Learning curves for cardiothoracic and vascular surgical procedures – a systematic review

Objectives. The aim of this systematic review is to evaluate the learning curve (LC) literature and identify the LC of cardiothoracic and vascular surgical procedures. Summary and background. The LC describes an observation that a learner’s performance improves over time during acquisition of new motor skills. Measuring the LC of surgical procedures has important implications for surgical innovation, education, and patient safety. Numerous studies have investigated LCs of isolated operations in cardiothoracic and vascular surgeries, but a lack of uniformity in the methods and variables used to measure LCs has led to a lack of systematic reviews. Methods. The MEDLINE®, EMBASE^?, and PsycINFO® databases were systematically searched until July 2013. Articles describing LCs for cardiothoracic and vascular procedures were included. The type of procedure, statistical analysis, number of participants, procedure setting, level of participants, outcomes, and LCs were reviewed. Results. A total of 48 studies investigated LCs in cardiothoracic and vascular surgeries. Based on operating time, the LC for coronary artery bypass surgery ranged between 15 and 100 cases; for endoscopic vessel harvesting and other cardiac vessel surgery between 7 and 35 cases; for valvular surgery, which included repair and replacement, between 20 and 135 cases; for video-assisted thoracoscopic surgery, between 15 and 35 cases; for vascular neurosurgical procedures between 100 and 500 cases, based on complications; for endovascular vessel repairs between 5 and 40 cases; and for ablation procedures between 25 and 60 cases. However there was a distinct lack of standardization in the variables/outcome measures used, case selection, prior experience, and supervision of participating surgeons and a range of statistical analyses to compute LCs was noted. Conclusion. LCs in cardiothoracic and vascular procedures are hugely variable depending on the procedure type, outcome measures, level of prior experience, and methods/statistics used. Uniformity in methods, variables, and statistical analysis is needed to derive meaningful comparisons of LCs. Acknowledgment and application of learning processes other than those reliant on volume–outcomes relationship will benefit LC research and training of surgeons.     

Trends in endovascular surgery

Endovascular surgery is currently in its infancy. Much work is necessary before its full potential can be realized. Initial enthusiasm has appropriately turned into more sober, realistic cautiousness. This review summarizes experiences with angioscopy, IU, PTA, laser angioplasty, atherectomy, and stent placement. Solving the restenosis problem following endovascular interventions could significantly broaden the applications of endovascular surgery. The nursing challenges brought by this new field are not different from those of traditional vascular surgery and catheterization. Keeping up with the new technology as it quickly evolves and documenting clinical effectiveness probably require an endovascular nurse specialist in a center planning to do a great deal of procedures.     

Infrainguinal endovascular procedures should be reserved for patients who do not have good open surgical options

This article is the result of a debate. The motion proposed was "Infrainguinal endovascular procedures should be reserved for patients who do not have good open surgical options.' Arguments in favor of the motion were offered by Daniel J. Reddy of Henry Ford Hospital in Detroit, MI, and arguments against the motion were offered by Peter Kalman of Loyola University Medical Center in Maywood, IL.     

Endovascular training for obstetrician-gynecologists: Suggestions for credentialing.

This article suggests guidelines for training and credentialing of obstetrician-gynecologists to perform endovascular procedures. It concentrates on the performance of uterine artery embolization for symptomatic myomata. Comparison is made between other recommended case numbers for credentialing of surgeons, radiologists, and cardiologists. Educational courses are discussed, as are the credits obtained for a typical uterine artery embolization. Two paradigms of endovascular credentialing are appropriate for comparison: Cardiology standards for coronary artery interventions and vascular surgery standards for endovascular stent placement. Both require a course including laboratory and participation in 100 cases, 50 of which as primary operator. In addition, many countries require a certificate of fluoroscopy safety. A credentialing board will be created to verify both the standards and completion of course requirement and proctored cases. Credentialing will benefit both patients and obstetrician gynecologists who will be able to provide continuity of care not currently available. The gynecologist will be able to manage all complications, including myomata, which cannot be done under current circumstances.     

