In the Surgical Perspectives article, “Beyond the Crossroads: Who Will be the Caretakers of Vascular Injury Management,” published in the August edition of Annals of Surgery, DuBose et al1 share concerns regarding the current and future care of traumatic vascular injuries. The vascular surgery community and Program Directors in vascular surgery would like to comment on several assertions made by the authors, which includes a well-respected group of trauma surgeons, several of whom are also board-certified vascular surgeons.
Traumatic vascular injuries can result in significant morbidity and mortality, and as such, the optimal care of the patient with vascular trauma requires specific training and expertise. The tenets of vascular surgical teaching and practice are to provide comprehensive and lifelong care of patients with noncardiac vascular disease. This includes acquiring and utilizing advanced knowledge of all elements of the clinical evaluation and management of a patient with a vascular condition, incorporating noninvasive and invasive imaging, screening and surveillance, medical and critical care management, risk factor modification, and open and interventional techniques for patients with arterial, venous and lymphatic conditions.
As a whole, our specialty takes extreme pride in our ability to provide both open and endovascular treatment options that are grounded in evidence, improve outcomes, and align with our patients’ quality of life goals. Indeed, like trauma surgeons, approaching each patient with plans A, B, C, and D in mind is a central doctrine of our training. Our goal as vascular surgeons is always to provide the most efficient, beneficial, and durable procedure, understanding that sometimes an expeditious lifesaving treatment supersedes long-term durability, whether it be an endovascular or open intervention. Regardless of the technical approach employed, our core principles in vascular trauma are to provide rapid control of hemorrhage and restoration of perfusion to the affected region. These goals are designed to minimize blood loss, decrease transfusion requirements, mitigate injury to adjacent structures, limit ischemia/reperfusion injury, optimize limb salvage, and above all, save the patient.
ENDOVASCULAR APPROACHES TO VASCULAR TRAUMA
The use of endovascular techniques to treat vascular injury in the trauma setting is well-established. In an analysis of the National Trauma Data Bank, the use of endovascular procedures to treat traumatic vascular injuries increased significantly from 0.3% in 2002 to 9.0% in 2010 (P < 0.001), with injuries to the thoracic aorta and iliac arteries accounting for the majority of the increase.2 Notably, when outcomes were compared between matched patients undergoing open and endovascular procedures, patients who underwent endovascular procedures had significantly lower in-hospital mortality (12.9% vs 22.4%; odds ratio, 0.5; 95% confidence interval, 0.4–0.6; P < 0.001).2 In a subsequent analysis of patients sustaining inferior vena cava, abdominal aortic, or thoracic aortic injuries, the incidence remained constant from 2002 to 2014, but with decreasing mortality for blunt trauma (48.8% in 2002 to 28.7% in 2014; P < 0.001), and concomitant increasing use of endovascular procedures (1.0% in 2002 to 30.4% in 2014; P < 0.001).3 Furthermore, in the setting of solid organ and pelvic injury, an endovascular approach utilizing embolization is well-established, saving both the patient and the spleen.4 Finally, traumatic vascular injuries frequently involve the extremities, which are anatomic locations for which many Acute Care and Trauma Surgeons embrace the collaboration and assistance from their vascular surgeon colleagues.
VASCULAR SURGEONS: WELL-PREPARED PARTNERS
Vascular surgeons receive comprehensive training in the full range of endovascular and open techniques, as evidenced by ACGME case minimum requirements, as well as the content of the Vascular Surgery Qualifying and Certifying Exams. Over 15 years, from 1995 to 2009, there was a significant increase in the total number of operative cases reported to the American Board of Surgery - Vascular Surgery Board by both Qualifying and Recertifying Exam applicants.5 Importantly, the volume of open vascular surgical cases reported by vascular surgery fellowship graduates remained stable, suggesting that increasing employment of endovascular techniques has not had a negative effect on the open operative experience of today's trainees.5,6 Concerning the more recently established integrated vascular surgery residency paradigm, graduates have demonstrated comparable overall vascular surgery clinical experience to their fellowship-trained counterparts.7 The suggestion that vascular surgeons graduating today are less well prepared to care for traumatic vascular injuries is simply not supported by data.
We agree with DuBose et al that vascular patients are often transferred from rural and suburban centers to tertiary centers, sometimes with significant delays in reperfusion. Vascular trauma patients frequently sustain an extensive catalog of concurrent injuries, including orthopedic and neurologic, that often drive the transfer of patients to centers with higher levels of care. It may be valuable to investigate why patients with vascular trauma are transferred to tertiary high-volume centers; we welcome the opportunity to study this in collaboration with our trauma colleagues. It may be that tertiary centers, with ready access to all surgical specialties, offer more comprehensive care associated with better outcomes, and therefore provide the appropriate multispecialty team needed to manage complex traumatic injuries. This is certainly demonstrated for patients with traumatic aortic injuries. The perioperative mortality after TEVAR for traumatic aortic injury is significantly better at high-volume centers.8 We agree with the authors’ suggestion that there may be value in identifying which subset of patients would benefit from transferring from rural and suburban areas to tertiary centers through formal regionalization protocols. This does not, however, address the challenges inherent to providing initial management of complex vascular injuries in the rural settings where patients often present. The training of general and acute care surgeons to be prepared to provide frontline trauma care in rural settings is of critical importance and leaders in both general and vascular surgery must work together to ensure this unique workforce need is met.
