“I know I gotta get away and I know if I don’t, I’ll go out of my mind; better leave her behind with the kids, they’re alright, the kids are alright.” – Pete Townshend, The Who
Mankind harnesses the power of fire; the assembly line makes automobile travel feasible for the common person and aneurysms can be repaired with endografts. Maybe the latter does not quite have the impact on mankind as a whole but within the sphere of vascular surgeons, it certainly ranks up there with Neil Armstrong toeing the surface of the moon. And, as with all disruptive innovation (thanks Professor Christensen), there are always, always, unintended consequences. In the case of EVAR, this has come at the expense of the single greatest badge of honor carried by a vascular surgeon — the open aneurysm repair.
At the American College of Surgeons meeting in 2017, our colleagues from Michigan used Medicare claims data to demonstrate that in a four-year period (2010-2014), graduating vascular trainees saw a decline in median open AAA repairs of 10 to 6.4 and, further, that half (egads!) would graduate with less than five open AAA in their training. Much like the first person splashed with mud by a Model T, surgeons shouted at the passing endovascular revolution that we must put a stop to this menace. And the mud-stained clamoring persists to this day. But as a wise man once said, repeatedly, are we worrying about a problem we don’t have?
First, what is the number of open aneurysm repairs needed to be considered “proficient” at the procedure? Is it really the 10 in 2010? 20? 30? What are the components of aneurysm repair that are so critical to perform this hallmark feat of mankind? Is it the evaluation of a CT to know if it can be done and where the problems may lie? In the exposure of proximal and distal control? The ability to move the case along to avoid unnecessary insensible fluid loss and exposure of the patient to those dastardly foes sitting at the head of the bed doom scrolling Instagram while the patient slowly gets more and more tachycardic?
Lots of questions and many of the answers are uncomfortably gray and likely surgeon specific. I can only speak to my own experience. According to the ACGME case logs, I performed 42 open aneurysms of all types during my two-year fellowship (this doesn’t include the cases done as a surgery resident as those are not available online — evidently they burned all that parchment years ago). I can tell you for a fact as sure as the sun will rise tomorrow in the East and Coach K is the greatest NCAA basketball coach of all time, I did not sleep a wink the night before I did my first open aneurysm repair as faculty. Or my second, third and so on. And despite doing more open aortic cases in six months than I did in those two years of fellowship, I continue to learn things about aneurysm repair even to this day. One wise man taught me a nifty trick to staple the diaphragm when opening the chest and a different one told me never to operate on the aorta without talking to some family member first. A wise woman gave me some critical advice on suture technique and conduit choice in fixing a ruptured aneurysm in a 14-year-old. I haven’t really slept hard before any of those cases.
I would posit that proficiency in aneurysm repair is moving target and aspirational. IMHO (as the kids say), there is also a point at which you can only learn so much aortic surgery as a trainee. At some point, the hard lessons about retroaortic renal veins, mycotic fields and safely dissecting in redo cases comes with being the person whose name is on the consent. The good news is that we have help coming on the horizon. The advent of the entrustable professional activity (EPA) paradigm should provide a framework for providing this level of autonomy to trainees at high volume centers to have some of that critical attending level experience while still having a support structure to make mistakes.
Which brings us to our second point, not everyone is missing out on open aortic experience — and that is ok. In response to the outcry about trainees possibly graduating with less than five (egads! again) open aneurysm repairs, centers such as Boston University, Duke, UAB and the Cleveland Clinic have all published articles demonstrating that open aortic volumes are holding steady at more than 20 open repairs and, optimistically, are increasing if one incudes EVAR explant and open repair of occlusive disease at levels commensurate to the “golden age” of vascular fellowship before EVAR dominance. Some may argue that these papers represent a “flex” (as the kids say) and not “the real world” experience of vascular surgeons. However, Medicare claims data would argue otherwise. Consistently, EVAR represents > 80% of aneurysm repairs in the United States and that number has only risen to match the ability to rise up the aorta with branched and fenestrated devices.
As recent perusing of SVS Connect reveals, we actually all agree that being able to fix aneurysms open is the right thing to do for many patients, especially those with challenging anatomy and many years at risk. Even ChatGPT will tell you that EVAR dominates open repair in the short term by both complications and cost, but in the long game the costs of reintervention and surveillance combined with the complications and late aortic mortality makes open repair the more durable choice for patient living eight years. These cases should and can be done open. A solid open, non-re-operative aneurysm repair is a great case for a newly minted vascular surgeon to do — with their senior partner. It is my understanding that this has been the modus operandi for community practice since the inception of the vascular certificate in special training. All the other problems, mycotic, thoraco-abdominal and infected prior repairs, are best suited in centers who do these cases routinely anyway. Medicare claims and common sense would indicate that that is already being done.
Which brings us to our last point, you learn a lot more than just fixing an aneurysm when you do an open aneurysm repair. Amen and pass the communion plate. Absolutely, the role of the vascular surgeon in the modern American community is to be there to save a life when a trocar goes missing. Or to expose a spine so an orthopedist doesn’t biopsy the cava. I’ve got news for those not currently operating at major trauma centers; the modern vascular trainee is doing that, a lot. This isn’t your parent’s general surgery residency anymore. They have had their own disruptive events between non-operative trauma protocols and using the robot to do everything including entering their case logs from what I gather. The control and reconstruction of blood vessel injury is increasingly falling to the vascular team and almost exclusively the “intra-op” consult for bleeding.
Fortunately, this isn’t just the “back in my day” rantings of an aging aortic surgeon, our colleagues at LSU just presented this very data at the recent meeting of the SCVS. They looked at all things pertaining to blood vessels in the retroperitoneum — open AAA, thoraco-abdominal, aortobifems, mesenteric, bypass, spine exposures and trauma. Comparing trainees from 2021-2024 for the modern cohort against 2007-2010 as controls, the modern vascular integrated resident had 52.3 open aortic cases, the modern fellow 48.6 and the historic fellows 47.7.
So, maybe as The Who said, the kids are alright after all. Maybe the issue lies with how we see it, or as Cheap Trick would say, “Mommy’s alright, Daddy’s alright, they just seem a little weird.”
