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Increasing the Number of Integrated Vascular Surgery Residency Positions Is Necessary to Address the Impending Shortage of Vascular Surgeons in the United States
Abstracts from the 2017 New England Society for Vascular Surgery Annual Meeting hospital stays. These data demonstrate the importance of reporting 30day rather than in-hospital outcomes when evaluating postoperative adverse events.
NESVS1. Postdischarge Events After Lower Extremity Revascularization Ruby Lo, Peter Soden, Marc Schermerhorn. Beth Israel Deaconess Medical Center, Boston, MA Objective: Outcome studies using hospital discharge data likely underestimate postoperative morbidity and mortality after lower extremity revascularization because they fail to capture postdischarge events. However, the degree of underestimation and the timing of postdischarge complications are not well characterized. Methods: We used the American College of Surgeons National Surgical Quality Improvement Program procedure-targeted databases from 2011 to 2014 to tabulate 30-day adverse events (in the hospital and after discharge) for lower extremity bypass (LEB) and endovascular interventions (ENDO) performed for claudication and chronic limb-threatening ischemia (CLTI). Results: A total of 9165 patients underwent lower extremity revascularization (63% female; mean age, 68 years; 64% CLTI; 39% LEB). For CLTI, total 30-day mortality was 2.5% for ENDO (41% after discharge) and 3% for LEB (29% after discharge). Cardiac events occurred in 2.8% of ENDO patients (44% after discharge) and 3.9% of LEB patients (29% after discharge). Thirty-day reoperation rates were 13.2% for ENDO (49% after discharge) and 16.4% for LEB (41% after discharge). For claudication, total 30-day mortality was 0.4% (33% after discharge) for ENDO and 0.7% (17% after discharge) for LEB. Thirty-day reoperation rates were 4.1% for ENDO (60% after discharge) and 6.9% for LEB (52% after discharge; Table). Conclusions: As many as 41% of deaths, 44% of cardiac events, and 31% of wound infections after lower extremity revascularization occur after discharge, emphasizing the need for close surveillance after hospital discharge. The morbidity and mortality benefit of ENDO over LEB may be exaggerated by solely evaluating in-hospital data because ENDO patients have higher rates of postdischarge events as a result of shorter
Author Disclosures: R. Lo: None; P. Soden: None; M. Schermerhorn: Grants/Research Support: Medtronic, Cook; Consultant: Endologix
NESVS2. Increasing the Number of Integrated Vascular Surgery Residency Positions Is Necessary to Address the Impending Shortage of Vascular Surgeons in the United States Edward J. Arous, Dejah R. Judelson, Jessica P. Simons, Francesco A. Aiello, Danielle R. Doucet, Elias J. Arous, Louis M. Messina, Andres Schanzer. University of Massachusetts Medical School, Worcester, MA Objective: During the next two decades, the demand for vascular surgeons is expected to far exceed the current supply. Whereas the number of vascular fellowship programs/positions is stable, the number of vascular residency programs/positions has expanded dramatically. We sought to evaluate the qualifications of this new workforce and its ability to meet future needs. Methods: We conducted a retrospective review of national data compiled by the Association of American Medical Colleges and National Resident Matching Program regarding vascular residency programs (2008-2015) and fellowships (2007-2016). Variables included the number of applicants, sex, U.S. vs international medical graduates, and applicants per position. In addition, we conducted a retrospective review of applicants to the UMass Medical School residency program to examine the aforementioned variables and United States Medical Licensing Examination Step 1 and Step 2 CK scores.