Branding of vascular surgery

The Society for Vascular Surgery surveyed primary care physicians (PCPs) to understand how PCPs make referral decisions for their patients with peripheral vascular disease. Responses were received from 250 PCPs in 44 states. More than 80% of the respondents characterized their experiences with vascular surgeons as positive or very positive. PCPs perceive that vascular surgeons perform "invasive" procedures and refer patients with the most severe vascular disease to vascular surgeons but were more than twice as likely to refer patients to cardiologists, believing they are better able to perform minimally invasive procedures. Nevertheless, PCPs are receptive to the notion of increasing referrals to vascular surgeons. A successful branding campaign will require considerable education of referring physicians about the totality of traditional vascular and endovascular care increasingly provided by the contemporary vascular surgical practice and will be most effective at the local grassroots level.     

Endovascular training for obstetrician‐gynecologists: Suggestions for credentialing

This article suggests guidelines for training and credentialing of obstetrician‐gynecologists to perform endovascular procedures. It concentrates on the performance of uterine artery embolization for symptomatic myomata. Comparison is made between other recommended case numbers for credentialing of surgeons, radiologists, and cardiologists. Educational courses are discussed, as are the credits obtained for a typical uterine artery embolization. Two paradigms of endovascular credentialing are appropriate for comparison: Cardiology standards for coronary artery interventions and vascular surgery standards for endovascular stent placement. Both require a course including laboratory and participation in 100 cases, 50 of which as primary operator. In addition, many countries require a certificate of fluoroscopy safety. A credentialing board will be created to verify both the standards and completion of course requirement and proctored cases. Credentialing will benefit both patients and obstetrician gynecologists who will be able to provide continuity of care not currently available. The gynecologist will be able to manage all complications, including myomata, which cannot be done under current circumstances.     

Peripheral vascular disease endovascular management in patients scheduled for cardiac surgery: a clinical-angiographic approach

BACKGROUNDS: Endovascular management of peripheral vascular disease before cardiac surgery is still debated. We sought to present our preliminary experience of endovascular stent placement in patients scheduled for urgent cardiac surgery. METHODS: Between November 2003 and August 2005, 20 patients scheduled for urgent coronary surgery (13 males, mean age 72.5+/-5.3 years) underwent endovascular repair of PVD on the basis of clinical and angiographic indications. Aspirin (100 mg/day) plus low molecular weight heparin (nadroparin calcium) 100 IU/kg/12 h for urgent coronary surgical revascularization was administered after the procedure. RESULTS: Endovascular stenting has been performed in four clinical settings: renal artery stenting prior to coronary surgery (nine patients) to decrease the impact of extracorporeal circulation on an impaired renal function, iliac artery artery angioplasty and stenting (eight patients) in order to facilitate aortic balloon pump insertion after surgery, subclavian artery angioplasty and stenting propedeutical to arterial conduits bypass surgery (one patient), carotid artery stenting before coronary surgery (two patients). All patients underwent successful endovascular repair followed by cardiac surgery. At a mean follow-up of 12+/-4.6 months all patients are alive and without evident thrombosis or restenosis of the implanted vascular stents. CONCLUSIONS: Endovascular treatment of PVD in patients scheduled for urgent coronary surgery may be effective, relatively safe and lasting in spite of low dose antiplatelet regimen.     

Establishing an endovascular abdominal aortic program--decisions, decisions, decisions: The London Health Sciences Centre experience.

The endovascular repair of abdominal or thoracic aortic aneurysms is an alternative approach to conventional repair in the compromised patient. Although the long-term efficacy of these procedures has yet to be proved, there is growing interest among vascular surgeons and interventional radiologists throughout North America and Europe in the more frequent use of this technique. Starting an endovascular program necessitates extensive cooperation of the interdisciplinary vascular team. Decisions regarding patient selection, equipment, supplies, staff education, and the location of the procedure must be based on sound principles. This article demonstrates how a program can be planned, implemented, and evaluated by the use of a "decision tree." The experience of the London Health Sciences Centre will be used as a benchmark in the discussion of relative merits of branch points in program development. The article gives persons contemplating a program a structured process in decision making to avoid potential pitfalls.     

