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[Blade runner 3000]

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[SpliceOfLife]

Congrats!

 

[_DeBakey_]

Decided on vascular surgery quite late, but still managed to match. Willing to talk about the application process, rotations, interviews, program reviews, day to day, or just the field itself. Make sure to check out threads from the other users who also have acknowledged vascular surgery as the greatest specialty ever (haha).

Super generic of course, but what's the biggest piece of advice you would give someone looking at matching 0+5?

I have reached out to several in the field and they all said being known and dedicated to the field is one of the most important factors, what do you think solidified your match, especially since you mentioned that you decided on vascular kind of late?

Pros and cons you feel of 0+5 vs 5+2?

And of course; BIG CONGRATS on matching!

 

[YCAGA]

Decided on vascular surgery quite late, but still managed to match. Willing to talk about the application process, rotations, interviews, program reviews, day to day, or just the field itself. Make sure to check out threads from the other users who also have acknowledged vascular surgery as the greatest specialty ever (haha).

Congrats and thanks for doing this!

Did you dual apply to general surgery and if so did you face any discrimination from GS programs on the interview trail?

Did you do any aways in VS and how important do you think they are? I have read that aways aren’t super important for GS and can be a blessing or a curse, whereas in ortho they are basically required. Curious how VS compares.

 

[_DeBakey_]

Thanks!

Biggest piece of advice would be to be committed to the field and to make sure programs know you’re committed as well. It’s a tough residency with usually only 1 position per year per program. Board scores and research matter, but letters by far outweigh those in my experience. In a small field nothing says more than an academic reference as most vascular surgeons in residency programs know each other. Therefore either secure good letters from your own program (if your school has them) or rotate somewhere you can get a solid reference (also helps reinforce your own exposure and passion for the specialty). These people will make calls for you.

What solidified my match? My board scores and research were on par for the course. But my story explaining how I ended up in vascular and the program vouching for me made all the difference in securing the interview, while I feel enthusiasm and respect were the reasons I was ranked highly enough to match.

Fellowship route: you’re a full blown surgeon with enough time to know what you’re getting into (for those who didn’t realize it was the best field ever right away). You’ll come into your vascular training already having years of chief/senior resident experience. Running a service will not be new for you. There’s more open abdominal experience, but also more less relevant experience and an additional two years doing something other than vascular (more if your program has research years).

Residency: saves time, and your initial 2-3 years of general surgery are more tailored towards didactica and rotations more specific to vascular. No more bariatric months for example. Total vascular experience tends to be 3-3.5 years, so more time doing what you need to do. You’ll get early priority for vascular cases compared to general surgery residents. You may be less experienced in trauma ex laps, but better in endovascular training (everything tends to equalize a few years into practice however).

How much research did you have? Was it primarily vascular? I'm trying to get involved in some projects right now.

Another poster above me already mentioned this but I am curious if you did any dual applying to GS or if you did any auditions? Were they at the program you matched at?

I'm at a DO school so for us doing auditions is often very important (at least for for DO general surgery programs I've heard).

Thanks for doing this as well!

 

[YCAGA]

Definitely dual applied, had essentially two separate applications. Letters, personal statements, etc. Do not tell anyone you’re dual applying. General surgery will ask (which they’re not allowed to, so answer how you see fit) but vascular won’t care because they know it’s a necessity.

Vascular away rotations are important, but I wouldn’t do more than two (not including home vascular rotation if you have a residency program). You’d likely still need to fit in a general surgery sub internship at your home program early to get letters from them.

Realistically only your July and August months will yield any letters in time, so a September or October rotation is only for your personal benefit at increasing your shot at a program you may really want to match in. So maybe do a general surgery and two vascular rotations. It’s not as gunner of a field as ortho where people do five rotations.

Thanks! I assume GS programs ask when they see vascular surgery research? Do some people straight up deny that they are also applying vascular?

And would I be correct to assume that you don’t apply GS and vascular at the same school? So you essential eliminate any GS programs that also have a vascular program. Also assuming you apply to every vascular program.

My school doesn’t have a vascular residency program :/ does have fellowship though. I’m not really at a stage where I need to personally worry about aways (I don’t even know if I want to do integrated vascular lol), but what are your thoughts on M4 schedule if you don’t have a home program?

