John F. Eidt

An early validation of the Society for Vascular Surgery Lower Extremity Threatened Limb Classification System

OBJECTIVEnThe Society for Vascular Surgery (SVS) recently established the Lower Extremity Threatened Limb Classification System, a staging system using Wound characteristic, Ischemia, and foot Infection (WIfI) to stratify the risk for limb amputation at 1 year. Although intuitive in nature, this new system has not been validated. The purpose of the following study was to determine whether the WIfI system is predictive of limb amputation and wound healing.nnnMETHODSnBetween 2007 and 2010, we prospectively obtained data related to wound characteristics, extent of infection, and degree of postrevascularization ischemia in 139 patients with foot wounds who presented for lower extremity revascularization (158 revascularization procedures). After adapting those data to the WIfI classifications, we analyzed the influence of wound characteristics, extent of infection, and degree of ischemia on time to wound healing; empirical Kaplan-Meier survival curves were compared with theoretical outcomes predicted by WIfI expert consensus opinion.nnnRESULTSnOf the 158 foot wounds, 125 (79%) healed. The median time to wound healing was 2.7 months (range, 1-18 months). Factors associated with wound healing included presence of diabetes mellitus (P = .013), wound location (P = .049), wound size (P = .007), wound depth (P = .004), and degree of ischemia (P < .001). The WIfI clinical stage was predictive of 1-year limb amputation (stage 1, 3%; stage 2, 10%; stage 3, 23%; stage 4, 40%) and wound nonhealing (stage 1, 8%; stage 2, 10%; stage 3, 23%; stage 4, 40%) and correlated with the theoretical outcome estimated by the SVS expert panel.nnnCONCLUSIONSnThe theoretical framework for risk stratification among patients with critical limb ischemia provided by the SVS expert panel appears valid. Further validation of the WIfI classification system with multicenter data is justified.

Predicted shortfall in open aneurysm experience for vascular surgery trainees

OBJECTIVEnSince the introduction of endovascular aneurysm repair (EVAR), the volume of open aneurysm repair (OAR) has steadily declined since 2000. The introduction of next-generation devices and branched and fenestrated endograft technology continues to increase the anatomic applicability of EVAR, further decreasing the need for OAR. This study models the decline in OAR and uses historical trends to forecast future decline in volume and its potential effect on vascular surgery training.nnnMETHODSnAn S-curve modified logistic function was used to model the effect of introducing a new technology (EVAR) on the standard management of abdominal aortic aneurysm (AAA) with OAR starting in the year 2000, when an International Classification of Diseases, Ninth Revision, code was first introduced for EVAR. Patients who underwent EVAR and OAR for AAA were determined using the Nationwide Inpatient Sample from 1998 to 2011. Weighted samples and data from the United States Census Bureau were used to extrapolate these numbers to estimate population statistics. The number of cases completed at teaching hospitals was calculated using the Nationwide Inpatient Sample, and Accreditation Council for Graduate Medical Education case logs were used to forecast the number of cases completed by vascular surgery trainees.nnnRESULTSnThe highest number of OAR cases in this study was 42,872 in 2000 compared with just 10,039 in 2011. This was mirrored by a rise in EVAR from 2358 cases in 2000 (5.2%) to 35,028 in 2011 (76.5% by volume). Of the OAR volume in 2011, 6055 cases (60.3%) were completed at teaching institutions. An S-curve model with a correlation coefficient of R2 = 0.982 predicted 3809 open AAA cases at teaching hospitals by 2015, 2162 by 2020, and 1231 by 2025. When compared with the 2011 Accreditation Council for Graduate Medical Education National Resident Report, vascular surgery residents had 44.4% utilization with regard to OAR (2690 cases covered of 6055 total). When combined with the increase in vascular surgery trainees and lower number of open repairs, vascular fellows will complete about 10 OAR cases in 2015 and five OAR cases in 2020.nnnCONCLUSIONSnThe decreasing number of OAR cases will limit exposure for vascular trainees, who may be ill equipped to treat patients who require open repair beyond 2015. Additional methods for providing OAR training should be explored.

