The Impact of Increasing Endovascular Intervention for Claudication on Vascular Surgery Training Programs

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William B. Keeling, MD, Patrick A. Stone, MD, Paul A. Armstrong, DO, Heather Kearney, BA, Lisa Klepczyk, BA, Elizabeth Blazick, PA-C, Martin R. Back, MD, Brad L. Johnson, MD, Dennis F. Bandyk, MD, Murray L. Shames, MD.
University of South Florida, Tampa, FL, USA.

Background: Vascular residency programs have increasingly incorporated endovascular therapies into residency training. Claudication, a condition traditionally managed medically, has lent itself to treatment via endovascular techniques. We hypothesized that an increase in endovascular procedures for the management of claudication would result in a decrease in open procedures and a change in vascular resident training
Methods: We reviewed all patient charts from January 2000 through June 2005 at our institution. All patients with the diagnosis of claudication who underwent operative intervention with a vascular resident present at the operation were included. Procedures were designated as either inflow procedures (originating above the inguinal ligament) or runoff procedures (originating below the inguinal ligament). Periods were divided into years 2000 to 2002 (Period 1) and 2003 to 2005-projected (Period 2) according to our experience with endovascular techniques. Statistical analysis was undertaken with student’s t-test, chi-squared test, and log-rank test, and results were compared.
Results: From 2000 to 2005, there were 309 total procedures (173 open procedures - 56.0%:150 inflow procedures - 48.5%) performed for claudication with a vascular resident present. Of the total procedures, 116 (37.5%) were performed during period 1 while 193 (62.5%) were performed during period 2 (p<.001). Endovascular inflow procedures saw a significant increase from period 1 to period 2 (17 to 59; p=.02) whereas open procedures did not (45 to 29; p=.18). Total inflow procedures were not significantly changed (62 to 88; p=.13). Total runoff procedures, however, saw a significant increase from period 1 to period 2 (54 to 104; p=.02). Endovascular runoff procedures showed a trend toward an increase (9 to 51; p=.06), but open runoff procedures showed no difference between the two periods (45 to 54; p=.29). With a mean duplex follow-up of 16 and 18 months respectively for inflow and infrainguinal procedures, there was no difference in assisted patency rates between periods 1 and 2 (p=.66 inflow and p=.99 runoff). Lengths of stay also declined between periods 1 and 2 as a result of increasing endovascular interventions (6.5 v. 4.3 days for inflow group [p=ns]; 6.9 v. 3.5 days for runoff group [p=.06]).
Conclusions: Our data demonstrate that vascular residents are performing significantly more operative procedures for the treatment of claudication, and these procedures are largely endovascular. This training, however, has not come at the expense of open procedures as there has been no significant decrease in these procedures. Endovascular procedures have proven to be durable, and due to the prevalence of endovascular methods, lengths of stay have declined. We conclude that the operative experience in our training program has shifted to reflect an increase in endovascular procedures for the management of claudication and possibly a decrease in the threshold for operative intervention.

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