 

[YCAGA]

I will also say

Some general surgery programs ask, those ones tended to be the malignant programs in my interview experience. Those ones also did a ton of interview and match violations which is a story for another day. Your response is up to you, you can counter illegal and unethical questions by denying your application to vascular, you can be honest, or you can skillfully change the subject, or just tell them not to ask banned questions if you’re brave enough like some people I’ve heard.

I applied to both fields in the same program. The vast majority of time, nobody would know unless the program director or secretaries are similar. I’ve even gotten both general and vascular interviews at some programs.

You don’t need to apply to every vascular program. A reasonable application yields many interviews in the vascular world, as the criteria for inviting tends to be fairly similar. Out of the 65 programs, I wouldn’t do more than 40, places you actually want to go to. Applicants had way too many interviews to attend in the past cycle, and applying to additional programs you won’t attend has low marginal benefit.

A vascular fellowship is good enough. Other residencies will know the leadership at your program, so I wouldn’t worry. Would recommend a general surgery and two vascular rotations. If you can do a vascular elective during your third year, take it. Do research with them and scrub in your spare time, but I’m not sure whether using one of your fourth year rotations to do a month at a program you can’t match at would be the most efficient use of time. My personal opinion based on little experience, so I could be wrong though.

Thanks again. I am learning a lot. I didn’t even know asking about applying to GS was a banned question.

We have two 2-week “career exploration” electives during M3 but otherwise just core rotations and last I checked vascular wasn’t an option during our 8 weeks of general surgery, but they might be flexible. Did you shadow/scrub as an M2? And is research pretty much the only thing I can/should focus on during preclinical years if I decide vascular is for me?

 

[_DeBakey_]

Thanks!

Biggest piece of advice would be to be committed to the field and to make sure programs know you’re committed as well. It’s a tough residency with usually only 1 position per year per program. Board scores and research matter, but letters by far outweigh those in my experience. In a small field nothing says more than an academic reference as most vascular surgeons in residency programs know each other. Therefore either secure good letters from your own program (if your school has them) or rotate somewhere you can get a solid reference (also helps reinforce your own exposure and passion for the specialty). These people will make calls for you.

What solidified my match? My board scores and research were on par for the course. But my story explaining how I ended up in vascular and the program vouching for me made all the difference in securing the interview, while I feel enthusiasm and respect were the reasons I was ranked highly enough to match.

Fellowship route: you’re a full blown surgeon with enough time to know what you’re getting into (for those who didn’t realize it was the best field ever right away). You’ll come into your vascular training already having years of chief/senior resident experience. Running a service will not be new for you. There’s more open abdominal experience, but also more less relevant experience and an additional two years doing something other than vascular (more if your program has research years).

Residency: saves time, and your initial 2-3 years of general surgery are more tailored towards didactics and rotations more specific to vascular. No more bariatric months for example. Total vascular experience tends to be 3-3.5 years, so more time doing what you need to do. You’ll get early priority for vascular cases compared to general surgery residents. You may be less experienced in trauma ex laps, but better in endovascular training (everything tends to equalize a few years into practice however).

This advice is gold!

So this may be a loaded question but what did your 3rd and 4th year look like in terms of auditions and electives overall?

I was told I should be looking to do 2-3+ auditions in vascular and one in general surgery (auditions play a bigger role in former DO general surgery).

 

[TypeADissection]

Congrats. Welcome to the club. Your next 5 years are going to be some of the best and worst of times, but you'll look back on it fondly. Whenever we get together for meetings again in person, opening round of beers is on me. Cheers.

 

[LucidSplash]

Congrats. Welcome to the club. Your next 5 years are going to be some of the best and worst of times, but you'll look back on it fondly. Whenever we get together for meetings again in person, opening round of beers is on me. Cheers.

2nd/3rd on me I guess since I’m an attending now.

I am so ready for in person meetings again!

 

[TraumaLlamaMD]

At my Easter basket the rabbits were very receptive to students scrubbing in.

Ok this is pretty funny after all!

 

[_DeBakey_]

I think your plan is fine. Make sure you have some light rotations during December and January especially so you can attend as many Easter egg hunts as possible.

Any advice on good light rotations during that time which may be useful for vascular?

 

[YCAGA]

Any advice on good light rotations during that time which may be useful for vascular?

Does your school let you miss rotations during interview season? We are required to take those months off

 

[SpinDrift]

Any insight as to how competitive 0+5 residency is? I've read on other forums that its inflated due to dual specialty applications and some applicants only applying to a handful of 0+5 spots but when its charted it makes it seem like all 140 applicants applied to all spots available.

