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Objective: The reported impact of trainees on major surgical procedures has been variable. Our goal was to assess the effect of involvement of senior residents and fellows on perioperative outcomes after endovascular (EVAR), open infrarenal (OIAR), and open juxtarenal aortic aneurysm repair (OJAR).
Methods: Patients undergoing EVAR, OIAR, and OJAR were identified in the National Surgical Quality Improvement Program (NSQIP) from 2005-2012. Patient characteristics of attendings with and without trainee (PGY 4 and higher) were compared. To compare outcomes, 1:1 propensity matching based on clinically important and significantly different at 0.2 level factors and multivariable analyses adjusting for the same factors were used.
Results: There were 16,977 patients identified - 12003 EVAR, 3655 OIAR, and 1319 OJAR. Case coverage was 48% attending only (AO), 25% senior resident (SR), and 37% fellow. Comparing to AO patients, EVAR patients with fellows and SR were more likely to be attended by vascular surgeons (VS) (98% vs. 95%), non-Caucasian (9% vs. 7%), functionally dependent (5% vs. 4%), emergent (7% vs. 5%), had a recent MI (1.4% vs. 1%), and ESRD (1.5% vs. 1%); OIAR patients - more likely to be attended by VS (98 vs. 92%), functionally dependent (15% vs. 11%), had ruptured aneurysm (22% vs. 18%); OJAR patients - more likely to be attended by VS (98% vs. 93%), but less likely ruptured (11% vs. 19%) and with ESRD (1% vs. 3%) (P<.01). Propensity matching and multivariate analysis showed that trainee involvement for EVAR was associated with increased operative time (Means Ratio 1.16, 95% CI 1.12-1.18, P<.01) (173 vs. 149 min). For OIAR and OJAR there was an increase in bleeding complications (OR 1.2, 1.03-1.5, and OR 1.4, 1.06-1.9, P<.01), operative time (Means Ratio 1.18, 1.15-1.2, P<.01 and 1.28, 1.22-1.35, P=.01) (217 vs. 186 min and 265 vs. 213 min), and length of stay (Means Ratio 1.15, 1.09-1.2 and 1.11, 1.02-1.21 P=.01) (median 8 vs. 7 days). There was no significant increase in death, cardiac, pulmonary, renal, septic, or wound complications.
Conclusion: Trainee involvement is associated with increased operative time for EVAR, OIAR, and OJAR. Furthermore, in OIAR and OJAR trainee involvement is associated with bleeding complications and increased LOS. However, despite this, there is no significant difference in perioperative mortality or morbidity across organ systems.