Beyond the Crossroads

Who Will be the Caretakers of Vascular Injury Management?

The optimal care of the patient with a vascular injury is a critical need in the modern era and beyond. Endovascular capabilities show promise, but are presently employed on a limited scale. Open skills will continue to be required but are increasingly difficult to acquire and maintain. Limited course offerings for Trauma/Acute Care Surgeons must be followed by more substantial changes in both training and guidelines for referrals within trauma systems.

Vascular injuries cause significant morbidity and mortality, and optimal care requires specific expertise and training. Unfortunately, initial acquisition of these skills and maintaining proficiency is an increasing challenge with these relatively uncommon injuries. There is a crossroads where we must choose to either abdicate all vascular trauma care to vascular surgeons or maintain vascular skills within the group of surgeons called on to provide trauma care. One could argue each path has merits. We are now beyond that crossroads and have failed to design a system that meets the need.

This problem is worsening. Deaths from trauma increased by 22.8% in the last decade with the majority of preventable causes of death from hemorrhage within 2.5 hours of injury.^1,2 A significant number of these deaths from bleeding involved a major vascular injury. Although there is an obvious need for readily available surgical providers to stop hemorrhage in the earliest phases after injury, there are real barriers to defining which providers are the best choice.

The continued shift in elective vascular surgery towards endovascular care, has resulted in decreased experience with the open surgical principles that remain mainstays of emergent operations for vascular trauma.^3–6 As a result, current graduating general surgery and vascular trainees, and practicing vascular surgeons are increasingly less well-prepared to rapidly achieve open exposure and control of injured vessels than previous generations of surgeons. In addition, practicing trauma surgeons in major civilian trauma centers also have increasingly limited experience with open vascular repair relative to even 2 decades ago, when trauma surgeons did most emergent vascular surgery.⁷ This loss of skill in open vascular management is perhaps most concerning in rural and military environments where endovascular options for trauma are not as readily available.

This will only worsen in the future. Within 5–10 years, an entire generation of civilian trauma surgeons experienced in open trauma vascular skills will leave active practice. As a result, much of the practical knowledge that these individuals have accumulated will be lost unless there is some mechanism to preserve and transmit it to future generations of trauma surgeons. Compounding the issue, there is also an emerging shortage of vascular surgeons in the United States, with very few of these specialists who incorporate the practice of general or trauma surgery into their active practices.

The recognition of vascular surgery as a unique credentialed specialty in the late 1990's started a schism separating the General/Trauma Surgeon from Vascular Surgery. This has continued, with the majority of vascular surgeons less engaged in the routine care of trauma patients. Simultaneously, trauma surgeons at many institutions are less capable of providing vascular trauma care and must increasingly rely on their vascular surgery colleagues to provide services no longer within their skillset. Many surgeons taking trauma call no longer have vascular privileges, and most young attending surgeons feel incapable of caring for vascular injury. In many instances, an unsupervised vascular fellow with the least trauma experience is the first consultant to provide assistance for vascular injuries. These vascular trainee “first responders” are the same chief residents who have received inadequate experience during their general surgery training due to decreased training requirements for vascular surgery procedures.^3–6 As vascular practitioners become more focused on elective endovascular procedures, they often develop “lesion vision,” similar to “tunnel vision,” focusing on obtaining gratifying before/after images, whereas failing to use the patient's other injuries or physiology in the decision making of how the vascular injury should be managed. Although advanced imaging and hybrid environments are promising, the focus on optimal images can cloud obvious indications for conversion to an open operation. Failure to fully prepare and drape the trunk and extremities to allow for rapid default for open proximal control or a later fasciotomy are classic examples.

Despite the potential initial promise of endovascular technologies for select trauma applications, the majority of contemporary vascular injuries continue to require open treatment.⁸ As open experience with vascular trauma has diminished, several concerning trends have emerged. Patients with injuries that may best be treated by open surgery receive endovascular care because that is what the local vascular surgeon knows. In addition, patients once effectively treated at rural and suburban centers by surgeons seasoned in open vascular repair are now transferred to a tertiary center. Even in the most mature trauma system, transfers take time. Vascular injuries are among the most time-sensitive conditions as patients can bleed out quickly and limb threatening ischemia occurs after several hours. We risk having generations of surgeons caring for trauma patients who cannot do even the most initial lifesaving vascular procedures like obtaining inflow control to prevent exsanguination or placing a temporary shunt to prevent distal ischemia.