Table. Postdischarge events after lower extremity revascularization Days from operation to adverse event, mean 6 SD Endovascular for CLTI Mortality Cardiac event
Cardiac event
51
1.5
1.0
41
1.6
1.2
44
26
1.0
0.3
23
11.9 6 9.2
268
6.7
6.5
49 29
3837 13.6 6 9.0
115
2.1
0.9
5 6 6.6
152
3.4
0.5
13
64
1.4
0.3
19
Wound infection 11.1 6 9.2
Endovascular for claudication Mortality Cardiac event
415
6.6
3.0
28
632
9.7
6.7
41
1460 14 6 6.2
6
0.3
0.1
33
4.4 6 5.6
8
0.4
0.1
25
2
0.1
0.0
0
60
1.6
2.5
60
Renal failure Reoperation
Proportion of events after discharge, %
57
Renal failure Reoperation
Postdischarge rate, %
6 6 9.6
Bypass for CLTI Mortality
In-hospital rate, %
2037 12.9 6 10.2
Renal failure Reoperation
No. of 30-day events
12.2 6 10.4
Bypass for claudication
1711
Mortality
6.1 6 6
12
0.6
0.1
17
Cardiac event
3.7 6 4.4
25
1.3
0.2
12 10
Renal failure Wound infection Reoperation
11.4 6 9.0
10
0.5
0.1
133
4.9
2.4
31
117
3.3
3.6
5%
CLTI, Chronic limb-threatening ischemia; SD, standard deviation.
e5
e6
Abstracts
Journal of Vascular Surgery August 2017
Results: From 2008 to 2015, the number of residency positions increased from 4 to 56. Concurrently, the number of applicants grew from 112 to 434 (Fig). This increase has been predominantly driven by a 575% increase in U.S. graduate applicants and a 170% increase in women applicants. The total number of applicants per residency position increased from 5.9 to 7.8. Meanwhile, the number of fellowship positions remained stable with an applicant to position ratio near 1:1 (Fig). Among residency applicants to UMass Medical School, the mean United States Medical Licensing Examination Step 1 and Step 2 CK scores have improved annually and consistently exceed the national average among U.S. applicants who have matched in their preferred specialty. Conclusions: Since the approval of a primary certificate in vascular surgery in 2005 and the subsequent rollout of residency programs in 2007, the number of programs and quality of applicants have continued to increase. Demand from qualified medical school applicants outnumbers the current supply of training positions by eightfold. In contrast, demand from fellowship applicants matches the supply of positions. With a growing public health need for vascular surgeons, these results suggest that additional residency positions would easily be filled with talented young surgeons.
Table. Demographics Preoperative Postanesthetic US, US only, mean (SD) mean (SD) or or No. (%) (n ¼ 99) No. (%) (n ¼ 225) P value Age, years
63 (16)
62 (17)
Male sex
47 (47)
99 (44)
Race
Author Disclosures: E. J. Arous: None; D. R. Judelson: None; J. P. Simons: None; F. A. Aiello: None; D. R. Doucet: None; E. J. Arous: None; L. M. Messina: None; A. Schanzer: None
NESVS3. Postanesthetic Ultrasound Facilitates More Preferential Hemodialysis Access Creation Without Affecting Access Patency Patrick McGlynn,1 Dean Arnaoutakis,1 Elise P. Deroo,2 Charles Keith Ozaki,1 Dirk M. Hentschel1. 1Brigham and Women’s Hospital, Boston, MA; 2Harvard Medical School, Boston, MA Objective: Environmental and clinical factors (ambient temperature, acute illness, recent phlebotomy, hypovolemia) affect preoperative ultrasound (US) vein mapping (pre-US) measurements. These factors may drive inadvertent exclusion of viable access construction options. We hypothesized that duplex US re-evaluation in the operating room after anesthetic administration (conscious sedation, regional, general; postUS) would identify preferable (more distal, autogenous) access configurations not appreciated on pre-US. In addition, post-US may also identify vessels with interval injury (thrombophlebitis, thrombosis) since the time of pre-US. Methods: A retrospective cohort study including all patients with pre-US followed by creation of a permanent dialysis access (fistula or graft) between January 2009 and December 2013 was completed. Pre-US reports (Intersocietal Commission for the Accreditation of Vascular Laboratories-approved laboratory) were reviewed for venous
.63 .35
White
51 (52)
117 (52)
d
Black
30 (30)
64 (28)
d
13 (13)
26 (12)
d
Asian
4 (4)
4 (2)
d
Native American
0 (0)
2 (1)
d
Not reported
1 (1)
12 (5)
d
Body mass index
30.4 (8.4)
30.0 (7.8)
.67
37 (37)
136 (60)
d
Hispanic
<.001
Anesthesia Local + conscious sedation Regional
13 (13)
11 (5)
d
General
48 (49)
78 (35)
d
1 (1)
0 (0)
d
Prior access
25 (25)
27 (12)
.01
Peripheral vascular disease
18 (18)
35 (16)
.63
Coronary artery disease
29 (29)
61 (27)
.69
Congestive heart failure
35 (35)
74 (33)
.70
Hypertension
95 (96)
216 (96)
1.0
Diabetes
55 (56)
125 (56)
1.0
History of smoking
59 (60)
114 (51)
.12
End-stage renal disease on dialysis
44 (44)
120 (53)
.09
Not reported
Fig. Supply and demand for vascular surgery fellowship and residency positions (2008-2015).
