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Melanie Cole, MS (Host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And today, we're highlighting Perspectives on Aortic Surgery Training Among Vascular Trainees: Barriers and Opportunities for the Future. Joining me today is Dr. Salvatore Scali. He's a Professor of Surgery in the Division of Vascular Surgery and Endovascular Therapy, and he's the Program Director of the Vascular Surgery Fellowship at the University of Florida College of Medicine.

Dr. Scali, it's such a pleasure to have you with us. As we begin this great topic, can you describe the current state of aortic surgery training among vascular trainees? Help us to understand the historical context and current trends in this type of training.

Salvatore Scali, MD: Yes. Good afternoon. Thank you so much for inviting me. I think this is a really terrific topic to sort of discuss and has major implications across virtually the entire training paradigm in Vascular Surgery. It's something that's sort of been percolating, if you will, for the last 10 or 15 years in the field.

What happened traditionally before the 1990s in the modern era of aortic surgery, when the introduction of endovascular implants became FDA approved is historically everybody at any given training program was only exposed to open aortic surgery. And so, virtually all trainees when they transitioned into independent practice were all assumed to have comparable ability to handle the entire gamut, entire spectrum, if you will, of open aortic surgery, whatever that may be constituted by.

However, since the 1990s, we've seen this rapid proliferation and adoption and really supplanting open aortic repair by emerging technologies, really disruptive technologies, which are good in the way of sort of introducing therapies that frankly are less invasive to the patient, albeit they come at certain costs, if you will, unintended consequences, as it were.

And so, currently in the United States, it's estimated that somewhere between 35,000 and 40,000 patients undergo some type of aortic repair, whether it be the arch, the descending thoracic aorta, the thoracoabdominal aorta, the infrarenal aorta. Most of the repairs generally are occurring in the juxtarenal and infrarenal aortic position. So, that's somewhere around 25,000 or so, give or take repairs annually. And in the U.S., at least the contemporary estimates are that between 75% and 80% of all aortic repairs that are occurring in that infrarenal or juxtarenal position are performed with an aortic endograft or implant. So, only about 20-25% of patients undergo open aortic surgery. So, one can sort of just sort of do the back-of-the-paper calculation and understand that that necessarily reduces the open aortic surgical exposure and experience that trainees will get in the United States. And this sort of siren call went out about 10 years ago with Dr. Anahita Dua, who is now a faculty member at Mass General Hospital, as well as Gil Upchurch, who is our Chair of Surgery here at the University of Florida. When he was at the University of Virginia and was chief there, written a paper with Dr. Dua, looking at the time, this is now a 10-year look back, at what the estimates or projected estimates were going to be for vascular trainees, understanding that as endovascular proliferation became increasingly sort of, you know, supplanting open aortic repairs, we would see a requisite drop in the open aortic surgical exposure for the trainees. And they were projecting that by the year 2020, that they predicted about five open AAA repairs per trainee was going to be the estimate.

So, a more contemporary paper around 2022 by George, et al, tried to see if the predictions were correct, if you will. And so, they did a actual accounting, looking at estimated annual number of aortic procedures and looking at open aortic repair, either being done for occlusive indication or degenerative aneurysm. And lo and behold, while they didn't find that five open repairs per trainee number, they still found an alarmingly low number. The average graduate who goes through a vascular fellowship, which is the two years of training that we offer here for people who've completed an accredited general surgery program like we do here at UF. For our fellows in the United States, they finish with an average of about between 10 to 15 open AAA repairs with another 10 to 15 being done with aortofemoral reconstruction for occlusive disease. So, not quite that five number that was estimated, but still a low number. Slightly lower estimates have been found for integrated residency programs, which we don't have here at UF, but over 60 positions annually are graduated with trainees. And so, the mean number of open aortic operations were only about 10 as of 2017 for an open aneurysm repair for a vascular surgical resident, so still relatively small numbers when you compare it to historical estimates. Year over year, trainees would be you generally finish with two to threefold higher experience. And so, that's kind of what the current state is, where we're estimating it. The average graduate in the United States has a mean-- you know, when we talk about mean numbers, that means there's a bell curve distribution. And so, there's people who are going to be skewed right or left of that mean number. So, there are a number of programs, and this is something that the University of Michigan sort of highlighted in their manuscript in about 2020, when they sort of said, "Well, how many trainees in the United States do in fact exceed even the SVS-endorsed annual minimum, which at a center level is supposed to be 10 open aortic repairs per year?" And currently, 40% of senior trainees, whether they're in a residency or in a fellowship, perform less than five open aortic repairs during their training.

