bypass from 2005 to 2012. Patients were stratified according to the training level of the most senior operating trainee. Univariate and multivariate analyses, as well as propensity score matched analysis, were performed to compare patient cohorts on operative time, length of hospital stay (LOS), bleeding, early graft failure, unplanned readmission, and 30-day mortality. RESULTS: A total of 19,579 patients were identified, of which 35.6% were female and 64.4% were male; mean age was 67.6 years. A PGY1 (postgraduate year) was the highest level trainee operating on 2.5%, a PGY2-4 for 26.2%, and a PGY5+ (postgraduate year 5 or greater) for 37.1%. Attending surgeons operated without trainees on 34.2%. PGY5+s were more likely to operate on patients who were younger, non-White, male, and on dialysis. In multivariable analysis, involvement of any surgical trainee was associated with procedures that took a greater length of time, had a greater odds of blood transfusion, and necessitated a longer hospital LOS relative to procedures performed by an attending surgeon alone. Only bypasses wherein PGY5+s were involved were associated with greater odds of early graft failure, unplanned readmission, and 30-day mortality when compared with procedures done without trainee involvement. After excluding lower extremity bypasses in which an attending surgeon operated without a trainee, propensity score matching analysis showed that patients operated on by PGY5+s had longer operative time (4.11 vs. 3.96 hr, P < 0.0001) and greater rates of postoperative bleeding (9.77% vs. 8.15%, P = 0.004) relative to patients operated on by attendings assisted by PGY1-4s, but no statistically significant difference in LOS, early graft failure, unplanned readmission, and perioperative mortality. CONCLUSIONS: Operative involvement of senior trainees was associated with worse outcomes during infrainguinal bypass, potentially reflecting a lesser extent of attending surgeon involvement, but no difference in patient outcomes after bypass procedure.

Endovascular aneurysm repair simulation can lead to decreased fluoroscopy time and accurately delineate the proximal seal zone.

BACKGROUND: The use of simulators for endovascular aneurysm repair (EVAR) is not widespread. We examined whether simulation could improve procedural variables, including operative time and optimizing proximal seal. For the latter, we compared suprarenal vs infrarenal fixation endografts, right femoral vs left femoral main body access, and increasing angulation of the proximal aortic neck. METHODS: Computed tomography angiography was obtained from 18 patients who underwent EVAR at a single institution. Patient cases were uploaded to the ANGIO Mentor endovascular simulator (Simbionix, Cleveland, Ohio) allowing for three-dimensional reconstruction and adapted for simulation with suprarenal fixation (Endurant II; Medtronic Inc, Minneapolis, Minn) and infrarenal fixation (C3; W. L. Gore & Associates Inc, Newark, Del) deployment systems. Three EVAR novices and three experienced surgeons performed 18 cases from each side with each device in randomized order (n = 72 simulations/participant). The cases were stratified into three groups according to the degree of infrarenal angulation: 0° to 20°, 21° to 40°, and 41° to 66°. Statistical analysis used paired t-test and one-way analysis of variance. RESULTS: Mean fluoroscopy time for participants decreased by 48.6% (P < .0001), and total procedure time decreased by 33.8% (P < .0001) when initial cases were compared with final cases. When stent deployment accuracy was evaluated across all cases, seal zone coverage in highly angulated aortic necks was significantly decreased. The infrarenal device resulted in mean aortic neck zone coverage of 91.9%, 89.4%, and 75.4% (P < .0001 by one-way analysis of variance), whereas the suprarenal device yielded 92.9%, 88.7%, and 71.5% (P < .0001) for the 0° to 20°, 21° to 40°, and 41° to 66° cases, respectively. Suprarenal fixation did not increase seal zone coverage. The side of femoral access for the main body did not influence proximal seal zone coverage regardless of infrarenal angulation. CONCLUSIONS: Simulation of EVAR leads to decreased fluoroscopy times for novice and experienced operators. Side of femoral access did not affect precision of proximal endograft landing. The angulated aortic neck leads to decreased proximal seal zone coverage regardless of infrarenal or suprarenal fixation devices.

Learning Curve of Robotic-Assisted Anastomosis: Shorter than the Laparoscopic Technique? An Educational Study.

BACKGROUND: Achieving aortic anastomosis in laparoscopic surgery remains a technical challenge. The Da Vinci robot could theoretically counteract this issue by minimizing the technical challenge. The aim of this study was to compare the learning curves of performing vascular anastomoses by trainees without any experience using purely laparoscopic versus robotic-assisted techniques. METHODS: Surgery residents were randomly included in the laparoscopic group (group A, n = 3) and the robotic group (group B, n = 3). They performed 10 end-to-end anastomoses on 18-mm-diameter tubular expanded polytetrafluoroethylene grafts. The parameters recorded were duration to complete the anastomosis and an indirect sealing quality evaluation (ISQE) defined as the following ratio: number of stitches with a distance of less than 4 mm/total number of stitches. RESULTS: The mean duration to perform the anastomosis decreased from 2340 s (±64) for the first anastomosis to 651 s (±248) for the last in group A (P < 0.05) and from 1989 s (±556) to 801 s (±120) in group B (P < 0.05). The mean ISQE increased from 74% (±18) for the first anastomosis to 98% (±3) for the last in group A (P < 0.05) and decreased from 100% to 98% (±2) in group B (nonsignificant). The mean duration to perform the first anastomosis was lower in group B than in group A (P < 0.05). The mean duration to perform the last anastomosis was not significantly different between the groups. Sealing tended to be better in group B for the first anastomosis compared with group A. CONCLUSIONS: Minimally invasive laparoscopic technique training demonstrates a learning curve to perform vascular anastomoses. The robotic-assisted technique tended to improve suturing skills and should be considered as a valuable tool to reduce the technical learning curve.

