Future of Vascular Surgery

[babybat]

I am a Canadian student hoping to apply to Canadian programs in Vascular and General Surgery with the option of applying to American vascular fellowships after GSx. Here, most (all?) vascular programs have moved to 0+5 model. I am wondering how things look in the US? Are you guys also phasing out the 5+2 model? Also interested in any info on vascular fellowships in America, I hear you guys have it rough in residency. I am in first year so a lot can change by the time I would be finishing GSx residency if that happens.

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[ThoracicGuy]

What have you heard is particularly rough for residency?

 

[babybat]

What have you heard is particularly rough for residency?

Hours and pay mostly, though I dont think we are much different. Perhaps just less of us talking about it online

 

[ThoracicGuy]

Hours and pay mostly, though I dont think we are much different. Perhaps just less of us talking about it online

Hours will be 80 hours a week, give or take. Pay is reasonable at that level (as a PGY 6/7), which will be higher than the average 4 person family income. I don't think that will be an issue.

 

[LucidSplash]

There are still plenty of vascular fellowships. Many programs have both 0+5 and 5+2. My hospital specifically we have both and no plans to phase out fellowship.

 

[Medstart108]

I am a Canadian student hoping to apply to Canadian programs in Vascular and General Surgery with the option of applying to American vascular fellowships after GSx. Here, most (all?) vascular programs have moved to 0+5 model. I am wondering how things look in the US? Are you guys also phasing out the 5+2 model? Also interested in any info on vascular fellowships in America, I hear you guys have it rough in residency. I am in first year so a lot can change by the time I would be finishing GSx residency if that happens.

Vascular is moving away from open and so a lot of the skills you learn in general surgery may not be transferable. Definitely try to match into vascular, if not then I believe US fellowships will be an option in the future. With these kinds of things, I would not be worried that things will be phased out, there is always a way to get extra training because you are providing a service at a low price while doing it.

 

[LucidSplash]

Vascular is moving away from open and so a lot of the skills you learn in general surgery may not be transferable. Definitely try to match into vascular, if not then I believe US fellowships will be an option in the future. With these kinds of things, I would not be worried that things will be phased out, there is always a way to get extra training because you are providing a service at a low price while doing it.

I value my general surgery training and I do a lot of open surgery still. I think the integrated residency route is also excellent, but I would draw the line at saying open skills aren’t necessary. Sure I don’t need to take out a gallbladder or colon anymore, but I use my general surgery skills daily. There will always be a need for open surgery skills.

 

[babybat]

I value my general surgery training and I do a lot of open surgery still. I think the integrated residency route is also excellent, but I would draw the line at saying open skills aren’t necessary. Sure I don’t need to take out a gallbladder or colon anymore, but I use my general surgery skills daily. There will always be a need for open surgery skills.

Do you think the balance of procedures is shifting to be much more endovascular? I'm interested in both but I would want to have a consistent number of open procedures (at least 20% let's say).

 

[LucidSplash]

Do you think the balance of procedures is shifting to be much more endovascular? I'm interested in both but I would want to have a consistent number of open procedures (at least 20% let's say).

I do what I call “high octane community vascular surgery.” I do a lot of endo too. But I do fistulas/revisions, leg bypass, open aneurysm, amputations, open thrombectomy, fasciotomy, carotid endarterectomy…

I don’t do thoracic outlet because I don’t like it and I have a partner with an especial interest. Or open thoracic aneurysm because I don’t like operating in chest and have partners that love it.

There will always be a place for both.

 

[Medstart108]

Do you think the balance of procedures is shifting to be much more endovascular? I'm interested in both but I would want to have a consistent number of open procedures (at least 20% let's say).

You'll definitely have 20%. Still plenty of opportunity for fistulas, carotids. At least at my center, they seem to be moving away from lower limb bypasses and more towards stenting. A few open AAAs and ABFs. I would say 20% of your practice is very doable, but endo is definitely going to become bigger as the years go by. There are vascular surgeons who don't see enough volume to feel comfortable doing open AAAs anymore.

 

[babybat]

You'll definitely have 20%. Still plenty of opportunity for fistulas, carotids. At least at my center, they seem to be moving away from lower limb bypasses and more towards stenting. A few open AAAs and ABFs. I would say 20% of your practice is very doable, but endo is definitely going to become bigger as the years go by. There are vascular surgeons who don't see enough volume to feel comfortable doing open AAAs anymore.

