OBJECTIVES:Nutcracker syndrome (NCS) is an uncommon vascular disease, characterized by anatomical compression of the left renal vein (LRV). Associated symptoms include flank and pelvic pain, as well as hematuria and varicocele. Our objective was to examine the contemporary management of NCS including diagnostic workup for and outcomes of nonoperative and operative treatments. METHODS:Patients diagnosed with NCS between 2000 and 2024 were identified through the Vascular Low Frequency Disease Consortium. Demographic, diagnostic, and treatment modalities were reported, including primary and secondary patency, reintervention, and symptom resolution/recurrence. Patient characteristics were reported using descriptive statistics and Kaplan-Meier analysis was used to report outcomes. RESULTS:NCS was diagnosed in 250 patients at 17 institutions. The mean patient age at diagnosis was 37 ± 15 years, 90% were female, and 83% were White. Presenting symptoms and findings included nonpositional flank pain (58%), chronic pelvic pain/dyspareunia (49%), hematuria (48%), nonpositional abdominal pain (47%), and varicocele (3.3%). Diagnostic workup of NCS included computed tomography scan of the abdomen/pelvis (84%), venogram (63%), duplex ultrasound examination (35%), and magnetic resonance imaging (17%). Imaging demonstrated a mean aortosuperior mesenteric artery angle of 27.7°. On duplex ultrasound examination, the mean peak systolic velocity of the LRV was 108.9 ± 99.0 cm/s at the compression point and 21.7 ± 9.5 cm/s at the hilum, with a peak systolic velocity ratio of 4.98, whereas venography demonstrated a mean renocaval pressure gradient of 3.92 ± 2.40 mm Hg. Nonoperative treatment with oral analgesics (29%), nutritional counseling/feeding regimen (16%), or simple expectant management (55%) was used in 116 patients and successful in 90 patients (78%) with a mean follow-up of 328 days. Indications for nonoperative management included mild symptoms (64%), young age (10%), and patient preference (8.4%). Of the 26 patients (22%) who failed nonoperative treatment, 20 were subsequently managed with surgery. In the 134 patients who underwent surgery, either as initial treatment or after nonoperative failure, 60 (44%) had a LRV transposition, 43 (31%) underwent a gonadal/ovarian vein transposition, 18 (12%) underwent renal autotransplantation, and 19 (13%) underwent endovascular therapy. The overall 3-year primary patency and secondary patency were 65% (95% confidence interval [CI], 51-76) and 96% (95% CI, 88-99), respectively. The 3-year freedom from reintervention and symptom recurrence were 67% (95% CI, 53-78) and 60% (95% CI, 48-70), respectively. Patients who underwent endovascular intervention had inferior primary patency and freedom from symptom recurrence: 35% (95% CI, 1.22-78) and 46% (95% CI, 7.99-79), respectively. CONCLUSIONS:Approximately 20% of patients with NCS initially managed nonoperatively progressed to operative intervention. Surgery was associated with excellent secondary patency, but a substantial number of patients required reinterventions and 40% developed symptom recurrence by 3 years, highlighting the need for judicious patient selection for surgery through preoperative counseling and shared decision-making. Endovascular therapy was associated with significantly worse results for all outcomes and, therefore, is not appropriate as initial treatment.