Procedural skills quality assurance among Australasian College for Emergency Medicine fellows and trainees

Objective: Presently, no objective quality control mechanism exists for monitoring procedural skills among Australasian College for Emergency Medicine trainees. The present study examined trainee and fellow procedural experience and perceived competency, participation in accredited training courses and support for a procedural logbook. Methods: A cross‐sectional mail survey of Australasian College for Emergency Medicine advanced trainees and fellows was performed. Experience and perceived competency in 23 common and important ED procedures were examined. Results: In total, 202 fellows and 264 trainees responded (overall response rate 39.0%). Overall, fellow procedural experience and perceived competency were reasonable. However, some fellows had never performed a number of procedures including some common procedures (e.g. nasal packing, fracture reduction) and there were reports of ‘very poor’ competency for 17 (73.9%) procedures. Trainee experience and perceived competency were less than the fellows but showed similar patterns. Perceived numbers of each procedure required to achieve competency varied considerably between the procedures and among the respondents. However, there were no significant differences in the perceived numbers reported by the trainees and the fellows (P > 0.05). Variable proportions of trainees and fellows had undertaken courses that incorporated procedural skills training. More fellows (75.7%, 95% confidence interval 69.1–81.4) than trainees (59.9%, 95% confidence interval 53.6–65.8) supported the use of a procedural logbook (P = 0.003). Conclusions: Lack of experience in some procedures among some fellows, especially commonly performed procedures, might represent a deficiency in existing quality assurance mechanisms for procedural skills training. Greater participation in skills courses, to improve experience in difficult and uncommonly encountered procedures, is recommended. Improved quality assurance mechanisms, including a procedural logbook, should be considered.     

Anastomotic devices for coronary surgery

Proximal and distal anastomotic devices will play different roles in advancing minimally invasive cardiac surgery. In the wake of the first experiences with the St. Jude Symmetry?, data will be needed to support new technology adoption. The value of anastomotic technology will be greater in the off‐pump and small access coronary techniques. When coronary vascular connectors provide the same or better patency than suture cardiac surgeons will use them for most cases because they will be faster and more reliable. This burgeoning field of anastomotic connectors is already beginning to spill over into other specialties. There is promise for these devices in vascular procedures. It is predicted that similar devices will also be used for bowel anastomoses. With continued evolution of anastomotic devices, it is easy to visualize that in the near future the majority of anastomoses may be performed with a manual or automatic device as opposed to the current conventional suture technique.     

Recent advances in vascular surgery]

In the recent years, the vascular reconstructions are being performed regularly in patients with chronic arterial occlusion, while no remarkable advances are observed in cases with acute arterial deterioration. The poor results of the vascular surgeries for the acute arterial occlusion are mainly due to myonephropathic metabolic syndrome (MNMS). The thrombectomy which is performed by Fogarty's balloon catheter is the simplest technique and found to be useful in patients suffering from thromboembolism. But it should be applied carefully to avoid vascular injury. The surgical techniques have been remarkably improved especially in the area of tibial bypass surgery and endovascular surgery. The former has been achieved by tourniquet occlusion technique and the later by angioplasty with a metal stent.     

Abdominal aortic aneurysm repair in cardiac high risk patients – medication, surgery or stent?

With increasing age of the general population, a higher awareness of the disease, better screening methods and the option of less invasive therapeutical strategies, the incidence of abdominal aortic aneurysms (AAA) is rising steadily. Since AAA is a disease of the elderly patient with generalized atherosclerosis, there is a high coincidence with other vascular morbidities. Especially the presence of coronary artery disease and concomitant left ventricular dysfunction proves many of those patients to be cardiac high risk patients with respect to an operative approach. On the other hand, a high coincidence of severe peripheral arterial occlusive disease might hamper the endovascular approach and endovascular therapy might carry a high risk for these patients as well. Therefore, it is of utmost importance to consider how and when cardiac high risk patients with AAA should be treated. In this review therefore special aspects such as the choice of medical treatment, the need of preoperative coronary revascularization and the situation in old patients are discussed in detail.     