Maybe this is a dumb question but what is driving this change? Is it evidence-based, patient or surgeon preference or something else?

 

[Medstart108]

Maybe this is a dumb question but what is driving this change? Is it evidence-based, patient or surgeon preference or something else?

Its driven by evidence that all but the most complex lesions can be stented safely and improving endovascular technology as well. Patients don't often have a preference I find, especially the vascular patient population tends to be pretty agreeable to what is recommended.

 

[Lem0nz]

I do what I call “high octane community vascular surgery.”

All I could picture was itchy and scratchy and massive bloodletting.

 

[LucidSplash]

All I could picture was itchy and scratchy and massive bloodletting.

Sometimes it looks a lot like this. 😂

 

[LucidSplash]

Its driven by evidence that all but the most complex lesions can be stented safely and improving endovascular technology as well. Patients don't often have a preference I find, especially the vascular patient population tends to be pretty agreeable to what is recommended.

And eventually all the endo stuff fails if the patient lives long enough. We all do endo first 95% of the time for PAD but that’s not the end of the story if you follow the patient long enough. Especially in diabetic/renal failure patients.

 

[DOVinciRobot]

And eventually all the endo stuff fails if the patient lives long enough. We all do endo first 95% of the time for PAD but that’s not the end of the story if you follow the patient long enough. Especially in diabetic/renal failure patients.

The joke in our general surgery program is that you do the stenting as the junior resident and then come back to do the bypass as the 5.

 

[babybat]

I do what I call “high octane community vascular surgery.” I do a lot of endo too. But I do fistulas/revisions, leg bypass, open aneurysm, amputations, open thrombectomy, fasciotomy, carotid endarterectomy…

I don’t do thoracic outlet because I don’t like it and I have a partner with an especial interest. Or open thoracic aneurysm because I don’t like operating in chest and have partners that love it.

There will always be a place for both.

yea vascular surgery seems so darn cool

 

[Chillbo Baggins]

I do...fasciotomy

This is a bit off topic, but this is a component of vascular training, correct? We've had an issue lately with vascular consulting us for rule out compartment syndrome, often *on their own patients*, and they've been trying to say they aren't comfortable doing fasciotomies, especially of the upper extremity. In one instance I had to go to the OR to squeeze the arm/forearm of a pt vascular was actively repairing a leak in the brachial artery from angio access leak.

We think it's primarily mediated by the fact we always have residents in house, while vascular there only has daytime APPs so they're dumping on us, but figured I'd ask if, in general, fasciotomies are something you guys feel ok handling.

 

[Smurfette]

The joke in our general surgery program is that you do the stenting as the junior resident and then come back to do the bypass as the 5.

Yup. Our slogan was "fem-pop, fem-clot, fem chop" on the vascular service. Just took a while to get through all the steps.

 

[DOVinciRobot]

This is a bit off topic, but this is a component of vascular training, correct? We've had an issue lately with vascular consulting us for rule out compartment syndrome, often *on their own patients*, and they've been trying to say they aren't comfortable doing fasciotomies, especially of the upper extremity. In one instance I had to go to the OR to squeeze the arm/forearm of a pt vascular was actively repairing a leak in the brachial artery from angio access leak.

We think it's primarily mediated by the fact we always have residents in house, while vascular there only has daytime APPs so they're dumping on us, but figured I'd ask if, in general, fasciotomies are something you guys feel ok handling.

At our shop our vascular attendings will call ortho for help with the forearm fasciotomies, but we still do neuro checks and such afterwards. Lower extremity we do fairly often and without any consulting.

 

[LucidSplash]

This is a bit off topic, but this is a component of vascular training, correct? We've had an issue lately with vascular consulting us for rule out compartment syndrome, often *on their own patients*, and they've been trying to say they aren't comfortable doing fasciotomies, especially of the upper extremity. In one instance I had to go to the OR to squeeze the arm/forearm of a pt vascular was actively repairing a leak in the brachial artery from angio access leak.

We think it's primarily mediated by the fact we always have residents in house, while vascular there only has daytime APPs so they're dumping on us, but figured I'd ask if, in general, fasciotomies are something you guys feel ok handling.