.64
SD, Standard deviation; US, ultrasound. The results for change in operative plan, more distal access placement, and arteriovenous fistula creation were compared using logistic regression. Covariates were selected for the model by using backwards elimination including covariates with P value < .10. Covariates include anesthesia type (P < .001), dialysis status (P ¼ .1), and history of prior access (P < .001). and arterial diameters and presence of a continuous outflow tract. The preoperative access plan was defined according to guidelines (radial-cephalic > brachial-cephalic > brachial-basilic > forearm graft > upper arm graft) by applying the Silva criteria (vein >2.5 mm, artery >2 mm). Using logistic regression, we tested the association of a post-US with a change in operative plan (primary end point) and placement of a more preferred access (more distal, autogenous; secondary end points). We also analyzed access survival using Cox proportional hazards. Results: There were 324 accesses that met inclusion criteria including pre-US, of which 225 also had a post-US. Post-US was associated with a change in operative plan (adjusted odds ratio [OR], 2.04; 95% confidence interval [CI], 1.21-3.43). Post-US was associated with more preferential access placement (adjusted OR, 1.87; 95% CI, 1.00-3.49) and a nonsignificant trend toward higher odds of fistula placement (adjusted OR, 1.21; 95% CI, 0.58-2.54 (Table; Fig). Neither general nor regional or local anesthesia was associated with placement of more preferential accesses in the post-US group. There were no differences in primary patency (19%; 14%), primary assisted patency (63%; 63%), or secondary patency (84%; 85%) comparing those who did and did not have postUS at 2 years. Conclusions: Post-US positively affects hemodialysis access placement strategies without compromising access patency. Post-US stands as a useful adjunct for hemodialysis access creation.
NESVS1. Postdischarge Events After Lower Extremity Revascularization Ruby Lo, Peter Soden, Marc Schermerhorn. Beth Israel Deaconess Medical Center, Boston, MA Objective: Outcome studies using hospital discharge data likely underestimate postoperative morbidity and mortality after lower extremity revascularization because they fail to capture postdischarge events. However, the degree of underestimation and the timing of postdischarge complications are not well characterized. Methods: We used the American College of Surgeons National Surgical Quality Improvement Program procedure-targeted databases from 2011 to 2014 to tabulate 30-day adverse events (in the hospital and after discharge) for lower extremity bypass (LEB) and endovascular interventions (ENDO) performed for claudication and chronic limb-threatening ischemia (CLTI). Results: A total of 9165 patients underwent lower extremity revascularization (63% female; mean age, 68 years; 64% CLTI; 39% LEB). For CLTI, total 30-day mortality was 2.5% for ENDO (41% after discharge) and 3% for LEB (29% after discharge). Cardiac events occurred in 2.8% of ENDO patients (44% after discharge) and 3.9% of LEB patients (29% after discharge). Thirty-day reoperation rates were 13.2% for ENDO (49% after discharge) and 16.4% for LEB (41% after discharge). For claudication, total 30-day mortality was 0.4% (33% after discharge) for ENDO and 0.7% (17% after discharge) for LEB. Thirty-day reoperation rates were 4.1% for ENDO (60% after discharge) and 6.9% for LEB (52% after discharge; Table). Conclusions: As many as 41% of deaths, 44% of cardiac events, and 31% of wound infections after lower extremity revascularization occur after discharge, emphasizing the need for close surveillance after hospital discharge. The morbidity and mortality benefit of ENDO over LEB may be exaggerated by solely evaluating in-hospital data because ENDO patients have higher rates of postdischarge events as a result of shorter
Author Disclosures: R. Lo: None; P. Soden: None; M. Schermerhorn: Grants/Research Support: Medtronic, Cook; Consultant: Endologix
NESVS2. Increasing the Number of Integrated Vascular Surgery Residency Positions Is Necessary to Address the Impending Shortage of Vascular Surgeons in the United States Edward J. Arous, Dejah R. Judelson, Jessica P. Simons, Francesco A. Aiello, Danielle R. Doucet, Elias J. Arous, Louis M. Messina, Andres Schanzer. University of Massachusetts Medical School, Worcester, MA Objective: During the next two decades, the demand for vascular surgeons is expected to far exceed the current supply. Whereas the number of vascular fellowship programs/positions is stable, the number of vascular residency programs/positions has expanded dramatically. We sought to evaluate the qualifications of this new workforce and its ability to meet future needs. Methods: We conducted a retrospective review of national data compiled by the Association of American Medical Colleges and National Resident Matching Program regarding vascular residency programs (2008-2015) and fellowships (2007-2016). Variables included the number of applicants, sex, U.S. vs international medical graduates, and applicants per position. In addition, we conducted a retrospective review of applicants to the UMass Medical School residency program to examine the aforementioned variables and United States Medical Licensing Examination Step 1 and Step 2 CK scores.