A systematic review of assessment of skill acquisition and operative competency in vascular surgical training

OBJECTIVEnThe aim of this systematic review is to describe the literature and assessment tools evaluating vascular surgical operative performance that could potentially be used for the assessment of educational outcomes applicable to the Milestone Project and the Next Accreditation System.nnnMETHODSnA systematic review of PubMed/MEDLINE, EMBASE, PsycINFO, and key journals from 1985 to 2013 was performed to identify English-language articles describing assessment of vascular surgical skills and competence. Qualifying studies were abstracted for data concerning study aims, study and assessment setting, skills measured, and metrics used to determine competency. Strengths, weaknesses, and psychometric robustness of the assessment tools were determined.nnnRESULTSnThe literature search identified 617 citations. After title and abstract review, 65 articles were retrieved for full-text assessment and 48 articles were included in the final review. Twenty-nine articles assessed open vascular skills; 19, endovascular skills; six, nontechnical skills; and one, teamwork skills. The majority (84%) of studies were performed in a simulated environment, four (8%) were performed in the operating room, and the remaining three were performed in both a simulated environment and an operating room. Strengths and weaknesses of assessment tools were study and assessor dependent, with none applicable to all study scenarios or procedures.nnnCONCLUSIONSnThe literature describing assessment tools pertinent to vascular surgery is diverse. Existing assessment tools may be relevant to individual technical skill acquisition assessment; however, an operative assessment tool relevant to vascular/endovascular surgery and generalizable to the wide spectrum of technical and nontechnical skills pertinent to vascular surgery needs to be developed, validated, and implemented to allow the practical assessment of resident readiness to operate in an unsupervised setting.

A Regional Experience With Vascular Surgery Mock Oral Examinations

INTRODUCTIONnIn 2006 the Southern Association for Vascular Surgery (SAVS) implemented a mock oral examination program to prepare trainees for the Vascular Surgery Certifying Examination (VCE).nnnMETHODSnParticipating examinees and examiners were identified from SAVS Recorder records and contacted via e-mail with a request to participate in an anonymous online survey. Examinees were asked about passage on American Board of Surgery examinations and perceptions of the mock oral program. Examiners were asked for their perceptions of the examination, applicant performance, and perceived areas for training improvement. Board passage rates for the group and national comparison data were provided in a de-identified fashion by American Board of Surgery.nnnRESULTSnFrom 2006 to 2014, 158 examinees and 86 examiners participated in the SAVS mock orals program. In all, 33% of examinees and 35% of examiners completed the anonymous survey. Of the examinees, 27 (60%) reported passage of the mock oral examination on their first attempt and 7 of 9 (78%) reported passage on the second attempt. Second year in training was significantly associated with passage of the mock oral (p = 0.002). Of the examinees questioned, 100% would recommend the SAVS mock oral examinations to future trainees. Of the responding examiners, 90% felt that the SAVS mock oral examinations were comparable to the VCE and 87% strongly agreed that the exercise was a valuable preparatory tool. Examiners identified ability to describe technical aspects of open vascular techniques and management of complications associated with vascular disease processes and operations as commonly displayed deficits among examinees (80% and 77%, respectively). In all, 115 examinee participants from the SAVS mock orals had taken the VCE between 2006 and 2014. Of them, 90 (78%) passed the VCE on their first attempt. During the same time interval, the national first-time pass rate for the VCE was 86%.nnnCONCLUSIONSnAlthough participation in the SAVS mock orals was overwhelmingly assessed as a positive preparatory experience by examinees and examiners, no incremental advantage in VCE passage was observed. Explanations for the worse-than-average performance on the VCE are not clear but likely involve numerous factors, including participation bias. Importantly, examiners in the SAVS mock oral process felt that the exercise closely simulated the VCE and uniformly reported pervasive deficits in the areas of demonstrated understanding of open surgical techniques and management of complications. This investigation guides further examination of VCE simulation exercises to assist in guiding the use of educational resources at both institutional and professional society levels.

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

OBJECTIVEnEndovascular 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.nnnMETHODSnDeidentified data were provided by the Vascular Surgery Board on the number of procedures performed by each 2014 fellowship and residency (0xa0+ 5) graduate during training. Data were analyzed using parametric and nonparametric methods, where appropriate.nnnRESULTSnOf 125 trainees (109 fellows, 16 residents), 33 (27%) performed 10 or fewer infrapopliteal vein bypasses and 37xa0(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 (rxa0= 0.19; Pxa0= .03). There was no difference between fellows and residents in the mean number of bypass operations performed during training (17.3 vs 19.1; Pxa0= .50; range, 0-53). However, residents performed more infrapopliteal endovascular procedures than fellows did (median, 29 vs 16; Pxa0= .03; range, 0-128).nnnCONCLUSIONSnMore 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.