Lower leg yes. Thigh I guess, not that hard, rarely need to do. Some place is Ortho department. Forearm, not if I can help it. We do not really do these in training, typically the domain of hand or PRS or Ortho. I have done a grand total of 3 in my life. Once in Gen surg with a particular trauma attending who didn’t like to consult anyone else for anything. Once in fellowship I forget why but typically whoever was on call for hand would do. And once as an attending because I work at a community hospital and it was a delayed dx and I was there and PRS was tied up at another hospital 40 mins away. But in general I always ask hand to do it. They are more familiar with the forearm anatomy and those almost always need PRS for closure anyway. Also I am not comfortable with releasing the carpal tunnel based on my training or determining if hand fasciotomies are needed so overall the best people to do that are hand/PRS trained IMHO.

As far as “checking for compartment syndrome” I do not ask anyone else to do this in a leg. Where I trained there was an issue where the only striker needle in the hospital was “owned” by the Ortho residents and so if you wanted compartments checked for whatever reason we would have to call them and ask them to do it. And then they would always be pissed off about it even though it was above all our paygrades and ultimately the chairs got involved and it got resolved that Ortho would do them if a vascular attending deemed it necessary and then 6 months later we’d rehash it again with same result. 🤷🏼‍♀️

 

[Chillbo Baggins]

Lower leg yes. Thigh I guess, not that hard, rarely need to do. Some place is Ortho department. Forearm, not if I can help it. We do not really do these in training, typically the domain of hand or PRS or Ortho. I have done a grand total of 3 in my life. Once in Gen surg with a particular trauma attending who didn’t like to consult anyone else for anything. Once in fellowship I forget why but typically whoever was on call for hand would do. And once as an attending because I work at a community hospital and it was a delayed dx and I was there and PRS was tied up at another hospital 40 mins away. But in general I always ask hand to do it. They are more familiar with the forearm anatomy and those almost always need PRS for closure anyway. Also I am not comfortable with releasing the carpal tunnel based on my training or determining if hand fasciotomies are needed so overall the best people to do that are hand/PRS trained IMHO.

I guess that's fair. I don't find the difficulty of all of them (besides hand/foot) to very different, but I suppose I am working with the gross anatomy a lot more overall to be comfortable with it.

I thought it was funny regarding my brachial a. example that with that attending's open approach to the antecub, if fasciotomies had been needed, he would've just needed to run his fingers up and down the ends of the incision a little bit!

As far as “checking for compartment syndrome” I do not ask anyone else to do this in a leg. Where I trained there was an issue where the only striker needle in the hospital was “owned” by the Ortho residents and so if you wanted compartments checked for whatever reason we would have to call them and ask them to do it. And then they would always be pissed off about it even though it was above all our paygrades and ultimately the chairs got involved and it got resolved that Ortho would do them if a vascular attending deemed it necessary and then 6 months later we’d rehash it again with same result. 🤷🏼‍♀️

Oh lord 🙈, well I guess it's not an isolated experience. I'm sure those ortho residents would have loved to give up ownership of the needle haha

 

[droliver]

I work with 8 vascular surgeons in community practice and I’ve never heard of them not doing their own UE fasciotomy if needed. If you’re doing shunts, fistulas, and subclavian work it seems absolutely prerequisite to be competent at that. They’re usually the guys that get called by anesthesia or radiology with blown IV and contrast extravasation. Orthopedics does it on the trauma cases.

 

[LucidSplash]

I work with 8 vascular surgeons in community practice and I’ve never heard of them not doing their own UE fasciotomy if needed. If you’re doing shunts, fistulas, and subclavian work it seems absolutely prerequisite to be competent at that. They’re usually the guys that get called by anesthesia or radiology with blown IV and contrast extravasation. Orthopedics does it on the trauma cases.

Practice patterns will vary of course but I can tell you based on a recent straw poll on this topic on a national group chat of vascular surgeons that the vast majority deferred to PRS/hand for these so I feel confident in saying your experience, while valid obviously, is outside the average.

Will say have had a number of vascular surgeons tell me a recent trend has been younger orthopedic surgeons at a variety of institutions calling vascular for AKA/BKA because they “don’t feel comfortable.” Seems insane to me but they are claiming that they don’t get enough exposure in training. I don’t know how much is they just don’t want to do it though. Has not happened to me but again, practice patterns will vary.