Background: There remains a role for open aortic surgery within the landscape of progressively evolving endovascular techniques in management of abdominal aortic disease. Graduates from vascular surgery training programs must be equipped to address open aortic surgery inclusive of aneurysmal, occlusive, mesenteric, venous, and mycotic processes. Programs are faced with the challenge of adequately preparing trainees in an environment where open aortic surgery cases are decreasing nationally. In addition to decreasing volume of open aortic surgery on a national level, the complexity of patients receiving open aortic surgery is increasing as endovascular techniques advance to handle more complex anatomy. As a result, open aortic surgery is being performed at a concentrated number of centers, further challenging many training programs. This is a retrospective review of graduate case logs at a single large academic institution between 2004 and 2023 aimed at investigating trends in trainee exposure to aortic surgery over time. Methods: This is a single large academic institution retrospective review of Accreditation Council for Graduate Medical Education (ACGME) case logs for graduates of both the traditional (5 + 2) fellowship (2004-2023) and the integrated (0 + 5) residency (2015-2023). Primary endpoints include total cases, total open abdominal cases, total open aneurysm cases, and total endovascular abdominal aortic cases. Secondary analysis includes evaluation of endovascular case volume over time and analysis of graduate gender-based differences in case volume. Results: A total of 30 trainees graduated from this institution between 2004 and 2023; 23 traditional fellows (5 + 2) and 7 integrated residents (0 + 5). On average, graduates performed 1325.2 +/- 439 total cases during their training with no significant difference between fellowship and residency graduates. Total case volume did not change across time. On average, graduates performed 69.5 +/- 17.5 open abdominal cases with no significant variation between fellowship and residency graduates (P > .05). The number of open abdominal cases performed during training did not change across time. Open aortic aneurysm repairs (average, 27.2 +/- 7.6) and open reconstruction of aortoiliac occlusive disease (average, 26.4 +/- 10.3) were the most frequent cases within the open abdominal category. There was no variation across time or graduate type for cerebrovascular, peripheral obstructive, or endovascular categories (P > .05). There was no variation in total case volume or open abdominal cases when compared across genders (P > .05). Conclusions: No variation in open abdominal cases performed by vascular surgery graduates was observed across time in this retrospective review of a single large academic institution. There appears to be a notable concentration of cases toward large academic centers resulting in stability in case volume at this institution. Results of this study can inform discussions regarding the utility of advanced aortic fellowships and assist future trainees with selecting programs that align with their clinical career goals. The ability to perform complex open and endovascular operations is a cornerstone of the vascular surgery specialty, and results of this study highlight that recently graduated trainees from this institution and similar institutions remain dynamic in their abilities and are prepared to address open abdominal surgery.

OBJECTIVE:This study aimed to identify the scope of VCE responsibilities as well as areas of improvement for the VCE role. DESIGN:An 11-item free response/multiple-choice survey was distributed to prospective participants. Quantitative data was analyzed using descriptive statistics (mean and standard deviation) and qualitative methods were used to analyze free response data. SETTING:Participants completed the survey electronically. PARTICIPANTS:Current vice chairs of education from across the United States were recruited. RESULTS:Twenty-five of 60 identified VCE (42% response rate) completed the survey. Responders held the VCE position for 4.7±3.2 years. The majority of respondents reported that they oversaw all educational activities in their department. Twenty-two respondents (88%) indicated that their job responsibilities were appropriate, while two (8%) felt their roles were not well-defined. Four VCE (16%) desired more control over the departmental budget for education-related activities, while two (8%) felt that their role was undermined by their Department Chairperson. Oversight and coordination of departmental education activities was the most frequently reported value for the VCE role. Eighteen respondents (72%) received compensation for their VCE role, but 7 (28%) did not. CONCLUSIONS:The results of this survey provide insight into the responsibilities and perceived value of the VCE role in surgery. This survey also identified areas of concern which merit intradepartmental examination in order to improve the effectiveness of the VCE role at a local level.