Table. Postdischarge events after lower extremity revascularization Days from operation to adverse event, mean 6 SD Endovascular for CLTI Mortality Cardiac event
Cardiac event
51
1.5
1.0
41
1.6
1.2
44
26
1.0
0.3
23
11.9 6 9.2
268
6.7
6.5
49 29
3837 13.6 6 9.0
115
2.1
0.9
5 6 6.6
152
3.4
0.5
13
64
1.4
0.3
19
Wound infection 11.1 6 9.2
Endovascular for claudication Mortality Cardiac event
415
6.6
3.0
28
632
9.7
6.7
41
1460 14 6 6.2
6
0.3
0.1
33
4.4 6 5.6
8
0.4
0.1
25
2
0.1
0.0
0
60
1.6
2.5
60
Renal failure Reoperation
Proportion of events after discharge, %
57
Renal failure Reoperation
Postdischarge rate, %
6 6 9.6
Bypass for CLTI Mortality
In-hospital rate, %
2037 12.9 6 10.2
Renal failure Reoperation
No. of 30-day events
12.2 6 10.4
Bypass for claudication
1711
Mortality
6.1 6 6
12
0.6
0.1
17
Cardiac event
3.7 6 4.4
25
1.3
0.2
12 10
Renal failure Wound infection Reoperation
11.4 6 9.0
10
0.5
0.1
133
4.9
2.4
31
117
3.3
3.6
5%
CLTI, Chronic limb-threatening ischemia; SD, standard deviation.
e5
e6
Abstracts
Journal of Vascular Surgery August 2017
Results: From 2008 to 2015, the number of residency positions increased from 4 to 56. Concurrently, the number of applicants grew from 112 to 434 (Fig). This increase has been predominantly driven by a 575% increase in U.S. graduate applicants and a 170% increase in women applicants. The total number of applicants per residency position increased from 5.9 to 7.8. Meanwhile, the number of fellowship positions remained stable with an applicant to position ratio near 1:1 (Fig). Among residency applicants to UMass Medical School, the mean United States Medical Licensing Examination Step 1 and Step 2 CK scores have improved annually and consistently exceed the national average among U.S. applicants who have matched in their preferred specialty. Conclusions: Since the approval of a primary certificate in vascular surgery in 2005 and the subsequent rollout of residency programs in 2007, the number of programs and quality of applicants have continued to increase. Demand from qualified medical school applicants outnumbers the current supply of training positions by eightfold. In contrast, demand from fellowship applicants matches the supply of positions. With a growing public health need for vascular surgeons, these results suggest that additional residency positions would easily be filled with talented young surgeons.