 

[droliver]

Will say have had a number of vascular surgeons tell me a recent trend has been younger orthopedic surgeons at a variety of institutions calling vascular for AKA/BKA because they “don’t feel comfortable.” Seems insane to me but they are claiming that they don’t get enough exposure in training. I don’t know how much is they just don’t want to do it though.

I strongly suspect it’s “they (Ortho) don’t want to do it”

Speaking of local market trends: As far as plastics and hand/UE goes here, there’s just under 20 of them in private practice, and only 1 older surgeon has hand privileges anywhere. It’s a rapidly dying component of contemporary plastic surgery practice as hand surgery is increasingly an odd fit in most markets where elective hand surgery is dominated by orthopedics

 

[Chillbo Baggins]

Practice patterns will vary of course but I can tell you based on a recent straw poll on this topic on a national group chat of vascular surgeons that the vast majority deferred to PRS/hand for these so I feel confident in saying your experience, while valid obviously, is outside the average.

Will say have had a number of vascular surgeons tell me a recent trend has been younger orthopedic surgeons at a variety of institutions calling vascular for AKA/BKA because they “don’t feel comfortable.” Seems insane to me but they are claiming that they don’t get enough exposure in training. I don’t know how much is they just don’t want to do it though. Has not happened to me but again, practice patterns will vary.

That's disappointing. I will definitely feel comfortable doing both upper and lower amps in practice. But I guess it is program dependent. I also had the benefit of rotating on vascular as an intern (my class was the first to do vasc in addition to trauma surg) and getting first dibs on all the BKA/AKAs, so I ended up doing more LE amps as an intern that most of the graduating residents at the time, so maybe my experience was skewed...

 

[LucidSplash]

That's disappointing. I will definitely feel comfortable doing both upper and lower amps in practice. But I guess it is program dependent. I also had the benefit of rotating on vascular as an intern (my class was the first to do vasc in addition to trauma surg) and getting first dibs on all the BKA/AKAs, so I ended up doing more LE amps as an intern that most of the graduating residents at the time, so maybe my experience was skewed...

Yeah I mean I was trying to be nice but as droliver states above, strongly suspect they just don’t want to do. Easiest way to avoid doing something is to tell hospital administration you “don’t feel comfortable.”

 

[LucidSplash]

I strongly suspect it’s “they (Ortho) don’t want to do it”

Speaking of local market trends: As far as plastics and hand/UE goes here, there’s just under 20 of them in private practice, and only 1 older surgeon has hand privileges anywhere. It’s a rapidly dying component of contemporary plastic surgery practice as hand surgery is increasingly an odd fit in most markets where elective hand surgery is dominated by orthopedics

Agreed I know far more older PRS/hand guys than younger ones. My hospital we have an older solo private practice PRS/hand trained guy who will do just about anything and does a lot of debridements and such even. Very old school, when he retires practice patterns I suspect will change significantly. There is a younger Ortho hand surgeon but she is happy with her elective outpatient practice and so takes call when necessary but happy to have older private PRS guy do as much of that as he wants which is almost always unless out of town.

 

[TypeADissection]

All I could picture was itchy and scratchy and massive bloodletting.

No no no. It is called the "therapeutic releasing of bad humours." It can sometimes look like a murder scene though...

I do what I call “high octane community vascular surgery.” I do a lot of endo too. But I do fistulas/revisions, leg bypass, open aneurysm, amputations, open thrombectomy, fasciotomy, carotid endarterectomy…

I am in a similar position. Going through my monthly OR logs, I am surprised at how much open surgery is still a part of my practice and I consider myself someone who is very very endo aggressive especially for CLI. But when push comes to shove, sometimes you just have to do it open. I'm also thankful I had a good aortic experience in my training. I was told that I'd never do another open aorta if I left academia by a few of my attendings, and that just hasn't been true. I recently threw down an did an open juxtarenal rupture with my PA and just saw the guy for his 1-mo F/U doing great. It is practice dependent though, and if I was to join my buddy's large PP; I'd be driving all over the city and cranking out VV, angios and fistulagrams like a madman.

 

[Buzz Me]

Yup. Our slogan was "fem-pop, fem-clot, fem chop" on the vascular service. Just took a while to get through all the steps.

We always called it "fem-pop, fem-stop, fem-chop."