Treatment failure after rotational atherectomy and balloon angioplasty in recurrent cystic adventitial disease of the popliteal artery: a case report

Cystic adventitial disease (CAD), which usually affects the popliteal artery, is a rare vascular condition in which fluid accumulates in the sub-adventitial layer, compressing the lumen. Historically, surgical treatment is preferred over endovascular or minimally invasive techniques, due to its lower recurrence rates. Here, the case of a 67-year-old male patient, in whom rotational atherectomy was performed for recurrent CAD following surgical cyst excision and patch angioplasty is reported. The patient’s symptoms recurred one day after the rotational atherectomy procedure and repeat computed tomography angiography showed recurrence of the disease. Due to gradual worsening of the condition during 8 months of follow-up, left distal femoral artery to popliteal artery (below-the-knee) bypass surgery was performed using an ipsilateral reversed great saphenous vein graft. Follow-up has continued for 2 years without complications or requirement of additional treatment. This novel case is the first report of atherectomy attempted for recurrent CAD that led to an early recurrence. Our experience emphasises that additional surgical approaches should be selected over endovascular procedures for treating recurrent CAD.     

Endovascular snare retrieval of an Angio‐Seal causing acute limb ischemia

Vascular complications (VCs) remain an important source of morbidity and mortality following percutaneous arterial catheterization. Vascular closure devices are popular and frequently used, but sometimes cause vessel occlusions that may require vascular surgery or complex endovascular procedures. In this case report, we describe the endovascular retrieval of an embolized Angio‐Seal device causing acute limb ischemia in a severely diseased 75‐year‐old female patient. This case highlights the endovascular technique using a snare catheter and adds another example to the growing evidence of an endovascular approach to manage vascular access site complications in comorbid patients at risk.     

Computer-aided surgery: concepts and applications in vascular surgery

Computer-aided surgery makes use of a variety of technologies and information sources. The challenge over the past 10 years has been to apply these methods to tissues that deform, as do vessels when relatively rigid flexible objects are introduced into them (Lunderquist rigid guide wire, aortic prosthesis, etc) Three stages of computer-aided endovascular surgery are examined: sizing, planning, and intraoperative assistance. The authors' work shows that an approach based on optimized use of the imaging data acquired during the various observation phases (pre- and intraoperative), involving only lightweight computer equipment that is relatively transparent for the user, makes it possible to provide useful (ie, necessary and sufficient) information at the appropriate moment, in order to aid decision making and enhance the security of endovascular procedures.     

Present and future developments of the virtual surgery and tele-virtual surgery system

One of the applications available now in the medical field is the virtual surgery system. This system allows surgeons a safe place to master surgical techniques and to plan surgical procedures before the operation. To provide the system for use in a clinical situation, a soft tissue model and a force feedback device suited for the surgery is required. In this paper, we would like to introduce our virtual surgery system, which possesses a soft tissue model that can show accurate, real-time deformation and is equipped with a force feedback device that allows the user to experience the tactile sensations. In addition, we will introduce our tele-virtual surgery simulation system for training in the procedures used in robotic surgery.     

