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Training In Complex Open Aortic Surgery Is Fading: A Two-decade Analysis Of Vascular Surgery Trainees In The United States
Mohammed Hamouda, MD1, Eastern Kang, PhD
1, Benjamin J. Pearce, MD
2, Adam W. Beck, MD, FACS
2, J. Westley Ohman, MD
3, Mahmoud B. Malas, MD, MHS, FACS
1.
1University of California San Diego, La Jolla, CA, USA,
2University of Alabama at Birmingham, Birmingham, AL, USA,
3Washington University, St. Louis, MO, USA.
OBJECTIVES: Open aortic surgery is increasingly limited to endograft explants, infections, and complex reconstructions unsuitable for EVAR. As these cases grow more challenging, ensuring adequate training in complex open aortic surgery is more critical now than ever. We report national trends in complex open aortic operative volumes among vascular surgery trainees in the United States.
METHODS: Accreditation Council for Graduate Medical Education (ACGME) reports were reviewed for all complex open aortic operations performed by graduating vascular surgery fellows (VSF) from 2000-2001 to 2023-2024 and integrated residents (VSR) from 2012-2013 to 2023-2024. Complex aortic operations include open repair of suprarenal, thoracic, and thoracoabdominal aneurysms, aorto-enteric fistulas and explantation of infected grafts. A Pruned Exact Linear Time method was used to find pattern change points in volume of complex open aortic cases over time, and Bayesian Information Criterion was implemented to assess model goodness of fit.
RESULTS: A significant decline in complex open aortic volume was observed among vascular surgery trainees over the past two decades. Among VSF, the total case volume dropped from 11.0 in 2001 to 5.7 in 2024 (Fig). The change point happened in 2009, when the mean volume decreased from 10.8 cases before 2009 to 8.1 (95%CI: 7.7-8.5). A second change point occurred in 2022, with a decrease to 5.7 cases (95%CI: 4.9-6.5). For VSR, the average volume dropped from 14.0 in 2013 to 6.4 in 2024. The respective change point was observed after the first graduating class of 2013, with the mean complex aortic volume declining to 7.2 cases (95%CI: 6.6-7.8).
CONCLUSIONS: Exposure of VSF and VSR to complex open aortic surgery has declined roughly by half, coinciding with increasing procedural complexity. While one might argue that advanced aortic fellowships could further concentrate case exposure at certain institutions, these data underscore the need to carefully examine training pathways. Trainees should weigh their career aspirations in open aortic surgery when selecting programs, as opportunities for high-volume exposure are becoming increasingly limited.
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