Rapid assessment of technical competency: the 8-min suture test.

BACKGROUND: Although simulation training and evaluation have become increasingly popular for teaching minimally invasive surgery, tools to measure open surgical skills remain underdeveloped. As there is increasing demand for objective measures of technical competency at the completion of surgical training (postgraduate year [PGY]-6 and -7), this project was designed to assess the feasibility, reliability, and validity of a novel open surgical skills evaluation tool, the 8-min suture test (8MST). METHODS: During an annual surgical skills laboratory session, fellows and residents were asked to complete a simulated end-to-end vascular anastomosis. They were limited to 8 min to perform the anastomosis between two 12-mm Dacron grafts mounted on a customized platform. Their real-time and video-recorded performance was scored by two blinded evaluators and compared with their faculty-rated technical performance on clinical rotations completed around the time of 8MST administration. RESULTS: PGY-6 and PGY-7 trainees were compared across several domains including 8MST total score (4.6 versus 5.5, P = 0.030), 8MST setup score (2.3 versus 2.4, P = 0.797), 8MST technical score (2.3 versus 3.1, P = 0.026), and clinical performance score (3.1 versus 3.6, P = 0.006). Comparison of 8MST total score to the clinical performance score identified a strong relationship with a Pearson r = 0.55 (P < 0.001) and r(2) = 0.30. Additionally, 8MST displayed high inter-rater reliability and test-retest reliability. CONCLUSIONS: The 8MST is a rapid, feasible, inexpensive, reliable, and valid test for assessment of surgical trainee technical abilities.

The effect of trainee involvement on perioperative outcomes of abdominal aortic aneurysm repair.

OBJECTIVE: Although the effect of trainee involvement has been evaluated across different specialties, their effects on perioperative outcomes after abdominal aortic aneurysm (AAA) repair have not been examined. Our goal was to examine the association between resident and fellow intraoperative participation with perioperative outcomes of endovascular AAA repair (EVAR), open infrarenal AAA repair (OIAR), and open juxtarenal AAA repair (OJAR). METHODS: The American College of Surgeons National Surgical Quality Improvement Program data set (2005-2012) was queried to identify all patients who underwent EVAR, OIAR, or OJAR. Multivariate analysis was performed to assess the association of trainee involvement with perioperative morbidity and mortality. RESULTS: We identified 16,977 patients: 12,003 with EVAR, 3655 with OIAR, and 1319 with OJAR. Propensity matching and multivariate analyses revealed that there was no significant difference in perioperative death, cardiac arrest/myocardial infarction, pulmonary, renal, venous thromboembolic, or wound complications, or return to the operating room. However, trainee involvement in AAA repair led to a significant increase in operative time for EVAR (163 ± 77 vs 140 ± 67 minutes; P < .001), OIAR (217 ± 91 vs 185 ± 76 minutes; P < .001), and OJAR (267 ± 115 vs 214 ± 106 minutes; P < .001) and an extended length of stay for EVAR (3.1 ± 5.3 vs 2.8 ± 4.5 days; P < .001) and OIAR (10.6 ± 11.8 vs 9.1 ± 8.9 days; P < .001). CONCLUSIONS: Trainee participation in aneurysm repair was not associated with major adverse perioperative outcomes. However, it was associated with an increased operative time and length of stay and therefore may lead to increased resource utilization and cost.

Practice and education of the vascular access.

INTRODUCTION: The Japanese Society for Dialysis Access (JSDA) has held the practical skills trainings for the doctors working for the vascular access (VA) access since 2014 in order to improve both quality and quantity of the VA construction. Terumo Medical Pranex (Kanagawa, Japan) is the institution of the general medical training established for the creation and the spread of medical technique, and it also has the hybrid simulator of VA. METHODS AND RESULTS: In the training institute in 2014, not only the practical skills but also the training on the simulator from the basic lecture of VA construction were conducted. The dummy of a radical artery and a cephalic vein is faked in the forearm on the simulator. Two carotid arteries of a pig are made as the position of a pair of artery and vein. The pig's skin taken from the neck to the chest is covered on the proceed part, then the dummy forearm was completed. We can make recognize the beats in the artery. We also can make a fake avf in the dummy forearm instead. The instructor is directly able to give the trainees the lectures while watching the scenes. jsda will continue to make such efforts from now. CONCLUSIONS: We are concerned that the more the VA access would be demanded, the more the VA construction would be needed. So, the matter of the urgency is the training of the doctors working for VA construction.

How to make an aortic root replacement simulator at home.

There is a paucity of low-fidelity and cost-efficient simulators for training cardiac surgeons in the aspects of aortic root/valve replacement. In this study we addressed this training challenge by creating a low-fidelity, low-cost but, at the same time, anatomically realistic aortic root replacement simulator for training purposes. We used readily available, low cost materials such as lint roller tubes, foam sheet, press-and-seal bags, glue, plywood sheet, heat-shrink sleeving tubes and condoms as the basic material to create a low-fidelity, aortic root, training simulator. We constructed a multi-purpose, anatomically realistic aortic root simulator using the above materials, both time- and cost-efficiently, using the minimum of surgical equipment. This simulator is easy to construct and enables self-training in major techniques of aortic root replacement as well as in stentless valve implantation for trainees in cardiac surgery.

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.