Peripheral vascular surgery in the high-risk patient

In peripheral vascular surgery a patient not infrequently becomes a high-risk case on account of local causes (morphological, haemodynamic), especially during long operations. Hence, low-risk procedures like partial or palliative operations, including extraanatomical procedures, and appropriate anaesthesiological methods are very important. This report includes several possibilities of peripheral arterial reconstruction, as well as a review of experience gained in 37 axillo(bi)femoral and 54 cross-over bypasses, 41 closed retrograde TEA's of the iliac region, 30 transluminal dilatations, 580 embolectomies, 257 reconstructions of the deep femoral artery and 19 in situ vein bypasses (Hall). The distribution of extraanatomical procedures in a high-risk and a local or angiological-morphological situation showed that after one year only 50% of high-risk patients were still alive compared with 85% of the latter group. Local anaesthesia was very suitable for embolectomies, whilst for other indications we prefer spinal and peridural or combined regional and general anaesthesia, with the proviso that the patient is in the hands of a skilled anaesthesiologist.     

Improving ACGME Compliance for Obstetric Anesthesiology Fellows Using an Automated Email Notification System

Background  The Accreditation Council for Graduate Medical Education establishes minimum case requirements for trainees. In the subspecialty of obstetric anesthesiology, requirements for fellow participation in nonobstetric antenatal procedures pose a particular challenge due to the physical location remote from labor and delivery and frequent last-minute scheduling. Objectives  In response to this challenge, we implemented an informatics-based notification system, with the aim of increasing fellow participation in nonobstetric antenatal surgeries. Methods  In December 2014 an automated email notification system to inform obstetric anesthesiology fellows of scheduled nonobstetric surgeries in pregnant patients was initiated. Cases were identified via daily automated query of the preoperative evaluation database looking for structured documentation of current pregnancy. Information on flagged cases including patient medical record number, operating room location, and date and time of procedure were communicated to fellows via automated email daily. Median fellow participation in nonobstetric antenatal procedures per quarter before and after implementation were compared using an exact Wilcoxon-Mann-Whitney test due to low baseline absolute counts. The fraction of antenatal cases representing nonobstetric procedures completed by fellows before and after implementation was compared using a Fisher''s exact test. Results  The number of nonobstetric antenatal cases logged by fellows per quarter increased significantly following implementation, from median 0[0,1] to 3[1,6] cases/quarter ( p  = 0.007). Additionally, nonobstetric antenatal cases completed by fellows as a percentage of total antenatal cases completed increased from 14% in preimplementation years to 52% in postimplementation years ( p  < 0.001). Conclusion  Through an automated email system to identify nonobstetric antenatal procedures in pregnant patients, we were able to increase the number of these cases completed by fellows during 3 years following implementation.     

Centralization, certification, and monitoring. Readmissions and complications after surgery

Research on adverse outcomes following common surgical procedures has suggested the importance of hospital and surgeon variables. Policy directions depend on which factors are important in influencing patient outcomes and what sorts of policies are feasible. Focusing on where a given procedure is performed highlights a concern for centralization; emphasizing who should perform a particular operation implies physician certification. Finally, monitoring involves identifying particular hospitals that appear to have relatively poor (or relatively good) results. This paper analyzes patient, surgeon, and hospital characteristics associated with serious postdischarge complications of hysterectomy, cholecystectomy, and prostatectomy in patients age 25 and over in Manitoba, Canada, following surgery during 1974 through 1976. The three procedures differ markedly in the ease of prediction of the probability of complications and in the predictive importance of patient, hospital, and physician variables. The predictors worked fairly well for cholecystectomy, somewhat less well for hysterectomy, and not well at all for prostatectomy. Hospital variables were not generally important in the multiple logistic regressions. After controlling for case mix and type of surgery, physician surgical experience was found to account for relatively large differences (almost two to one) in the probability of patient complications following cholecystectomy. Cholecystectomy might be a candidate for certification because of the epidemiology of the operation. As of the mid-1970s, a substantial proportion of the cholecystectomies were being performed by physicians with comparatively little ongoing experience with this type of procedure. Moreover, a monitoring perspective identified one hospital with a significantly higher postcholecystectomy complication rate, even after physician experience was taken into account. Both identifying which procedures should be attended to and focusing on problems following surgery are important beyond Manitoba and highly relevant to such American requirements as Peer Review Organizations. Methods of increasing the efficiency of using claims data for quality assurance studies are outlined.