Just a few years ago, it was commonly accepted that training in complex endovascular aortic operations (e.g. physician-modified endografts [PMEGs], use of in-situ laser fenestration, redo-branched aortic interventions etc.) depended heavily on the location and practice of the institution where residents/fellows trained.
If vascular surgeons at a particular institution participated in these procedures, it was often with multiple vascular surgery attendings scrubbed or with interdisciplinary participation from either interventional radiology or cardiothoracic surgery. Trainees at high-volume institutions had the benefit of being able to participate in these procedures, but expertise did not necessarily affect board certification or job availability.
This is not to say either of those outcomes are affected by comfort with complex endovascular aortic procedures today. However, with the landscape of who we treat and what we treat them with constantly shifting, it’s an important aspect of training to re-assess. New data on long-term follow up after acute dissection now suggests early intervention may have benefit to aortic-specific survival and delayed disease progression.1 Publications have suggested a higher incidence of branch involvement in younger patients presenting with acute aortic dissection.2 And survival rates predict over 70% survival of both those fixed and unfixed, suggesting more chronic dissections may present requiring further intervention.
Even in the abdominal aneurysm sphere, an increasing number of commercially available branched devices have been placed in patients that may eventually require repair. And proximal degeneration of prior infrarenal repairs continues to necessitate proximal branched endograft extensions to achieve appropriate seal. Prior branched interventions such as snorkels—even physician-modified endografts—are not immune to endoleak and need for revision of branched interventions.
Not all trainees want to or plan to participate in complex endovascular aortic interventions in their future practice. But that does not negate the increased interest in those who can demonstrate competence in “backtable” endograft modification or comfort with in-situ laser fenestration, endoleak evaluation/repair, or deployment of off-the-shelf branched endografts. From speaking to several graduates who went to practice at mainly community or private settings, even they have been asked to participate or manage patients requiring “complex endovascular aortic techniques” because of their training background/procedural comfort. It’s clear that the patient need is present; with continued shortage in vascular surgeon availability, it makes sense increasingly complex aortic pathology has been identified at non-academic practices. It’s only time before these patients find a practitioner who can offer them an appropriate intervention, which could now be dictated by graduating trainee comfort with these practices.
A few years back, trainees were advised to interrogate program comfort with open intervention to ensure they received a well-rounded surgical training. As the landscape of vascular surgery continues to change, it may now be important for trainees to determine if they will have adequate exposure to complex aortic techniques, especially if they desire to work at a high-volume academic or community practice with general call. Though, at this current moment, comfort with these techniques do only serve to benefit trainees in what they can offer to their future practices.
References
- Nienaber CA, Kische S, Rousseau H, Eggebrecht H, Rehders TC, Kundt G, Glass A, Scheinert D, Czerny M, Kleinfeldt T, Zipfel B, Labrousse L, Fattori R, Ince H; INSTEAD-XL trial. Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial. Circ Cardiovasc Interv. 2013 Aug;6(4):407–16.
- Wu S, Cao C, Lun Y, Jiang H, Wang S, He Y, Sun J, Li X, He Y, Huang Y, Chen W, Xin S, Zhang J. Age-related differences in acute aortic dissection. J Vasc Surg. 2022 Feb;75(2):473–483.e4.
Saranya Sundaram, MD, is a fourth-year integrated vascular surgery resident at the Medical University of South Carolina (MUSC) in Charleston.
