Graduating vascular surgery trainee proficiency in endovascular and open peripheral revascularization procedures

Endovascular interventions for peripheral artery disease have increased in prevalence over time given the inherent benefits of minimally invasive approaches. Although it is essential that vascular surgery graduates are facile with endovascular techniques, the results of the BEST-CLI (Best Endovascular vs. Best Surgical Therapy in Patients With Critical Limb Ischemia) trial highlight the equivalent importance of ensuring trainee competence in open skills. Recent studies demonstrate increasing case volume of both endovascular and open procedures during vascular surgery training. Case volume is merely a surrogate marker for competence, however, and the objective competence attained by trainees at the time of graduation is unknown. We sought to investigate operative autonomy and competence of graduating vascular surgery trainees performing endovascular as compared with open peripheral vascular revascularization procedures.

Operative performance and autonomy ratings for infrainguinal endovascular and open revascularizations from the Society for Improving Professional Learning Operative application database were collected for all vascular surgery participating institutions from 2018 to 2023. The distribution for autonomy and performance ratings were determined by training level for endovascular and open procedures, respectively. Mixed effects logistic regressions were conducted to estimate the predictive association between procedure type and autonomy and performance assessment, adjusting for training level and case complexity. Subsequently, the estimated model was applied to predict the probability of a graduating trainee being rated as meaningfully autonomous or competent while performing endovascular and open procedures across various case complexities.

Sixty-nine residents from 23 programs (12 fellowship, 11 residency) were assessed on 706 revascularization procedures (n = 383 endovascular; n = 323 open). When controlling for training level and case complexity, there were no differences in autonomy (odds ratio [OR], 1.11; 95% confidence interval [CI], 0.62-1.99) or competency assessment (OR, 0.86; 95% CI, 0.46-1.59) for endovascular, as compared with open, peripheral revascularization procedures. For average complexity procedures, the predicted probability of a trainee being assessed as competent and autonomous at the time of graduation was high (competent: 88% endovascular, 86% open; autonomous: 96% endovascular, 97% open). The predicted probability of competence and autonomy for complex procedures was lower, but remained similar between groups (competent: 73% endovascular, 70% open; autonomous: 92% endovascular, 92% open).

There is no difference in the graduating level of autonomy and competence of endovascular as compared with open peripheral revascularization procedures for vascular surgery trainees. These findings suggest that vascular surgery trainees enter independent practice with adequate proficiency to use the full scope of techniques to care for patients requiring peripheral revascularization procedures.