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Barriers To Routine Use Of Mini-incision Carotid Endarterectomy; Results Of An SCVS Survey
Keerthivasan Vengatesan, MD, Ronald Truong, MD, Kyle J. Thompson, PhD, Alan M. Dietzek, MD.
Danbury Hospital, Danbury, CT, USA.
OBJECTIVES: Carotid endarterectomy (CEA) remains the gold standard for treating carotid atherosclerotic disease, exhibiting low morbidity and mortality rates. Mini-incision CEA (MI-CEA), utilizing incisions <5cm, has demonstrated benefits in reducing post-operative morbidity, pain, and improving aesthetics. Despite these advantages and the current trend towards minimally invasive procedures, most vascular surgeons continue to perform CEA with traditional 10-15cm incisions. This study aims to identify the factors that a sample of practicing U.S. vascular surgeons consider barriers to adopting MI-CEA.
METHODS: We designed a survey that was distributed nationally to practicing vascular surgeons who are members of the Society for Clinical Vascular Surgery (SCVS), regarding their experiences with MI-CEA. Questions focused on whether they perform MI-CEA, use of adjunctive measures (e.g. shunts), as well as examined what factors precluded surgeons from performing MI-CEA (not taught in training, doesn’t provide adequate surgical exposure, etc). Results were analyzed using descriptive statistics, and subgroup analyses were performed looking at relationships between various respondent characteristics (e.g. years in practice, taught in training) and frequency of MI-CEA.
RESULTS: Our MI-CEA survey was sent to 1110 SCVS members of which 146 (13.1%) responded. 85% of respondents trained in a conventional fellowship, and years in practice ranged from 2 months to 53 years, with a median 14 years in practice. MI-CEA was performed at least once by 65.8% of respondents and in 19.2% of respondents, MI-CEA was always performed. Respondents who performed MI-CEA less frequently were significantly more likely to report that it provides less exposure (p<0.0001) and that patients are unconcerned about incision size (p<0.0001). Only 31.5% of respondents were trained to perform MI-CEA prior to beginning practice, however those surgeons were significantly more likely to have performed MI-CEA in practice (p<0.0001). Additionally, surgeons who always performed MI-CEA with patch angioplasty were significantly more likely to do so even in patients with higher-risk features (e.g. high bifurcation, short or obese neck, redo surgery) (p<0.0001), although this was not observed in those who always utilized shunts during MI-CEA (p=0.1099)
CONCLUSIONS: While the majority of SCVS respondents have performed MI-CEA at least once in their practice careers, most do not perform it routinely. This study also shows that greater exposure to MI-CEA during training may dispel perceived limitations to this approach and achieve wider adoption.
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