So that number, while it wasn't the number that was found in those other manuscripts, it is relevant for a number of trainees in the United States that they're not finishing with a robust exposure to open aortic surgical experience, which calls into question their proficiency and their aptitude to perform these operations, because increasingly it's recognized that in the era of endovascular repair, the patients who do undergo open repair, that 20% or 25% that's still relegated to that, generally, have more complex repairs. And this has been shown time and again. So, you're asking trainees to transition into practice, to take on potentially more difficult and challenging anatomies, and it's still expecting a similar outcome, which to date we haven't shown an erosion in the overall outcomes. So, hospitals and centers and practices have been able to sort of shoulder or bolster this relative deficiency in open aortic surgical exposure training. But we wonder at what point will we start to see incremental increases in mortality outcome, which is the one that we look at most of the time, 30-day mortality or in-hospital mortality for open aneurysm care. Because we are seeing an uptick in emergency open aortic surgery outcome, meaning patients who get open repair for an emergency indication, such as rupture or symptoms, we are seeing some evidence that there's an increased mortality signal that's being found, at least when you look in the quality registries. Whether that's reflected in national practice, it's not clear. But given that in aggregate, I think that's the current state of where with training, in terms of what the  exposures are, what the sort of estimates are for the average trainee. We're fortunate here at the University of Florida to not have that issue as the second busiest aortic center in the United States and performing over 900 aortic operations from the valve to the bifurcation and/or open or hybrid. Our trainees, at least in our fellowship, finished with between 80 and 100 open aortic operations. And about open AAA repair is anywhere from 40 to 50. So, we are in the sort of higher percentile nationally. And so, we're fortunate locally to not have this concern, but it is a concern when you're supposed to be a steward of the training programs around the country and you sort of talk with other trainees and other faculty members at other centers and try to understand how can we kind of overcome this potential deficiency so that patients don't suffer and that we don't see a fall-off in the outcomes, which historically have been quite good for these repairs.

Melanie Cole, MS: Wow, that was fascinating, Dr. Scali. And we're going to get into the proficiency angle of this in just a bit. But when you're speaking about open versus endovascular training in your opinion and with your program, what then would be the key components of aortic surgery training programs today? I'd like you to speak about those different training pathways. You've spoken about case volume standards. But since we are seeing the drop in open versus endovascular, and I see what you're saying about future inability to rise to the need of emergent situations, what do you feel are the most important key components?

Salvatore Scali, MD: Yeah, this is a great question. And I think it's fairly nuanced and it's multi-level to answer. I would first start out by saying for those listening, there are technically three pathways to receiving vascular certification, but really two dominant pathways. There are these early specialization integrated pathways, but there's the 0 and 5, which is the surgical residency coming directly out of medical school and entering a surgical residency at an accredited program where you have a minimum of a five-year integrated experience between some general surgery training and traditional vascular training. And then, there's the traditional 5-2 paradigm. The third paradigm, which is the early specialization after your fourth year. There are only a few centers in the country that actually do this. And so really, the two major pathways for training are the ones described. And really, there hasn't been any evidence to suggest that either pathway is superior or inferior. I would say they're comparable pathways. The integrated residency for many years was thought to be vulnerable to perhaps having surgeons that would not be proficient in open surgery, and that just hasn't held true. All of the integrated residencies that are out there now produce an excellent product. We've had partners in our own practice who have been trained in those paradigms, and we know that they are proficient. Where the issue is in either paradigm, whether it's the integrated residency pathway or the traditional 5-2 pathway is whether or not your given program has sufficient volume to ensure technical proficiency and competency in a given procedure like open AAA repair.