 

[SpinDrift]

I've heard that the University of Kentucky and the University of Utah both have 0+5 programs in the works.....anyone know of any other new ones popping up?

 

[YCAGA]

What are people’s thoughts on CT surgery residency/fellowship (the 2-3 year one) after integrated vascular surgery residency? This program offers it and says they are the only place in the country. Vascular Surgery Residency Program | Allegheny Health Network

I know one surgeon locally who did general surgery and then vascular and CT surgery fellowships so 9 years of post graduate training. He does CT work and heart transplants…apparently this route isn’t unheard of for people who want to do heart transplants. He is super nice from what I have heard and I am going to shadow him, just curious what you all think. @TypeADissection @ThoracicGuy (let me know if there are other CT and vascular attendings/residents frequent posters on here…your two usernames are just the most memorable to me).

 

[YCAGA]

About 181 applicants for 79 spots in 2021, with ~65/95 MD seniors who matched. Not sure if there’s any way to tell how competitive any specialty is if you incorporate dual applicants. I’m sure many dermatology or plastics applicants also have backup specialties too.

The strongest correlation for matched vs unmatched MD’s on 2020 charting outcomes seems to be going to a top 40 NIH funded medical school, which makes sense since those schools often have a 0+5 program. 40% of matched MD applicants went to a top MD school, but the match rates within groups was 92% for top 40 students and 74% for everyone else.

 

[ThoracicGuy]

What are people’s thoughts on CT surgery residency/fellowship (the 2-3 year one) after integrated vascular surgery residency? This program offers it and says they are the only place in the country. Vascular Surgery Residency Program | Allegheny Health Network

I know one surgeon locally who did general surgery and then vascular and CT surgery fellowships so 9 years of post graduate training. He does CT work and heart transplants…apparently this route isn’t unheard of for people who want to do heart transplants. He is super nice from what I have heard and I am going to shadow him, just curious what you all think. @TypeADissection @ThoracicGuy (let me know if there are other CT and vascular attendings/residents frequent posters on here…your two usernames are just the most memorable to me).

To apply to the CT Surgery traditional pathway, you can complete General Surgery or an Integrated Vascular Surgery training program.

I suspect there aren't too many people that practice CT and Vascular on a regular basis, though there are some out there.

 

[YCAGA]

To apply to the CT Surgery traditional pathway, you can complete General Surgery or an Integrated Vascular Surgery training program.

I suspect there aren't too many people that practice CT and Vascular on a regular basis, though there are some out there.

Do you think there would be any strengths/weaknesses to either pathway (general surgery vs integrated vascular surgery) for someone who ends up doing CT surgery? I assume anyone doing a traditional CT fellowship is planning to practice mainly CT surgery and not much if any vascular or general surgery work, like you said.

 

[SpliceOfLife]

Do you think there would be any strengths/weaknesses to either pathway (general surgery vs integrated vascular surgery) for someone who ends up doing CT surgery? I assume anyone doing a traditional CT fellowship is planning to practice mainly CT surgery and not much if any vascular or general surgery work, like you said.

I think you should train in whatever area you plan on going into. It doesn't make sense to me to do a CT fellowship but then to spend most of your time in vascular or general surgery. If you want to do those fields then stick with those fields.

If you want to do CT surgery then also consider applying for integrated CT.

 

[ThoracicGuy]

Do you think there would be any strengths/weaknesses to either pathway (general surgery vs integrated vascular surgery) for someone who ends up doing CT surgery? I assume anyone doing a traditional CT fellowship is planning to practice mainly CT surgery and not much if any vascular or general surgery work, like you said.

I'd say generally pick one or the other. If you are unsure, go with General Surgery which allows both through the traditional fellowship pathways.

 

[_DeBakey_]

I’m drawn to doing vascular and then cardiac.

Do you think it’s rare to find surgeons due to not wanting to do both? Or is it difficult to be part of both departments?

One of the docs at Houston Methodist has done general surgery with vascular and cardiothoracic fellowships. I’m sure that’s even less common but truly a pathway to have training in all of it.

 

[YCAGA]

I’m drawn to doing vascular and then cardiac.

Do you think it’s rare to find surgeons due to not wanting to do both? Or is it difficult to be part of both departments?