OBJECTIVE:Entrustable professional activities (EPAs) have been embraced by the medical education community as a framework to guide competency-based education systems. The Vascular Surgery Board and Association for Program Directors in Vascular Surgery collaborated on the development of 15 vascular surgery EPAs, covering the core clinical activities of a vascular surgeon. We sought to explore engagement and perceptions of feasibility and utility of EPA assessment implementation for participants in a national, multi-institutional pilot. DESIGN:Faculty assessment and trainee self-assessment of 15 vascular surgery EPAs were rated on a 4-point entrustment scale: 1 = limited participation, 2 = direct supervision, 3 = indirect supervision, and 4 = practice-ready, with accompanying behavioral anchors describing the actions expected of a learner at each level. Following an introductory webinar, the American Board of Surgery EPA Application assessment tool (delivered via SIMPL) was provided to all participating programs. Surveys evaluating the perceived feasibility and utility of the EPAs were developed. The surveys were distributed to pilot participants via email in June 2024 and responses were collected using Qualtrics. For Likert-scale items, descriptive statistics were calculated. For open-ended responses, thematic analysis was conducted to explore perceptions of respondents. This retrospective cohort study received an exemption determination from the University of Utah Institutional Review Board prior to the initiation of study procedures. SETTING:This was a national, multi-institutional study. Participating programs included both academic, community, and hybrid programs. PARTICIPANTS:Thirty institutions (22 fellowship, 27 residency programs) participated in the pilot. Post-pilot surveys were completed by 89 participants, including 22 program directors (Response rate 73%), 13 program managers (Response rate 43%), 26 trainees, and 28 faculty. RESULTS:A total of 2746 EPA assessments were completed by faculty and trainees during the pilot. Regarding ease of integration of EPA assessments into perioperative workflow, 92% of trainees and 96% of faculty had neutral or positive responses. Eight four percent of trainees agreed that they were comfortable initiating EPA assessments. Seventy seven percent of trainees felt that EPA data would help them to set learning goals and 77% felt that EPA assessments helped them identify areas for improvement. For faculty, 74% felt the EPA assessments helped them identify topics on which to provide feedback. CONCLUSIONS:This study demonstrates the feasibility and utility of EPA workplace-based assessment implementation at a diverse subset of vascular surgery training programs. Integration into usual clinical workflow was viewed as easy by both faculty and trainees. Furthermore, trainees felt the assessments were helpful to their learning, and faculty felt the assessment anchors helped them give meaningful feedback to trainees. These findings support an overall positive reception to EPA assessments in vascular surgery.

PURPOSE:Workplace-based assessments (WBAs) of surgical trainees historically demonstrate poor alignment between faculty and learner perception of clinical encounters. Given trainee perception of receiving low autonomy is associated with higher rates of burnout, depression, and attrition, it is important to better align faculty and trainee perceptions of clinical experiences. This study aims to evaluate validity evidence data, including response process, internal structure, and consequences, of vascular surgery Entrustable Professional Activities assessments (EPAs) using national pilot implementation data. METHOD:A multi-institutional pilot implementation of vascular surgery EPAs was open to residencies and fellowships from April-June of 2024. Participating programs collected assessments of entrustment for clinical encounters. Faculty and trainee assessments were paired and descriptive statistics were conducted. A linear mixed-effects model was conducted to examine factors associated with alignment. Intraclass correlation (ICC) was calculated between trainee and faculty assessments. A random effects model was applied to demonstrate sources of variance in entrustment ratings. Linear mixed effects models were applied to examine encounter and demographic differences in faculty assessed and trainee self-assessed entrustment scores. RESULTS:Twenty-nine programs contributed 1,620 paired assessments (n = 79 trainees, n = 87 faculty). There were no differences in absolute alignment by demographics or phase of care. ICC for all EPAs combined was 0.76). Variance in entrustment ratings was attributed primarily to the interaction between EPA and trainee (31%), suggesting EPA assessments were able to discriminate proficiency within trainees across EPAs. Entrustment ratings were not different when considering demographic variables. CONCLUSIONS:In this retrospective analysis of national EPA pilot implementation data of residents, fellows, and faculty, strong response process and internal structure validity evidence was established. Shortcomings of other WBAs used in surgical training, such as poor alignment between faculty and trainee perceptions of an encounter, were not evident with the use of behaviorally-anchored EPA assessments.