TRAINING CHALLENGES AND CONSIDERATIONS
As vascular surgeons and program directors, we believe now is the time to work together to re-define competency goals for general surgeons and acute care/trauma surgeons in the care of vascular surgical patients and the conduct of vascular surgical interventions. The training paradigms available must reflect the desired competencies for surgeons once they are in practice. The ACGME-accredited Surgical Critical Care (SCC) fellowship requires the treatment of 200 critical care patients with no operative case minimums, making this training pathway potentially completely nonoperative. The American Association for the Surgery of Trauma (AAST)-accredited Acute Care Surgery fellowship denotes “essential” cases in vascular surgery to include the management of arterial injuries or occlusions, but only ten are required. Similarly, the AAST considers exposure of the brachial, femoral, popliteal, and infrarenal aorta “essential,” but requires only a few cases of each. Therefore, these training models, particularly SCC, rely heavily on the General Surgery Residency experience of the trainee.
General Surgery Residency requires just 50 vascular surgery cases, only 10 of which must be “exposure, endarterectomy, anastomosis” cases. Furthermore, the number of open arterial cases completed by graduating general surgery residents has declined significantly over the past 15 years, with the average number of vascular trauma cases at <2 since 2014.9 Thus, the training models presently in place for Trauma and Acute Care Surgeons do not reflect a goal for competency in the comprehensive management of traumatic vascular injuries. As suggested in the article, despite the quality of national society's courses, we believe only through ACGME and RRC accredited programming and rigor can surgeons be adequately trained to care for the complex vascular trauma patient.
The American Trauma Society and American College of Surgeons note that Level 1 and 2 Trauma Centers include 24-hour in-house coverage by general surgeons and prompt availability of care by a variety of specialties, including vascular surgery.10 Given the requirement to have vascular surgeons promptly available, it seems that a binary, all-or-none decision regarding “who takes care of vascular trauma” is not needed. When vascular and acute care / trauma surgery groups are working in harmony, particularly at the centers represented in this author group, the skillset of each surgeon can be capitalized upon to optimize patient care in a collaborative environment. The real issue is regional variation in the availability of vascular surgeons. To that end, the Association of Program Directors in Vascular Surgery is committed to tackling these issues and perhaps even further amplifying our curriculum to enhance and verify vascular trauma as an essential core competency of our specialty.
The true north that guides all of us as surgeons, regardless of our training paradigm or specialty, is the patient. We must come together in productive dialogue to improve surgical outcomes, set aside egos and biases, and focus on what is needed for the optimal care of our patients. The rapidly evolving and increasingly complex surgical and endovascular approaches that enhance patient outcomes also necessitate a team approach to trauma care delivery. So, the short answer to the surgical perspective question posed, “Who will be the caretakers of vascular injury management?” is, in our opinion, Vascular Surgeons in collaboration with Trauma Surgeons.
1. DuBose JJ, Morrison JJ, Scalea TM, et al. Beyond the crossroads: who will be the caretakers of vascular injury management? Ann Surg
2. Branco BC, DuBose JJ, Zhan LX, et al. Trends and outcomes of endovascular therapy in the management of civilian vascular injuries. J Vasc Surg
3. Branco BC, Musonza T, Long MA, et al. Survival trends after inferior vena cava and aortic injuries in the United States. J Vasc Surg
4. Crichton JCI, Naidoo K, Yet B, et al. The role of splenic angioembolization as an adjunct to non-operative management of blunt splenic injuries: a systematic review and meta-analysis. J Trauma Acute Care Surg
5. Eidt JF, Mills J, Rhodes RS, et al. Comparison of surgical operative experience of trainees and practicing vascular surgeons: A report from the Vascular Surgery
Board of the American Board of Surgery. J Vasc Surg
6. Schanzer A, Steppacher R, Eslami M, et al. Vascular surgery
training trends from 2001-2007: a substantial increase in total procedure volume is driven by escalating endovascular procedure volume and stable open procedure volume. J Vasc Surg
7. Tanious A, Wooster M, Jung A, et al. Comparison of the integrated vascular surgery
resident operative experience and the traditional vascular surgery
fellowship. J Vasc Surg
8. Mohapatra A, Liang NL, Makaroun MS, et al. Improved outcomes of endovascular repair of thoracic aortic injuries at higher-volume institutions. J Vasc Surg
9. Potts JR, Valentine RJ. Declining resident experience in open vascular operations threatens the status of vascular surgery
as an essential content area of general surgery training. Ann Surg
10. Rotondo MF, Cribari C, Smith RS. Resources for Optimal Care of the Injured Patient 2014. 6th ed. [American College of Surgeons web site]. Available at: https://www.facs.org/quality-programs/trauma/tqp/center-programs/vr/resources
. Accessed September 22, 2020.