Whitaker Litton, Etkin Yana, Manvar-Singh Pallavi, Stefanov Dimitre G, Kota Akhil, Landis Gregg
Surgery Department, Nuvance Health, Danbury, CT.
Surgery Department, Northwell, New Hyde Park, NY.
Ann Vasc Surg. 2025 Apr;113:346-352. doi: 10.1016/j.avsg.2024.07.126. Epub 2024 Sep 26.
There has been ensuing interest in adopting transcarotid artery revascularization (TCAR), because of its low perioperative stroke and complication rates. In our study, we aimed to identify the case number at which there is improvement in TCAR technical proficiency. We also assessed how surgeon experience influenced outcomes.
The primary outcome was technical proficiency, measured by skin-to-skin, fluoroscopy, and flow reversal times. Secondary outcomes included hospital length of stay and perioperative complication rate. Data was collected from a deidentified database, which included all patients that had a TCAR between 2017 and 2023 at 1 of 4 hospitals. Cases were grouped by the experience of the surgeon who performed the case (≤10 and > 10 years). Linear mixed models were used to analyze primary outcomes after being log-transformed, due to their skewed distributions. The estimated level of the outcome was compared at the first, fifth, 10th and 15th surgery between surgeon groups, and the significance level was adjusted using the Bonferroni correction.
There were 160 cases performed by 13 surgeons included in the study. Patients with hostile necks (23.9% vs. 9.7%, P = 0.015) and contralateral occlusions (7.5% vs. 0%, P = 0.007) were operated on more frequently by surgeons with ≤10 years of experience. There was no difference in secondary outcomes between groups. While primary outcomes between groups were not significant when comparing median values, linear mixed models demonstrated a significant improvement among the group of surgeons with less experience after the 15th case relative to their senior partners. At this point, they were operating with 30% less skin-to-skin time (P = 0.002, 95% confidence interval (CI) 13%-44%) and 51% less fluoroscopy time (P = 0.005, 95% CI 20%-70%) compared to surgeons with >10 years of experience. There was no significant difference between groups with respect to flow reversal times.
There was significant improvement experienced by the junior attendings relative to their senior partners after the 15th case. This was not influenced by patient characteristics nor the type of anesthesia used.
由于经颈动脉血管重建术（TCAR）围手术期中风和并发症发生率较低，人们对采用该技术的兴趣与日俱增。在我们的研究中，我们旨在确定TCAR技术熟练程度有所提高时的病例数量。我们还评估了外科医生的经验如何影响手术结果。
主要结局指标是技术熟练程度，通过皮肤切开至皮肤缝合时间、透视时间和血流逆转时间来衡量。次要结局指标包括住院时间和围手术期并发症发生率。数据来自一个经过去识别处理的数据库，该数据库包含2017年至2023年期间在4家医院中的1家接受TCAR手术的所有患者。病例按照实施手术的外科医生的经验（≤10年和>10年）进行分组。由于主要结局指标的分布呈偏态，因此在进行对数转换后，使用线性混合模型进行分析。在外科医生组的第1次、第5次、第10次和第15次手术时，比较结局指标的估计水平，并使用Bonferroni校正调整显著性水平。
本研究纳入了由13名外科医生实施的160例手术。经验≤10年的外科医生对颈部情况复杂的患者（23.9%对9.7%，P = 0.015）和对侧闭塞患者（7.5%对0%，P = 0.007）进行手术的频率更高。两组之间的次要结局指标没有差异。虽然在比较中位数时，两组之间的主要结局指标没有显著性差异，但线性混合模型显示，经验较少的外科医生组在第15例手术后相对于经验丰富的同行有显著改善。此时，与经验>10年的外科医生相比，他们的皮肤切开至皮肤缝合时间减少了30%（P = 0.002，95%置信区间（CI）13%-44%），透视时间减少了51%（P = 0.005，95%CI 20%-70%）。两组之间的血流逆转时间没有显著差异。
经验较少的主治医师在第15例手术后相对于经验丰富的同行有显著改善。这不受患者特征或所用麻醉类型的影响。
