Endocompetence Leads to Increasingly Complex Cases without Sacrificing Safety in a Surgeon Based Endovascular Training Program

Jason Alexander, MD, Vascular surgery, university of southern california, Los angeles, CA; Fred Weaver, MD, Los angeles, CA; Doug Hood, Los angeles, CA; Vince Rowe, MD, Los angeles, CA; Steven Katz, MD, Los angeles, CA; Albert Yellin, MD, Los angeles, CA;

Purpose: Critically evaluate results and complications of an endovascular training program at an academic medical center designed and established solely within a vascular surgery service. Determine whether endovascular strategies change as endocompetence is gained within a vascular surgery training construct.
Methods: Review of all percutaneous endovascular procedures (PEP) from 2000-2004 performed exclusively by vascular surgeons at a university program. Procedures were then designated as exclusively diagnostic, interventions and complex interventions (defined as procedures involving multiple infrainguinal stents, renal or visceral interventions, brachiocephalic interventions, thrombolysis or embolization). Complications and mortality were tabulated for these procedures.
Results: Over the study period, the group performed 1201 PEP. In 2000, seventy-four procedures were performed primarily by one fellowship trained surgeon. Only six complex interventions were performed that year. By 2004, four surgeons performed 361 procedures, having obtained their skills in a preceptor construct program. Complex interventions were performed in 100 patients with increased comfort with endovascular procedures.
The major complication rate, as defined by the Society of Interventional Radiology clinical practice guidelines, for 1201 PEP was 1%. Five patients developed pseudoaneurysms requiring invasive therapy, five patients developed peripheral ischemia requiring operative intervention, one patient had retroperitoneal bleeding requiring multiple transfusions. There were four periprocedural deaths (three due to cardiac events and one due to sepsis following access complication). Despite an increase in the number and complexity of PEPs the annual complication rate decreased.

Conclusions: The acquisition of diagnostic and interventional endovascular skills can be obtained exclusively in a vascular surgery department. As surgeons gain endocompetence, the number and complexity of percutaneous interventions rapidly expands. The development of endovascular skills coupled with a formal background in vascular medicine allow surgeons to perform increasing numbers of complex arteriographic procedures without increasing the rate of complications.