Many people would say, "Well, why are you picking open AAA? Why can't it be any number of other operations that you do?" Well, that's a good question, but the reality is there are certain high impact, relatively low-frequency in most practices, maybe not at UF and other major vascular centers, but a lot of centers don't do a huge volume. And this relationship between volume and outcome has been discussed since 1979 by the Luft, et al, article that was the first sort of article that said, "Boy, centers that do more of this stuff tend to do better." Same thing as surgeons, the more you do of these complex operations, the better your outcomes and the more predictable it is. So, we know that there's a strong correlation between volume and outcome; ergo, how are you going to sort of, you know, expose your trainees to a sufficient volume that they're going to have reliable outcomes? And then, how do they maintain that once in practice? Because that's something we as training centers can't. We can't control what happens once they leave our environment. There's probably a need for appropriate use criteria in EVAR utilization. We're a significant outlier nationally. I mean, internationally, the United States does 80% of their repairs with EVAR as opposed to open repair, and we far outpace other first world nations. If you look at us and compare to other places like the United Kingdom, or if you look at New Zealand, you name it, Germany, et cetera, we just far outpace utilization of EVAR relative to open aortic repair. What the reasons are and what are the drivers is fairly complex, but we are just an outlier. And so, we're kind of doing it to ourselves. If we look at other first world nations, they use it about 60% to 70% max is what they are. And so, there's probably a pendulum shift that needs to occur in the United States to sort of self-correct who's getting EVAR and who's getting open. So, that's part of it.

So, we need appropriate use guidelines to be adopted by our societies. And we also need there to be more incentives to sort of how we onboard and credential surgeons for given high-impact operations. We do this for carotid surgery, for example, for if you want carotid stent privileges. When you apply as a program director, I sign off when trainees go and they join a new practice. I have to sort of say yes or no, they have sufficient exposure to get these. But particularly for carotid privileges, for stenting, you need to show additional training and/or you actually have to show a case list. That is not the case with anything else, including open aneurysm repair. So, it may be time to sort of revisit this for certain high-impact operations that have been in the public eye and have been watched by patient safety watchdog organizations, like Leapfrog and others. And open triple A is one of them. We know that these sort of marquee operations that are judged the sort of overall quality of care provision that centers give, open triple A being one of those hallmark operations, and maybe there needs to be a change in the credentialing paradigm pathways and having sort of endorsed minimum standards like what we do for carotid stenting, for initial credentialing, and maintenance of credentialing. And it shouldn't just necessarily be implied that with the vascular training certificate, that you can automatically do these operations.

The other thing that we probably need to sort of improve things for onboarding is having some type of description or at least something endorsed from the society that says when you are onboarding new surgeons, irrespective of their background and their exposure in their training program, we probably need some type of formal mentorship process. Right now, it happens organically. Me, as a program director, I'm very hopeful when my trainees go into a practice environment that they're going to have enough senior mentorship that are going to help them with their patient selection and perhaps in the actual conduct of some of those early operations, because it's so critically important, particularly as you're starting out as a young surgeon, to have reliable, good outcomes. Otherwise, those referrals aren't going to come, it's going to break the confidence of the surgeon. And ultimately, most importantly, the patients can suffer. And so, how do we leverage the wisdom and the experience of these mid and late career surgeons who've had the opportunity to accumulate that experience and how do you sort of impart that on. And so, it maybe that certain trainees need a longer pathway or runway to achieve that independence. But what that looks like, nobody's really sat down to really think about that. And so, we have to sort of generate focus groups, work groups, that's to be sort of driven at the societal level to really sort of come up with concensus documents. We probably sort of have to use and leverage things like Delphi consensus panels and things like that to understand what are the most important aspects of onboarding. Is it just technical? Is it patient clinical decision-making? How much do you sort of do? So, I think that that is going to be necessary for some of these more complex operations, including open aortic repair.

Melanie Cole, MS: It's very complex as well. And when you're speaking about mentorship, you're telling us about strategies and opportunities with mentorship for improving open aortic surgery training and just training in general. When we think of endovascular and the technological advances in your field, Dr. Scali, are just really amazing-- and this is for other providers that are looking to start programs or looking at your program-- how are you using these technological advances and integrating simulation or virtual training into this type of education and where does the mentor come into that working with their resident?

Salvatore Scali, MD: This is a great, great question. Simulation training has been something that's been touted for a very long time. It is required in certain environments, certainly fundamentals of laparoscopic training. They do simulation events. We use code simulation with ACLS recertification. So, we know that it can work in certain situations. And certainly, there are some very sophisticated simulation techniques that are out there. Companies offer these sort of supportive workshops. They can either come on site to do this. Societies offer it frequently when they sort of host their different educational meetings, but there's not a structured curriculum that integrates simulation in and of itself.

