Current graduates from both vascular surgery residency and fellowship programs are well prepared for surgical practice in aortic disease whether they are performing open repair or endovascular therapy, contrasting with research indicating that trainees are entering the workforce with inadequate experience of open aortic repair. That is the main finding of a new study set to be presented at the 2025 annual meeting of the Southern Association for Vascular Surgery (SAVS) in St. Thomas, the U.S. Virgin Islands (Jan. 22–25).
The analysis of Accreditation Council for Graduate Medical Education (ACGME) reports from 2013–2023 adds a counterweight to the increasingly accepted wisdom that current vascular fellows are graduating with less than five open abdominal aortic aneurysm (AAA) repairs on their docket when they complete training, according to senior author Young Kim, MD, an assistant professor of surgery at Duke University School of Medicine in Durham, North Carolina.
Crucially, Kim highlighted that trainee experience was robust across the breadth of open aortic cases, not only those which involve aneurysm repair.
“An open aorta is an open aorta, whether it is for occlusive disease or an infected aorta,” he tells Vascular Specialist. “There are a lot of very similar principles between the different types of aortic operations, but the well-cited study quoting the five-open-aortas statistic pertained only to open AAA repairs, and that was back in 2014, and looked at Medicare beneficiaries.”
Young and colleagues found that over the 11-year period of their analysis, the mean aortic case volume among graduating vascular surgery fellows and residents were 118.8 and 130.5, respectively.
The open aortic experience comprised 32.9 cases among fellows, including 17.5 aneurysm repairs and 15.5 operations for aortic occlusive disease, with a <1% decline in open aortic operations.
Endovascular aortic volume among fellows included 85.8 total cases, which increased by 1.5 each year. These included 42.2 endovascular aneurysm repairs (EVARs), 15.8 thoracic EVARs (TEVARs), and 27.8 aortoiliac angioplasty and/or stenting operations.
Among graduating residents, open aortic experience comprised 36.1 cases, including 18.3 aneurysm repairs and 17.7 operations for aortic occlusive disease, with no decline in open aortic operations. Residents’ endovascular aortic case volume included 94.4 total cases, which increased by three annually. These included 46.5 EVARs, 15.8 TEVARs, and 32.1 aortoiliac angioplasty and/or stenting operations.
“Having personally graduated from fellowship three years ago, and speaking with many other co-fellows and fellows in training at the moment, we all know this intrinsically to be not true for ourselves—that we graduate prepared for surgical practice in open AAA repairs,” Kim explains.
“I’m not sure how that speaks to the national trends, but it is hard to hear that as somebody who recently has gone through training, having other people tell me that we are not prepared for surgical practice in open AAA repairs. That was the impetus for taking a look at the data. Specifically, we wanted to look at the ACGME case logs because these are self-reported cases by each of the trainees during their training, so reliable in that regard.”
The types of open repairs included in the analysis ranged from infrarenal, suprarenal, thoracoabdominal and thoracic aneurysms, to aortoiliac bypasses and aortofemoral bypasses or resections for occlusive disease.
“Open aortic case volume for both residents and fellows was somewhere between 30 and 40 by the time of graduation,” Kim says. “That number didn’t really change much over the years, which really speaks to the consistency and reliability of the data for total open aortic case volume, so it’s not as if this data is unreliable.”
Still, as trainees enter practice, Kim adds, “the most important thing is having a supportive senior partner because, though you may have done a number of aortic cases during training, it is really only during the first few aortic cases you do in practice when the training wheels come off.”