One of the docs at Houston Methodist has done general surgery with vascular and cardiothoracic fellowships. I’m sure that’s even less common but truly a pathway to have training in all of it.

I’m just a medical student but I think it would be hard to be fresh and “good” at both. From what I understand, cardiac surgery especially is all about volume to be technically proficient (this applies to surgery in general though). Curious what actual surgeons think haha

 

[TypeADissection]

What are people’s thoughts on CT surgery residency/fellowship (the 2-3 year one) after integrated vascular surgery residency? This program offers it and says they are the only place in the country. Vascular Surgery Residency Program | Allegheny Health Network

I know one surgeon locally who did general surgery and then vascular and CT surgery fellowships so 9 years of post graduate training. He does CT work and heart transplants…apparently this route isn’t unheard of for people who want to do heart transplants. He is super nice from what I have heard and I am going to shadow him, just curious what you all think. @TypeADissection @ThoracicGuy (let me know if there are other CT and vascular attendings/residents frequent posters on here…your two usernames are just the most memorable to me).

I don't have a lot of insight into that program. I think the big thing is to find out where their graduates are going. Are they staying in academia? Are they going into PP? Are they primarily cardiac or vascular? How much thoracic are they doing? Who's giving them their board certification?

The bigger thing to ask yourself is how you want to spend your days. Every specialty has their own unique cross to bear, so you're going to have to find out what that thing is that you can tolerate. My former chief resident, who is now a cardiac surgeon once said, "We are all going to get woken up at 0200 for something. What is that thing you want to be woken up for?" In her case, she loves ascending arch and cardiac work. In vascular, there are a lot of stank feet. Many of my buddies in general surgery just couldn't stand the foot work or even the frequent bounce backs on the vascular service. For me, I was just drawn to the technicality and sophistication of the cases that I was able to do. I tinkered with the idea of CTS for a few months while on the service but realized that I didn't enjoy the thoracic and esophageal work as much as the cardiac work, and you're going to have to do both while in training. I also didn't like tumor board and vascular is about as far removed from Onc as anything can be for the most part, although there are a fair amount of carotid body tumors in this area. So, you just have to get exposure and really sit down and envision what you want in a future practice and how you want to go to work each day. Cheers.

 

[YCAGA]

I don't have a lot of insight into that program. I think the big thing is to find out where their graduates are going. Are they staying in academia? Are they going into PP? Are they primarily cardiac or vascular? How much thoracic are they doing? Who's giving them their board certification?

The bigger thing to ask yourself is how you want to spend your days. Every specialty has their own unique cross to bear, so you're going to have to find out what that thing is that you can tolerate. My former chief resident, who is now a cardiac surgeon once said, "We are all going to get woken up at 0200 for something. What is that thing you want to be woken up for?" In her case, she loves ascending arch and cardiac work. In vascular, there are a lot of stank feet. Many of my buddies in general surgery just couldn't stand the foot work or even the frequent bounce backs on the vascular service. For me, I was just drawn to the technicality and sophistication of the cases that I was able to do. I tinkered with the idea of CTS for a few months while on the service but realized that I didn't enjoy the thoracic and esophageal work as much as the cardiac work, and you're going to have to do both while in training. I also didn't like tumor board and vascular is about as far removed from Onc as anything can be for the most part, although there are a fair amount of carotid body tumors in this area. So, you just have to get exposure and really sit down and envision what you want in a future practice and how you want to go to work each day. Cheers.

Wow thank you so much! This is really great advice. It is cool that these integrated CT and vascular programs exist, but for me at least, it is a little intimidating trying to get enough exposure in medical school to these fields. Especially because I know I have the option of doing general surgery to get experience in them as a resident to better see what I like (and hate). I think that is what makes them a little different than ortho, uro, ENT, ophtho where you don’t have another path to reach those.

Also they are so competitive in terms of spots that it feels like I have to decide on one before M3 even begins if I want to be competitive in terms of research and connections.

 

[_DeBakey_]

I’m just a medical student but I think it would be hard to be fresh and “good” at both. From what I understand, cardiac surgery especially is all about volume to be technically proficient (this applies to surgery in general though). Curious what actual surgeons think haha

I'd like to hear too. Like I said, I know there are some who are double boarded, I'm curious what kind of procedures they are doing.

 

[LucidSplash]

I’m drawn to doing vascular and then cardiac.

Do you think it’s rare to find surgeons due to not wanting to do both? Or is it difficult to be part of both departments?