So, it would have to be something perhaps, again, at the societal level, like the Association for Program Directors of Vascular Surgery, where we would have to sort of come up with some standard rubric for programs to follow and saying, "This would be an expectation." Much like you get fundamentals of laparoscopic surgery, credentialing in general surgery, there's probably an equivalency, and there is something like that, albeit it doesn't happen routinely. It's not enforced. There are these sort of training offerings that happened through certain regional societies and national societies. But currently, it's not widely adapted to all training programs nationally. But if we really wanted to leverage that opportunity, it would be necessary as part of the training where we would have to sort of say, "This is being mandated now that you have to show fundamentals." That's helpful for the endograft portions. The open simulators to date haven't evolved to the level that the endovascular simulators work. So while it's nice to use simulation for the endo parts, we don't have, and we certainly need, better open simulators.

And so, that would be something we can't sort of create it as a homegrown effort at the center level or the training program level. You'd have to probably leverage some type of experience with industry partners to try to see if there's a way to do that. The problem is that implants that we use for open simulation are Dacron grafts, which there's just not a large push with a lot of the vendors who are giving you the woven synthetic grafts that you're using with open surgical repair to generate sophisticated simulators that really give you tactile feedback. The endovascular simulators do. They're quite remarkable, frankly, the types of simulations. So, we don't have the current fidelity with open simulation. There's decent simulators that are there. They're quite different and varied, the ones I've seen. But none of them has been adapted or certainly certified in the way we say that this is the right simulator. It gives all the different attributes. So, there is a real hole there in education where we would need to sort of make efforts to generate better open simulators to sort of help bolster those open surgical skill sets that we would ultimately need for trainees, particularly in programs if they're not getting sufficient exposure in the volumes.

Melanie Cole, MS: That makes a lot of sense and if they're not getting that caseload, as you say. So, that's an interesting initiative or something to look forward to in the future. But I'd like you to speak a little bit about multidisciplinary collaboration in aortic surgery training. How can that be enhanced? Because I think that it's important when we look at the benefits of integrating different specialties, Cardiology, Radiology, into this education for a more well-rounded situation.

Salvatore Scali, MD: Yeah, I couldn't agree with you more. You know, we're fortunate, at least in our training program to have a really great-- particularly with the thoracic and cardiovascular division, we have an excellent sort of rapport. You know, when there's more complex aortic cases where there's a lot of overlap between skill sets, for example, thoracoabdominal aneurysm repair, hybrid operations that involve arch and descending thoracic aorta. These are all sort of experiences and exposures where trainees and faculty interact across these different disciplines and case planning conferences, et cetera.

So, a lot of it has to start with culture. I know that's an easy word to say, but it's so true. I was fortunate that the place I landed with my first and only job in my entire career has a really great culture. There's a tremendous collaboration that occurs at the attending and leadership levels across sections, whether it be surgical oncology and doing major vascular reconstructions in collaboration with, you know, Surgical-Oncology, Urology, OB-GYN, et cetera, or commonly with the Thoracic and Cardiovascular section. It's helpful that our program locally has an i6 integrated TCV training program, and their residents spend time on our service. And so, there's natural sort of linkage that occurs there between not only sharing patients and sort of operating together, but training their trainees. And the quid pro quo then obviously is that our fellow trainees have opportunity to get exposure in those more complex aortic cases, whether they're hybrid or open or otherwise.

And so, a lot of it starts at the culture room, at the leadership level, which has to be at the center. So, you hope that that exists already, although that's probably the most important piece, but the piece that's least controllable when you're trying to develop policy and best practice, assuming those exist, which is a big assumption because I know many a partner and colleague in the field where they don't have that same collegial relationship with other sections. So, that really is a barrier. But if you have those opportunities, then absolutely, having shared conferences, when there are opportunities in given cases, particularly more complex cases, knowing that there are different parts of each case that different trainees could participate in. You know, you don't expect every trainee to be at their terminal year or have the ability as a finishing fellow or a graduating chief resident in Integrated Residency. Having those mid-level residents get exposure, seeing the exposure, helping with opening and closing, maybe at less stressful times where there you're not on the clock with a clamp, where you can actually take your time to saw maybe a distal anastomosis or something like that. Having trainees participate in different portions of those operations, you have to be a little bit creative, I think, if you're going to be an educator to sort of say, "How can I leverage what cases we do have to touch the most trainees across their training experience with us?" And a lot of times, you can do that by, again, having those relationships with other sections. And so, we do a lot of work to continue to cultivate that, whether it's fostering clinical research activities by having that sort of intellectual discourse and looking at outcomes together, that sort of bolsters the idea that we're going to continue to sort of get better as a section, be better educators, better for our patients. We're going to use educational resources. We're going to try to publish our outcomes, and then getting our trainees involved at all of those phases, I think that collaboration and multidisciplinary philosophy to the patient care will have those effects at all levels of training. I don't know if that makes sense. But that's generally been our approach. And again, we've had a lot of sort of trainees, I think, who've left the institution and reflect back on their experiences with us and say, "Boy, it was a really unique environment to be here. And you try to redevelop that culture, wherever you go. You may not be able to do it the same way, but there are certain attributes of that relationship that you want to foster. You go to your next environment. I say training environment because it is a practice. As I remind myself and all of my partners and trainees, every day is a school day. And so, it's not like, once you finish training, that you stop training. I train every day in what I do in my practice to try to improve for our patients. And so, just because you've done a bunch of aortic surgery during your fellowship or residency, it doesn't mean you don't learn once you become an attending.