The growth of trauma capabilities is an admirable testament to the efforts of the American College of Surgeons Committee on Trauma to improve outcomes after injury; however, the associated proliferation and “over-designation” of major trauma centers have resulted in the dilution of experience and opportunity for learning, and other potential problems. As a result, knowledge is becoming limited to senior surgeons, even at the busiest trauma facilities. The American College of Surgeons Committee on Trauma has recognized the challenge of “over-designation” as in issue for a variety of types of severe trauma and continues to work diligently in an attempt to reverse these developments, but with limited success to date. This trend in trauma center growth must be considered carefully in the future design of optimal trauma systems.

REVERSING THE CRISIS?

Some innovations to confront these challenges have been developed and employed with success. The American College of Surgeons Advanced Surgical Skills for Exposure in Trauma course is an outstanding method to teach open trauma vascular exposures. The Endovascular Skills for Trauma and Resuscitative Surgery course, currently undergoing revision, is an excellent offering designed to provide both open and endovascular trauma skills to acute care surgeons. Finally, the Basic Endovascular Skills for Trauma course of the American College of Surgeons has taught the use of Resuscitative Endovascular Balloon Occlusion of the Aorta to hundreds of acute care surgeons. These efforts have been largely successful in promoting the acquisition of basic procedural knowledge for both open and endovascular skills among trauma surgeons. They are; however, limited. A 1 or 2-day course taken at some poorly defined interval is a disappointing proxy for real training that prepares a surgeon to deal with the broad range of vascular injuries. There is a need to better define for whom these courses should be compulsory and the frequency at which they should be taken as refreshers to insure currency in these critical skillsets.

PROVIDING FOR THE FUTURE: TRAINING CHALLENGES AND CONSIDERATIONS

The options to “fix” the problem of future training of vascular trauma skills are quite limited; however, there are several potential solutions to preserving optimal care for vascular injuries. First, new comprehensive training paradigms must be considered. A growing cadre of young trauma surgeons with an interest in vascular injury have already completed vascular surgery fellowships. This pathway is long and selects out only those individuals most interested in vascular injury. Other training pathways are less clear. Interested surgical trainees are forced to manufacture hybrid programs within traditional trauma and vascular training pathways, usually in select high volume institutions where the leaders understand their training and career desires. No certification exists for these individuals, likely limiting their ability to obtain specific hospital privileges. In addition, surgeons who pursue additional training after some years in practice are undoubtedly challenged by the financial ramifications of going from an attending surgeon salary back to that of a trainee. These considerations may limit the growth of this pathway to vascular trauma specialization.

Expansion of existing acute care surgery (ACS) fellowship training might prove a more reasonable pathway. Although the value of ACS training remains a topic of discussion, the current design does not provide sufficient experience to achieve real vascular expertise.^9,10. The development of specific “Trauma -Vascular Programs” or modification of existing ACS curriculum options to provide for expanded incorporation of vascular surgery exposure may be viable pathways to expose trainees to the necessary volume to reliably attain critical vascular skills. Although this pathway may not afford the true combined practice that would be available to those carrying dual certification by the American Board of Surgery, it may prove valuable in improving the endovascular skills and restoring open skills for a new generation of trauma/acute care surgeons. Joint collaboration between the American College of Surgeons and the Society of Vascular Surgery to provide guidance on the development and maintenance of these training platforms would likely be paramount to success.

Second, as the skillsets needed for optimal care of vascular injuries care in multiply injured patients are less available, there may be value in concentrating a subset of patients through formal regionalization protocols. Regionalization is already used for both medical and surgical conditions – including burns and traumatic brain injury. Vascular injury centers of excellence with resources and appropriate expertise would provide optimal vascular injury care for the truly complex injuries/patients. The ideal construct of such centers; however, requires unique considerations such as the establishment of some threshold for patient volume appropriate for optimal maintenance of skills. In addition, the services traditionally providing interventional and vascular/endovascular care in these centers will have to collaborate and define roles.

CONCLUSIONS

The optimal care of the patient with a vascular injury is a critical need in the modern era and beyond. Endovascular capabilities show promise, but presently on a limited scale. Open skills will continue to be required but are increasingly difficult to acquire and maintain. Limited course offerings for trauma/acute care surgeons must be followed by more substantial changes in both training and guidelines for referrals within trauma systems.