One of the docs at Houston Methodist has done general surgery with vascular and cardiothoracic fellowships. I’m sure that’s even less common but truly a pathway to have training in all of it.

There will probably be a select subset of integrated vascular residents across the country who pursue cardiac fellowships but it will not be “the norm.” The surgeon at Methodist who does both vasc & cards did gen Surg—>vascular fellowship. Then later went back to do cardiac in order to be able to operate on the the entire aorta. Additionally, at that Methodist program, the residents have more than average interaction with cardiac because CTS and vascular are part of the same department there, which is less common across the country. So it makes sense that there will be trainees from there especially who would be develop that interest. I think they will most likely end up aortic specialists at big centers with that kind of training but who knows. But I don’t imagine they are going to be seeking out high volume dialysis or limb salvage practice positions with that kind of training. But it will depend on the individuals I supposed.

 

[LucidSplash]

I'd like to hear too. Like I said, I know there are some who are double boarded, I'm curious what kind of procedures they are doing.

Dr. Marvin D. Atkins Jr. | Houston Methodist

www.houstonmethodist.org

His profile lists what procedures he does. Just one guy but my guess is that such training will result in similar profiles.

 

[_DeBakey_]

Dr. Marvin D. Atkins Jr. | Houston Methodist

www.houstonmethodist.org

His profile lists what procedures he does. Just one guy but my guess is that such training will result in similar profiles.

That's the guy!

 

[LucidSplash]

This may be of interest.

 

[TypeADissection]

That's the guy!

Insert "LeonardoDiCapriopointing.gif"

 

[YCAGA]

This may be of interest.

Literally couldn’t have asked for a better video. Thank you!!!

 

[Banco]

This may be of interest.

Yo this channel has awesome surgery videos.

 

[LucidSplash]

Yo this channel has awesome surgery videos.

Yo yes it is a great resource.

 

[_DeBakey_]

That video was awesome and definitely informative about different possible training pathways.

What are the thoughts on that "old school" community surgeon who does, cardiac, thoracic and vascular? My hometown hospital had one of those guys before he retired, I think he was trained in general surgery --> CT but also did some vascular work.

Sorry if I'm coming off annoying lol, just trying to see what pathways and practice models may exist out there.

 

[LucidSplash]

That video was awesome and definitely informative about different possible training pathways.

What are the thoughts on that "old school" community surgeon who does, cardiac, thoracic and vascular? My hometown hospital had one of those guys before he retired, I think he was trained in general surgery --> CT but also did some vascular work.

Sorry if I'm coming off annoying lol, just trying to see what pathways and practice models may exist out there.

These guys exist but are fewer and far between each year. My friends that are CT who also do vascular do it because it is necessary, not because they want to. And they tend to stick to basic Fempop and such, depend on IR for lysis and angio, only do basic dialysis work if they do it, open declots etc. They tend not to have the endovascular skills with Gen surg and CT training only and also aren’t that interested. One friend who joined PP CTS on the edge of a big city did this but when that group ultimately dissolved he actively sought a job that did not require vascular work. Only did it because his senior partner did.

Frankly can’t really see integrated vascular + cardiac fellowship doing this at all, likely not the reason they choose to do the fellowship.

And quite frankly I think in this day and age there is simply too much to know and do in each field to do all 3 in a superior fashion.

 

[_DeBakey_]

These guys exist but are fewer and far between each year. My friends that are CT who also do vascular do it because it is necessary, not because they want to. And they tend to stick to basic Fempop and such, depend on IR for lysis and angio, only do basic dialysis work if they do it, open declots etc. They tend not to have the endovascular skills with Gen surg and CT training only and also aren’t that interested. One friend who joined PP CTS on the edge of a big city did this but when that group ultimately dissolved he actively sought a job that did not require vascular work. Only did it because his senior partner did.

Frankly can’t really see integrated vascular + cardiac fellowship doing this at all, likely not the reason they choose to do the fellowship.

And quite frankly I think I’m this day and age there is simply too much to know and do in each field to do all 3 in a superior fashion.

Exactly my thoughts ^^^

Thanks for the reply!

