The current status of aortic training among vascular surgery trainees in the United States
Background: The recent advent of endovascular aneurysm repair has shifted the landscape of abdominal aortic aneurysm treatment from an open to a primarily endovascular approach. Previous studies have reported a decline in open abdominal aortic aneurysm repair case volume for vascular surgery trainees because of this paradigm shift, suggesting that proficiency of graduating trainees in performing open aortic surgery may be at risk. However, these studies have not considered non-open abdominal aortic aneurysm repair aortic operations, including those performed for occlusive disease. In the present study, we report comprehensive operative volumes and trends in both open and endovascular aortic surgery among vascular surgery trainees in the United States. Methods: Accreditation Council for Graduate Medical Education reports were reviewed for all open and endovascular aortic operations performed by graduating vascular surgery fellows (VSFs) and integrated residents (VSR) from 2013 to 2023. Statistical analysis was performed using univariate tests and linear regression analysis. Results: Over the 11-year period, the mean aortic case volume among graduating VSFs and VSRs were 118.8 ± 6.4 per graduate and 130.5 ± 10.7 per graduate, respectively. The open aortic experience comprised 32.9 ± 1.1 cases (27%) among the VSF group, including 17.5 ± 1.3 aneurysm repairs and 15.5 ± 0.6 operations for aortic occlusive disease. There was a <1% decrease in open aortic operations among the VSF group (−0.3 cases/year, R2 = 0.55; P = .0008). Endovascular aortic volume among graduating VSF included 85.8 ± 7.0 total cases, which increased by +1.5 cases each year (R2 = 0.53; P = .002). These included 42.2 ± 3.6 EVARs, 15.8 ± 1.3 thoracic endovascular aneurysm repairs, and 27.8 ± 2.2 aortoiliac angioplasty and/or stenting operations. Among graduating VSRs, the open aortic experience was comprised of 36.1 ± 1.5 cases (28%), including 18.3 ± 2.0 aneurysm repairs and 17.7 ± 1.9 operations for aortic occlusive disease. There was no decrease in open aortic operations in this group (R2 = 0.00; P = .95). The endovascular aortic case volume among graduating VSRs included 94.4 ± 10.7 total cases, which increased by +3.0 cases annually (R2 = 0.85; P < .0001). These procedures included 46.5 ± 3.9 EVARs, 15.8 ± 2.9 thoracic endovascular aneurysm repairs, and 32.1 ± 10.9 aortoiliac angioplasty and/or stenting operations. Conclusions: Contrary to prior studies, open and endovascular aortic training among vascular trainees is more robust than previously reported. There does not seem to be a meaningful decrease in open aortic case volume among graduating trainees, and endovascular aortic experience continues to increase each year. This finding suggests that the current training paradigms continue to provide a well-rounded foundation in both open and endovascular aortic procedures.
