Summary
Background
Carotid endarterectomy (CEA) is regarded as a standard procedure in vascular surgery (VS), but training in CEA is often withheld, because an inferior outcome is feared. Yet, VS training guidelines require minimum caseload experience as the primary operator and/or first assistant for training recognition.
Methods
Retrospective analysis of the vascular database of a university based tertiary care center. Training procedures were defined as procedures performed by a trainee vascular surgeon under supervision of a vascular surgeon; teaching procedures as procedures performed by a vascular surgeon assisted by a trainee. All other procedures were routine.
Results
From February 2002 to April 2011 nine VS trainees performed 816 CEAs either as primary surgeon (n = 353, 43 %) or as first assistant (n = 463, 57 %). A total of 244 months of VS training was evaluated. The average number of CEAs was 1.8 as primary operator and 3.9 as first assistant per month. There was no significant difference in the incidence of perioperative stroke and death between patients undergoing CEA performed by VS trainees or by senior surgeons.
Conclusions
A VS trainee can expect to perform an average of 50 or more CEAs as primary operator and 80 or more CEAs as first assistant during a training period of 36 months. This exceeds the numbers required by the Austrian Medical Council and the European Vascular Board. There was neither an inferior overall outcome nor a higher complication rate between patients undergoing CEA performed by trainees as primary operator or as first assistant.
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References
Lutz HJ, Michael R, Gahl B, Savolainen H. Is carotid endarterectomy a trainee operation? World J Surg. 2009;33:242–5.
Sandermann J, Panduro Jensen L. The Danish specialist training in vascular surgery. Eur J Vasc Endovasc Surg. 2002;23:353–7.
Pai M, Handa A, Hands L. Adequate vascular training opportunities can be provided without compromising patient care. Eur J Vasc Endovasc Surg. 2002;23:524–7.
Bradbury AW, Brittenden J, Murie JA, Jenkins AM, Ruckley CV. Supervised training in carotid endarterectomy is safe. Br. J. Surg. 1997;84:1708–10.
Stone ME, Kunjummen BJ, Moran JC, Wilkerson DK, Zatina MA. Supervised training of general surgery residents in carotid endarterectomy performed on awake patients under regional block is safe and desirable. Am Surg. 2000;66:781–6.
Naylor AR, Thompson MM, Varty K, Sayers RD, London NJ, Bell PR. Provision of training in carotid surgery does not compromise patient safety. Br J Surg. 1998;85:939–42.
Mas JL, Chatellier G, Beyssen B, EVA-3S Investigators. Carotid angioplasty and stenting with and without cerebral protection: clinical alert from the Endarterectomy Versus Angioplasty in patients with Symptomatic Severe Carotid Stenosis (EVA-3S) Trial. Stroke. 2004;35:18–20.
Lamont PM, Scott DJ. The impact of shortened training times on the discipline of vascular surgery in the United Kingdom. Am J Surg. 2005;190:269–72.
Kaafarani HM, Itani KM, Petersen LA, Thornby J, Berger DH. Does resident hour reduction have an impact on surgical outcomes? J Surg Res. 2005;126:167–71.
Beard JD, Choksy S, Khan S. Assessment of operative competence during carotid endarterectomy. Br J Surg. 2007;94:726–30.
Austrian Society for Vascular Surgery. Available http://www.vascsurg.at/oeggweb/ausbildungsordnung.html. Accessed:
Liapis CD, Bell PR, Mikhailidis D, et al. ESVS Guidelines. invasive treatment for carotid stenosis: indications, techniques. Eur J Vasc Endovasc Surg. 2009;37(4 Suppl):1–19.
Brott TG, Halperin JL, Abbara S, et al. ASA/ACCF/AHA/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the management of patients with extracranial carotid and vertebral artery disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Neuro-Interventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Developed in collaboration with the American Academy of Neurology and Society of Cardiovascular Computed Tomography. J Am Coll Cardiol. 2011;57:e16–94.
Archie JP. Prospective randomised trial of carotid endarterectomy with primary closure and patch reconstruction: the problem is power. J Vasc Surg. 1997;25:1118–20.
Reigner B, Reveilleau P, Gayral M, Papon X, Enon B, Chevalier JM. Eversion endarterectomy of the internal carotid artery: midterm results of a new technique. Ann Vasc Surg. 1995;9:141–6.
Rijbroek A, Wisselink W, Rauwerda JA. The impact of training in unselected patients on mortality and morbidity in carotid endarterectomy in a vascular training center and the recommendations of the European Board of Surgery Qualification in Vascular Surgery. Eur J Vasc Endovasc Surg. 2003;26:256–61.
Gelabert HA, Moore WS. Carotid endarterectomy: current status. Curr Prob Surg. 1991;28:181–262.
Sajid MS, Vijaynagar B, Singh P, Hamilton C. Literature review of cranial nerve injuries during carotid endarterectomy. Acta Chir Belg. 2007;107:25–8.
Schauber MD, Fontenelle LJ, Solomon JW, Hanson TL. Cranial cervical nerve dysfunction after carotid endarterectomy. J Vasc Surg. 1997;25:481–7.
Shah DM, Darling III RC, Chang BB, et al. Carotid endarterectomy by eversion technique. Its safety and durability. Ann Sur. 1998;228:471–8.
Assadian A, Senekowitsch C, Pfaffelmeyer N, Assadian O, Ptakovsky H, Hagmüller GW. Incidence of cranial nerve injury after carotid eversion endarterectomy with a transverse skin incision under regional anaesthesia. Eur J Vasc Endovasc Surg. 2004;28:421–4.
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Metzger, P., Aspalter, M., Guggenbichler, S. et al. Case numbers in carotid surgery training can be accomplished and are not associated with an inferior outcome. Results of a university based tertiary care center study. Eur Surg 46, 239–243 (2014). https://doi.org/10.1007/s10353-014-0274-8
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DOI: https://doi.org/10.1007/s10353-014-0274-8