 

[TypeADissection]

These guys exist but are fewer and far between each year. My friends that are CT who also do vascular do it because it is necessary, not because they want to. And they tend to stick to basic Fempop and such, depend on IR for lysis and angio, only do basic dialysis work if they do it, open declots etc. They tend not to have the endovascular skills with Gen surg and CT training only and also aren’t that interested. One friend who joined PP CTS on the edge of a big city did this but when that group ultimately dissolved he actively sought a job that did not require vascular work. Only did it because his senior partner did.

Frankly can’t really see integrated vascular + cardiac fellowship doing this at all, likely not the reason they choose to do the fellowship.

And quite frankly I think in this day and age there is simply too much to know and do in each field to do all 3 in a superior fashion.

I agree completely. The body of knowledge has changed as well as the skillset. You have to be doing it regularly to get really good at it. Having been an attending now for 6 months, it's scary to think how much better I am now than I was when I started. Vascular surgery is an imperfect solution to a complex series of problems that many people don't want to get involved in. Everything we do will eventually fail because vascular surgery by its nature is constructive. We make bypasses from weird places sometimes, or sew grafts into difficult places, or do EVARs, or recanalize long segments of occluded vessels, etc. Compare that to other specialties where you're essentially taking things out and so be it (gross oversimplification). But by the very nature of being constructive, it requires us to start thinking multiple steps ahead about what our Plans B and C will be or our "Break Glass in Case of Emergency" plan when everything goes wrong. So now extrapolate that to someone who is a general surgeon who is also dabbling in vascular or thoracic surgery. I am not trying to throw shade at all, but you can't tell me that they will be able to think through the nuances of decision making for vascular patients the same that a trained vascular surgeon will; or even be able to provide the same breadth of operations. In my humble opinion, I think those days of general surgeons being able to do everything are long gone. My residency PD was one of those guys, but there isn't a single one of us that left our program being able to do all that he could do. The times have changed, the training has changed. Cheers.

 

[_DeBakey_]

I agree completely. The body of knowledge has changed as well as the skillset. You have to be doing it regularly to get really good at it. Having been an attending now for 6 months, it's scary to think how much better I am now than I was when I started. Vascular surgery is an imperfect solution to a complex series of problems that many people don't want to get involved in. Everything we do will eventually fail because vascular surgery by its nature is constructive. We make bypasses from weird places sometimes, or sew grafts into difficult places, or do EVARs, or recanalize long segments of occluded vessels, etc. Compare that to other specialties where you're essentially taking things out and so be it (gross oversimplification). But by the very nature of being constructive, it requires us to start thinking multiple steps ahead about what our Plans B and C will be or our "Break Glass in Case of Emergency" plan when everything goes wrong. So now extrapolate that to someone who is a general surgeon who is also dabbling in vascular or thoracic surgery. I am not trying to throw shade at all, but you can't tell me that they will be able to think through the nuances of decision making for vascular patients the same that a trained vascular surgeon will; or even be able to provide the same breadth of operations. In my humble opinion, I think those days of general surgeons being able to do everything are long gone. My residency PD was one of those guys, but there isn't a single one of us that left our program being able to do all that he could do. The times have changed, the training has changed. Cheers.

I would love to be able to do 0+5 and then do 2/3 of CTS and do "cardiovascular". I was told by a doc that did this path that in other countries this is more of the norm? Doing carotids, AAA, PAD along with the CABGs. The thoracic side is more separate and probably better suited for the general surgery trained folks.

Again I hate looking like some starry eyed med student but I hope I can find a way to make whatever path I chose, work for me

 

[LucidSplash]

I agree completely. The body of knowledge has changed as well as the skillset. You have to be doing it regularly to get really good at it. Having been an attending now for 6 months, it's scary to think how much better I am now than I was when I started. Vascular surgery is an imperfect solution to a complex series of problems that many people don't want to get involved in. Everything we do will eventually fail because vascular surgery by its nature is constructive. We make bypasses from weird places sometimes, or sew grafts into difficult places, or do EVARs, or recanalize long segments of occluded vessels, etc. Compare that to other specialties where you're essentially taking things out and so be it (gross oversimplification). But by the very nature of being constructive, it requires us to start thinking multiple steps ahead about what our Plans B and C will be or our "Break Glass in Case of Emergency" plan when everything goes wrong. So now extrapolate that to someone who is a general surgeon who is also dabbling in vascular or thoracic surgery. I am not trying to throw shade at all, but you can't tell me that they will be able to think through the nuances of decision making for vascular patients the same that a trained vascular surgeon will; or even be able to provide the same breadth of operations. In my humble opinion, I think those days of general surgeons being able to do everything are long gone. My residency PD was one of those guys, but there isn't a single one of us that left our program being able to do all that he could do. The times have changed, the training has changed. Cheers.