Table. Demographics Preoperative Postanesthetic US, US only, mean (SD) mean (SD) or or No. (%) (n ¼ 99) No. (%) (n ¼ 225) P value Age, years
63 (16)
62 (17)
Male sex
47 (47)
99 (44)
Race
Author Disclosures: E. J. Arous: None; D. R. Judelson: None; J. P. Simons: None; F. A. Aiello: None; D. R. Doucet: None; E. J. Arous: None; L. M. Messina: None; A. Schanzer: None
NESVS3. Postanesthetic Ultrasound Facilitates More Preferential Hemodialysis Access Creation Without Affecting Access Patency Patrick McGlynn,1 Dean Arnaoutakis,1 Elise P. Deroo,2 Charles Keith Ozaki,1 Dirk M. Hentschel1. 1Brigham and Women’s Hospital, Boston, MA; 2Harvard Medical School, Boston, MA Objective: Environmental and clinical factors (ambient temperature, acute illness, recent phlebotomy, hypovolemia) affect preoperative ultrasound (US) vein mapping (pre-US) measurements. These factors may drive inadvertent exclusion of viable access construction options. We hypothesized that duplex US re-evaluation in the operating room after anesthetic administration (conscious sedation, regional, general; postUS) would identify preferable (more distal, autogenous) access configurations not appreciated on pre-US. In addition, post-US may also identify vessels with interval injury (thrombophlebitis, thrombosis) since the time of pre-US. Methods: A retrospective cohort study including all patients with pre-US followed by creation of a permanent dialysis access (fistula or graft) between January 2009 and December 2013 was completed. Pre-US reports (Intersocietal Commission for the Accreditation of Vascular Laboratories-approved laboratory) were reviewed for venous
.63 .35
White
51 (52)
117 (52)
d
Black
30 (30)
64 (28)
d
13 (13)
26 (12)
d
Asian
4 (4)
4 (2)
d
Native American
0 (0)
2 (1)
d
Not reported
1 (1)
12 (5)
d
Body mass index
30.4 (8.4)
30.0 (7.8)
.67
37 (37)
136 (60)
d
Hispanic
<.001
Anesthesia Local + conscious sedation Regional
13 (13)
11 (5)
d
General
48 (49)
78 (35)
d
1 (1)
0 (0)
d
Prior access
25 (25)
27 (12)
.01
Peripheral vascular disease
18 (18)
35 (16)
.63
Coronary artery disease
29 (29)
61 (27)
.69
Congestive heart failure
35 (35)
74 (33)
.70
Hypertension
95 (96)
216 (96)
1.0
Diabetes
55 (56)
125 (56)
1.0
History of smoking
59 (60)
114 (51)
.12
End-stage renal disease on dialysis
44 (44)
120 (53)
.09
Not reported
Fig. Supply and demand for vascular surgery fellowship and residency positions (2008-2015).
.64
SD, Standard deviation; US, ultrasound. The results for change in operative plan, more distal access placement, and arteriovenous fistula creation were compared using logistic regression. Covariates were selected for the model by using backwards elimination including covariates with P value < .10. Covariates include anesthesia type (P < .001), dialysis status (P ¼ .1), and history of prior access (P < .001). and arterial diameters and presence of a continuous outflow tract. The preoperative access plan was defined according to guidelines (radial-cephalic > brachial-cephalic > brachial-basilic > forearm graft > upper arm graft) by applying the Silva criteria (vein >2.5 mm, artery >2 mm). Using logistic regression, we tested the association of a post-US with a change in operative plan (primary end point) and placement of a more preferred access (more distal, autogenous; secondary end points). We also analyzed access survival using Cox proportional hazards. Results: There were 324 accesses that met inclusion criteria including pre-US, of which 225 also had a post-US. Post-US was associated with a change in operative plan (adjusted odds ratio [OR], 2.04; 95% confidence interval [CI], 1.21-3.43). Post-US was associated with more preferential access placement (adjusted OR, 1.87; 95% CI, 1.00-3.49) and a nonsignificant trend toward higher odds of fistula placement (adjusted OR, 1.21; 95% CI, 0.58-2.54 (Table; Fig). Neither general nor regional or local anesthesia was associated with placement of more preferential accesses in the post-US group. There were no differences in primary patency (19%; 14%), primary assisted patency (63%; 63%), or secondary patency (84%; 85%) comparing those who did and did not have postUS at 2 years. Conclusions: Post-US positively affects hemodialysis access placement strategies without compromising access patency. Post-US stands as a useful adjunct for hemodialysis access creation.