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Transcarotid Artery Revascularization Learning Curves Differ between Surgeon Experience Level.

Litton Whitaker1, Yana Etkin2, Pallavi Manvar-Singh2

  • 1Surgery Department, Nuvance Health, Danbury, CT.

Annals of Vascular Surgery
|September 28, 2024
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Summary

Surgeons performing transcarotid artery revascularization (TCAR) achieve significant technical proficiency, particularly reduced skin-to-skin and fluoroscopy times, after approximately 15 cases. This learning curve is independent of patient factors or anesthesia type.

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Area of Science:

  • Vascular Surgery
  • Interventional Cardiology
  • Surgical Education

Background:

  • Transcarotid artery revascularization (TCAR) is gaining traction due to its favorable perioperative outcomes.
  • Assessing the learning curve for TCAR is crucial for optimizing its adoption and ensuring patient safety.
  • Surgeon experience is a key factor in procedural efficiency and outcomes.

Purpose of the Study:

  • To determine the case number threshold for improved technical proficiency in TCAR.
  • To evaluate the impact of surgeon experience (≤10 vs. >10 years) on TCAR outcomes.
  • To analyze the relationship between case volume and procedural efficiency metrics.

Main Methods:

  • A retrospective analysis of 160 TCAR cases performed between 2017-2023 at four hospitals.
  • Technical proficiency was measured by skin-to-skin, fluoroscopy, and flow reversal times.
  • Linear mixed models analyzed outcomes, comparing surgeons with ≤10 and >10 years of experience at specific case milestones (1st, 5th, 10th, 15th).

Main Results:

  • Surgeons with less experience (≤10 years) frequently managed more complex cases, including those with hostile necks and contralateral occlusions.
  • While median outcome values did not differ significantly, linear mixed models revealed significant improvements for less experienced surgeons after the 15th case.
  • Junior surgeons demonstrated a 30% reduction in skin-to-skin time and a 51% reduction in fluoroscopy time compared to senior surgeons after 15 cases.

Conclusions:

  • Junior surgeons show significant improvement in TCAR efficiency after approximately 15 cases, matching or exceeding senior surgeon benchmarks.
  • This learning curve progression is not affected by patient complexity or anesthesia choices.
  • TCAR technical proficiency is attainable and improves with experience, supporting its wider implementation.