Especially that plan B,C etc stuff. Sometimes after an endo intervention, if I think likelihood of longevity is in question for whatever reason (anatomy, complexity of the problem, compliance, almost anything), I’ll get BLE vein mapping before the patient leaves the hospital. The residents think I’m nuts but sometimes but I’m like “yeah but if she comes back with a bad problem at 2 am then at least you’ll have that info already.”

Vascular patients man. Will keep you on your toes.

 

[LucidSplash]

I would love to be able to do 0+5 and then do 2/3 of CTS and do "cardiovascular". I was told by a doc that did this path that in other countries this is more of the norm? Doing carotids, AAA, PAD along with the CABGs. The thoracic side is more separate and probably better suited for the general surgery trained folks.

Again I hate looking like some starry eyed med student but I hope I can find a way to make whatever path I chose, work for me

Yes probably more common to do cardiac and vascular together in other countries. Because it was that way here 50 years ago. But also I bet “other countries” are doing less advanced endovascular work. When it was all open, that was one thing.

But you saw the videos. Doing cardiac & vascular is possible these days, just not common. But the whole doing general surgery plus cardiac plus vascular when you graduate and are in practice is essentially dead.

If you’re competitive for integrated cardiac or vascular, I recommend that ultimately you pick the thing you like absolutely best and marshall your resources to apply to that field; if you want to do the vascular or cardiac fellowship afterward, you’ll have that option.

And it is good to have enthusiasm. And maybe you’ll be one of these rare dual boarded cardiac and vascular surgeons. But construct your plan in a way that you’ll get the training in the area you like best first, so if you get tired or change your mind along the way, you’ll have that “best” thing to fall back on.

 

[TypeADissection]

...I’ll get BLE vein mapping before the patient leaves the hospital. The residents think I’m nuts but sometimes but I’m like “yeah but if she comes back with a bad problem at 2 am then at least you’ll have that info already.”

Vascular patients man. Will keep you on your toes.

I literally did this on Monday. Complex patient w/ redo groins from endarts and cutdowns from a previous EVAR. Now presents with CLTI LLE w/ rest pain. ABI is 0.18 and toe pressure is 8 (maybe). Can't go R2P or even get a good run because his LSCA is occluded. On Duplex it does look like his AT is patent but there's diffuse atherosclerosis throughout. So now I'm thinking about trying to get across that and then stent on the way out. Can't get a CTA w/ runoff because he's been borderline living in CKD3-4. I'm thinking of antegrade accessing his CFA and shooting a run through microsheath and then seeing what his distal target is for bypass. He has juicy GSVs B/L. Then throwing down and coming off profunda for inflow and stay out of doing a three-do groin exposure. Oh yeah. The joys of vascular surgery. I swear, the people that go into this field are just built a little different. Cheers.

 

[_DeBakey_]

Yes probably more common to do cardiac and vascular together in other countries. Because it was that way here 50 years ago. But also I bet “other countries” are doing less advanced endovascular work. When it was all open, that was one thing.

But you saw the videos. Doing cardiac & vascular is possible these days, just not common. But the whole doing general surgery plus cardiac plus vascular when you graduate and are in practice is essentially dead.

If you’re competitive for integrated cardiac or vascular, I recommend that ultimately you pick the thing you like absolutely best and marshall your resources to apply to that field; if you want to do the vascular or cardiac fellowship afterward, you’ll have that option.

And it is good to have enthusiasm. And maybe you’ll be one of these rare dual boarded cardiac and vascular surgeons. But construct your plan in a way that you’ll get the training in the area you like best first, so if you get tired or change your mind along the way, you’ll have that “best” thing to fall back on.

I will definitely continue to dream big, but keep my head down and remain aware of the reality of everything we have been discussing.

 

[LucidSplash]

I literally did this on Monday. Complex patient w/ redo groins from endarts and cutdowns from a previous EVAR. Now presents with CLTI LLE w/ rest pain. ABI is 0.18 and toe pressure is 8 (maybe). Can't go R2P or even get a good run because his LSCA is occluded. On Duplex it does look like his AT is patent but there's diffuse atherosclerosis throughout. So now I'm thinking about trying to get across that and then stent on the way out. Can't get a CTA w/ runoff because he's been borderline living in CKD3-4. I'm thinking of antegrade accessing his CFA and shooting a run through microsheath and then seeing what his distal target is for bypass. He has juicy GSVs B/L. Then throwing down and coming off profunda for inflow and stay out of doing a three-do groin exposure. Oh yeah. The joys of vascular surgery. I swear, the people that go into this field are just built a little different. Cheers.