Melanie Cole, MS: It makes a lot of sense, Dr. Scali. And it speaks to the quality of your education and you as an educator and mentor. As we wrap up, and you're telling us how proficiency, when you're speaking about past residents that you've had in aortic surgery, can impact the career trajectories of vascular trainees, what advice would you give to an aspiring vascular surgeon interested in specializing in aortic surgery? What would you like them to know?

Salvatore Scali, MD: Most every trainee who finishes, certainly in our program and at other programs around the country, there is an expectation, and certainly, I believe, a hope that they're going to be safe, competent surgeons who are going to do well for their patients, but also recognizing that you have to sort of check yourself at the door. You have to kind of know and have some introspection. For example, if I finished my training and I had never done a carotid stent, I was fortunate where I trained, and I'd done quite a bit. So, I was immediately ready to sort of get the credential and to be independent. But had I not had that exposure, I would never assume or want that credential or try for that credential. I would seek out mentorship. I would understand where my limitations are, because you have to always check your ego at the door. It's about the patient first. It's not about doing the next great case or cool case. It's about the patient and delivering high quality care. And you have to do it over and over and over again. Each patient expects that of us as a team. And so, you're not siloed when you "finish your training", and you enter into independent practice, recognize that you have to sort of know your own limitations. If you feel confident and comfortable in your skills, and you feel like you've had a robust open aortic experience, then by all means, do those cases. But I still strongly recommend that with your partners and in your practice environment, you get feedback from them about the patient selection, the plan of the operation, and know that somebody is immediately available for backup, particularly in the beginning, when you're sort of on that learning curve alone. Because it's very easy, frankly, when somebody else is setting up that operation for you. Nobody's doing that for you when you transition into practice. You have to do that for somebody else or for yourself alone with a partner or with a PA.

So, not all trainees can be expected to have the same levels of confidence and proficiency. Some people just need a different on-ramp to independence during their early career. I try to educate all of the trainees that we have as they go through the job search, looking for the right culture, right fit, and then recognize their limitations. I'll tell trainees, I'll say, "Boy, you're really good at doing this. Maybe you're going to need a little more work on this. So even though you're going to be credentialed to do these things, you really need to seek out mentorship and help when you are faced with these types of scenarios." It's rare. Most of our trainees, frankly, because they do so much operating, can frankly handle everything, but every trainee is a little bit different. So, you have to be an honest broker when giving that feedback and assessment, certainly as a program director, as somebody who signs off on credentials for new trainees. But the trainee themselves has to have introspective and remember that you have to also not be afraid to ask for help, particularly early in your career when it comes to taking on these more complex cases.

Melanie Cole, MS: That's great advice, Dr. Scali. What an enlightening, eye-opening discussion that we had here today. I thank you so much for joining us and telling us what's really involved in the education for aortic surgery. And it's so complex, but you made it so clear and spoke about it so very well. So, thank you so much for sharing your incredible expertise with us today.

And to learn more about this and other healthcare topics at UF Health Shands Hospital, please visit innovation.ufhealth.org. And to listen to more podcasts from our experts, please visit ufhealth.org/medmatters. That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. Please always remember to subscribe, rate and review uF Health MedEd Cast on Apple Podcast, Spotify, iHeart, and Pandora. I'm Melanie Cole. Until next time, thanks so much for joining us.