Elsayed Nadin, Zarrintan Sina, Khan Maryam Ali, Naazie Isaac, DeMartino Randall, Malas Mahmoud B
Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA.
Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN.
Ann Vasc Surg. 2023 May;92:1-8. doi: 10.1016/j.avsg.2023.01.017. Epub 2023 Feb 6.
Since the introduction of endovascular aneurysm repair (EVAR) in 1992, the number of open AAA repair (OAR) cases continue to decline. The consequence of reduced OAR cases raises valid concerns related to patient safety and the future training of vascular surgeons that need to be appropriately addressed. Our objective is to analyze trends in OAR and EVAR cases and to assess their implications on the quality of vascular surgery training.
We analyzed the Accreditation Council for Graduate Medical Education (ACGME) case log database for total clinical experience in OAR and EVAR for graduating vascular surgery fellows (VSFs) finishing 5 + 2 programs between 2002 and 2019 and vascular surgery integrated residents (VSRs) between 2013 and 2019. VSF case totals were calculated by combining average total cases of open and endovascular supra- and infrarenal AAA repair during fellowship years combined with total cases performed during their general surgery residency. VSR case totals included only the cases performed during the 5-year residency period. Isolated Iliac and thoracic aortic aneurysms were excluded from our analysis.
The average number of OAR cases per trainee has decreased by 60% (from 36.9 to 14.7) with a rate of 1.4 cases per year (P < 0.001) for VSF. Meanwhile, EVAR average cases have increased by 102% (from 22 to 44.4). However, there were 2 different trends exhibited with EVAR over the study period. Between 2002 and 2007, EVAR cases tended to increase by 5.9 cases per year (P < 0.001). Whereas, between 2007 and 2019, there was a slightly decreased trend in EVAR cases by 0.3 cases per year (P = 0.01). For VSR, while no significant trend was observed in the mean number of OAR cases (Coef. -0.3, P = 0.2) due to the limited time frame, the proportion of open cases was significantly lower compared to endovascular cases. Additionally, there were 2 different trends exhibited with EVAR over the study period. Between 2013 and 2015, EVAR cases tended to increase by 1.7 cases per year (P = 0.1). Whereas, between 2015 and 2019, there was a slightly decreased trend in EVAR cases by 0.2 cases per year (P = 0.007).
A significant reduction in average OAR cases and an increase in EVAR cases were observed over the study period. Vascular surgery training programs may need to introduce further training programs in open surgical repair to ensure vascular surgery trainees have the required technical skills and expertize to perform such a high-risk procedure safely and independently.
自1992年血管内动脉瘤修复术（EVAR）问世以来，开放性腹主动脉瘤修复术（OAR）的病例数量持续下降。OAR病例减少的后果引发了对患者安全以及血管外科医生未来培训的合理担忧，这些问题需要得到妥善解决。我们的目标是分析OAR和EVAR病例的趋势，并评估它们对血管外科培训质量的影响。
我们分析了毕业后医学教育认证委员会（ACGME）的病例记录数据库，以获取2002年至2019年完成5+2项目的血管外科住院医师（VSF）以及2013年至2019年血管外科整合住院医师（VSR）在OAR和EVAR方面的总临床经验。VSF的病例总数是通过将其在住院医师培训期间开放性和血管内肾上下腹主动脉瘤修复的平均病例数与普通外科住院期间的病例数相加得出。VSR的病例总数仅包括5年住院期间所做的病例。孤立性髂动脉瘤和胸主动脉瘤被排除在我们的分析之外。
VSF每位学员的OAR平均病例数下降了60%（从36.9降至14.7），每年下降1.4例（P<0.001）。与此同时，EVAR的平均病例数增加了102%（从22增至44.4）。然而，在研究期间EVAR呈现出两种不同的趋势。2002年至2007年，EVAR病例每年倾向于增加5.9例（P<0.001）。而在2007年至2019年，EVAR病例每年略有下降趋势，为0.3例（P=0.01）。对于VSR，由于时间框架有限，OAR病例的平均数量未观察到显著趋势（系数为-0.3，P=0.2），但开放手术病例的比例明显低于血管内手术病例。此外，在研究期间EVAR也呈现出两种不同的趋势。2013年至2015年，EVAR病例每年倾向于增加1.7例（P=0.1）。而在2015年至2019年，EVAR病例每年略有下降趋势，为0.2例（P=0.007）。
在研究期间，观察到OAR平均病例数显著减少，EVAR病例数增加。血管外科培训项目可能需要引入更多开放性手术修复的培训项目，以确保血管外科住院医师具备安全独立进行此类高风险手术所需的技术技能和专业知识。
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