This is exactly the kind of case that your average Gen surg who dabbles in vascular or CTS who does a little vascular probably wouldn’t want to deal with. I know more than one who would just offer primary amp if the pop isn’t open.

Godspeed. Agree, sometimes I find myself muttering “this is such a stupid job” in the middle of a hard case but truth is I love it.

I like the sound of your plan. Antegrade here is just what I would do. If you aren’t even thinking of intervening endo then don’t bother with the antegrade approach, just stick the usual way ipsi and take your pics and get out. But if you still think you might have a chance from a combined antegrade access with maybe a retrograde tibial stick, then go for it endo. But I’d make sure I had a good shot of the PFA takeoff so there’s no inflow issues from the bypass you’re going to end up doing at some point on this person, even if not today.

Maybe consider lateral approach to the PFA.

 

[TypeADissection]

This is exactly the kind of case that your average Gen surg who dabbles in vascular or CTS who does a little vascular probably wouldn’t want to deal with. I know more than one who would just offer primary amp if the pop isn’t open.

Godspeed. Agree, sometimes I find myself muttering “this is such a stupid job” in the middle of a hard case but truth is I love it.

I like the sound of your plan. Antegrade here is just what I would do. If you aren’t even thinking of intervening endo then don’t bother with the antegrade approach, just stick the usual way ipsi and take your pics and get out. But if you still think you might have a chance from a combined antegrade access with maybe a retrograde tibial stick, then go for it endo. But I’d make sure I had a good shot of the PFA takeoff so there’s no inflow issues from the bypass you’re going to end up doing at some point on this person, even if not today.

Maybe consider lateral approach to the PFA.

I swear you're inside my head, because I've definitely had this running dialogue. I'm also definitely going lateral to catch the PFA when the time comes to throw down. And this ladies and gentlemen, is why we do vascular surgery. Not because it is easy, because it isn't. But because the few of us that do it on a daily basis just love the grind of getting through cases like this. And there are so many out there to be done. I did a fen this past week and the entire time when I was having trouble with the right renal, I just kept dropping f-bombs under my breath and cursing at myself for doing these cases. Then when it was all over and the completion aortogram looked pristine, I thought to myself, "Oh that wasn't too bad. The next one should be fun too." Cheers to all crazy enough to consider this.

 

[Banco]

I literally did this on Monday. Complex patient w/ redo groins from endarts and cutdowns from a previous EVAR. Now presents with CLTI LLE w/ rest pain. ABI is 0.18 and toe pressure is 8 (maybe). Can't go R2P or even get a good run because his LSCA is occluded. On Duplex it does look like his AT is patent but there's diffuse atherosclerosis throughout. So now I'm thinking about trying to get across that and then stent on the way out. Can't get a CTA w/ runoff because he's been borderline living in CKD3-4. I'm thinking of antegrade accessing his CFA and shooting a run through microsheath and then seeing what his distal target is for bypass. He has juicy GSVs B/L. Then throwing down and coming off profunda for inflow and stay out of doing a three-do groin exposure. Oh yeah. The joys of vascular surgery. I swear, the people that go into this field are just built a little different. Cheers.

I recognize some of these words.

 

[SpinDrift]

You and me both

 

[SpinDrift]

What's the word on integrated vasc residency lifestyle? I would assume its comparable to gen surg?

 

[_DeBakey_]

What's the word on integrated vasc residency lifestyle? I would assume its comparable to gen surg?

Also wouldn’t mind hearing this

 

[LucidSplash]

What's the word on integrated vasc residency lifestyle? I would assume its comparable to gen surg?

Vascular surgery is generally felt to have some of the highest acuity and most emergencies of most surgical specialties. Gen surg is up there too, neurosurg probably at the top.

So yes you should expect about the same “lifestyle” during residency/fellowship as Gen surg.

Vascular can get dumped on slightly less than Gen surg. But the flip side is that no one outside of vascular really understands vascular so you get a lot of consults because “blood vessels exist nearby.”