The Importance of Venous Case Requirements for the Vascular Trainee
By: Steven D. Abramowitz, MD and Angela A. Kokkosis, MD
The Mount Sinai Medical Center, New York, NY
In 2005, integrated vascular surgery residency (0+5) programs became the fourth approved training pathway granting a primary certificate in vascular surgery from the American Board of Surgeons. This novel paradigm represents a modern approach to vascular surgery training. Aside from shortening total training time, the model allows for a greater amount of time dedicated to comprehensive vascular education. However, despite this progressive paradigm, training requirements remain antiquated.
Program Requirements for Residency Education in Vascular Surgery are set forth and approved by the Accreditation Council for Graduate Medical Education (ACGME). Currently, 0+5 trainees are required to complete a total of 500 vascular cases, with a minimum of 250 being major vascular cases in seven defined operative categories (Table 1).1 It is readily apparent that only arterial work is considered under major vascular cases. Open venous cases are categorized as “minor open” and have no defined case distribution or procedural requirements.
This system is disadvantageous to both the Society for Vascular Surgery (SVS) and trainees. For the SVS, published guidelines by the Clinical Practice Council established obligatory areas of advanced knowledge and experience of vascular surgeons.2 These guidelines hold vascular surgeons accountable for open and endovascular treatment expertise in venous disorders of the neck, chest, abdomen, pelvis and upper and lower extremities.
A lack of venous operative objectives and categorized venous operative goals present challenges to the success of the training paradigm. Without graduation requirements documenting technical exposure to these procedures in defined categories, the SVS fails to translate its clinical practice goals to its educational mission. For surgical trainees, case exposure is the foundation of guaranteed technical competency. Defined major case categories ensure that trainees see an appropriate diversity of cases throughout their training regardless of trainee interest. In theory, 0+5 residents can complete their training with no guarantee of having participated in any open or endovascular venous cases.
Expanding the documentation of open and endovascular venous case exposure during training would modernize the current operative reporting system. It would allow the SVS to ensure vascular resident experience closely reflects modern practice expectations. Furthermore, it would enhance not just the 0+5 training experience, but also the experience of all vascular trainees, as it would guarantee a minimum technical and didactic exposure to open and endovascular venous procedures. This would add to the differentiation between vascular surgeons and other proceduralists in areas such as interventional cardiology or interventional radiology.
To modernize the current operative reporting standards, changes should be made to account for required open and endovascular venous case experience. Based on 0+5 resident experience at our institution, we recommend that current major case categories be supplemented with the designation of three major venous categories. We propose that venous case categorization not be based upon the differentiation between open and endovascular case type. Rather, these three designations should be based on the anatomic location of the treated disease process. This system would emphasize trainee exposure to venous pathology rather than specific treatment modalities. We propose the following additional major venous categories: Venous – Superficial System, Venous – Central Deep System and Venous – Peripheral Deep System.
The cases labeled as “Venous – Superficial System” would demonstrate trainee exposure to the treatment of the superficial venous pathophysiology in both the upper and lower extremity. This incredibly important category represents many of the cases that individual trainees may be performing in an office-based setting alone after graduation. While some cases may be considered cosmetic, such as the treatment of telangiectasias or reticular veins, documentation and requirement of formal supervision in treatment would differentiate our trainees from those in other specialties such as dermatology or plastic surgery, that seek to perform these procedures as well.
Diagnosis and management of varicose veins arising from the great saphenous or the small saphenous vein would also be included in the category. Motivation for varicose vein treatment may range from cosmesis to venous stasis ulcer management. However, procedural options remain relatively similar and include a variety of interventions e.g. sclerotherapy, catheter-based ablative procedures and stab phlebectomy. Documentation of operative volume in this category would also indirectly ensure that the graduating vascular trainee has had appropriate exposure to understanding the indications and merits of the varying treatment modalities. As more practices seek to diversify procedural volume and perform lucrative superficial venous work, structured training in this area seems paramount.
“Venous – Central Deep System” would encompass cases pertaining to centrally located venous pathology. Beyond the insertion of inferior vena cava filters for venous thromboembolism prevention, trainees should be responsible for demonstrating treatment exposure to a range of centrally occurring conditions. Cases in this category should allow trainees to show exposure to the open and endovascular management options of superior vena cava syndrome, acute iliofemoral deep vein thrombosis, chronic iliofemoral venous occlusion, etc. Treatment of these conditions represents unique endovascular and open skill sets for trainees. For example, the sizing considerations of a stent being deployed in the left iliac vein for the treatment of May-Thurner are unique and integral to preventing central stent migration.
Technical skills in the management of peripheral deep venous disease under “Venous – Peripheral Deep Venous,” would reflect exposure to thrombolysis, vein valve reconstruction, venous bypass, venoplasty and venous stenting. Each of these treatment modalities, be it treatment for thoracic outlet syndrome or post-thrombotic syndrome, require unique anatomic understanding, intra-operative radiographic interpretation and operative skills. Understanding the indications for and the operative steps required to treat the plethora of conditions in this anatomic distribution requires a minimal level of exposure. Residents at our institution perform dozens of cases in this proposed category each year. However current case standards do not allow for them to easily demonstrate their growing competency.
Adopting simple changes in the reporting standards for venous interventions would further modernize an already progressive training paradigm. Emphasis on venous case exposure in training would greater reflect the distribution of cases in a modern vascular surgery practice. It would help set our trainees apart from other specialties performing venous work. More importantly, it would help ensure continuity of excellence in our society by generating future surgeons with a wide breadth and depth of operative exposure in a formal training program.
- Accreditation Council for Graduate Medical Education (ACGME). “ACGME Program Requirements for Graduate Medical Education in Vascular Surgery.” Approved: September 29, 2013; effective: July 1, 2014.
- Calligaro KD, Toursarkissian B, Clagett GP, Towne J, Hodgson K, Moneta G. Guidelines for hospital privileges in vascular and endovascular surgery: Recommendations of the Society for Vascular Surgery. J Vasc Surg 2008; 47:1-5.