OBJECTIVE:To understand residency to fellowship transition by exploring the alignment of graduating general surgery (GS) residency and early vascular surgery fellowship (VSF) ACGME Milestones 2.0 competencies. BACKGROUND:Milestones 2.0 presents an opportunity to evaluate trainee progression from residency through fellowship. Understanding the residency-fellowship alignment of Milestones ratings is important for the training continuum and identifying early signals for struggling learners during this transition. METHODS:This is a retrospective national study of two VSF cohorts (starting 2022 and 2023) who previously completed GS residency. We compared ACGME Milestones 2.0 ratings from the final 2 years of residency to year-1 VSF using descriptive statistics and linear mixed effects regression models. RESULTS:Milestones data were collected for vascular surgery fellows ( n =266). Results showed significant PGY-5 GS-VSF predictive alignment for PC (β=0.20, P =0.004); MK (β=0.13, P =0.027); PROF (β=0.23, P <0.001); and ICS (β=0.17, P =0.01). These results translate to a mean fellowship Milestones level difference between learners up to 0.49 to 0.64 units for every 1-unit difference in Milestones between GS residents. SBP and PBLI ratings were not significantly aligned. Matched subcompetencies showed significant alignment (3 of 4 PC, 2 of 2 MK, 4 of 4 PROF, 2 of 3 ICS). CONCLUSIONS:The alignment between graduating GS residents and VSF year-1 Milestones ratings for PC, MK, PROF, and ICS demonstrates a continuum in educational outcomes and potential use to facilitate the residency-fellowship transition. These findings may support using Milestones 2.0 for residency-fellowship hand-off and performance analytics that may serve as early feedback to support trainees.

Objective: To understand residency to fellowship transition by exploring the alignment of graduating general surgery (GS) residency and early vascular surgery fellowship (VSF) ACGME Milestones 2.0 competencies. Background: Milestones 2.0 presents an opportunity to evaluate trainee progression from residency through fellowship. Understanding the residency-fellowship alignment of Milestones ratings is important for the training continuum and identifying early signals for struggling learners during this transition. Methods: This is a retrospective national study of two VSF cohorts (starting 2022 and 2023) who previously completed GS residency. We compared ACGME Milestones 2.0 ratings from the final 2 years of residency to year-1 VSF using descriptive statistics and linear mixed effects regression models. Results: Milestones data were collected for vascular surgery fellows ( n =266). Results showed significant PGY-5 GS-VSF predictive alignment for PC (β=0.20, P =0.004); MK (β=0.13, P =0.027); PROF (β=0.23, P <0.001); and ICS (β=0.17, P =0.01). These results translate to a mean fellowship Milestones level difference between learners up to 0.49 to 0.64 units for every 1-unit difference in Milestones between GS residents. SBP and PBLI ratings were not significantly aligned. Matched subcompetencies showed significant alignment (3 of 4 PC, 2 of 2 MK, 4 of 4 PROF, 2 of 3 ICS). Conclusions: The alignment between graduating GS residents and VSF year-1 Milestones ratings for PC, MK, PROF, and ICS demonstrates a continuum in educational outcomes and potential use to facilitate the residency-fellowship transition. These findings may support using Milestones 2.0 for residency-fellowship hand-off and performance analytics that may serve as early feedback to support trainees.

Objective Prior research demonstrates disproportionate emphasis on ‘confidence’ in narrative feedback for women trainees in nonsurgical specialties. Such feedback is often low-quality without corrective guidance. Whether similar feedback is given to women trainees in surgical specialties is unknown. Therefore, we investigated gender differences in agentic word use in operative feedback for vascular surgery trainees. Methods A retrospective review of operative faculty-delivered narrative feedback for a national, multi-institutional cohort of vascular surgery residents and fellows assessed using the Society for Improving Medical Professional Learning (SIMPL) operative application from 2018 to 2023 was performed. Natural language processing models were used to categorize themes using deductive, open coding. Assessments with agentic adjectives were qualitatively analyzed by gender using open and focused coding. We classified feedback as reinforcing (positive), corrective (negative), or neutral, and performed thematic comparisons by gender. Results Seventeen institutions contributed 1010 intraoperative SIMPL assessments with narrative feedback. Although women had disproportionately more feedback with agentic language, this was more commonly corrective for women (47.8% vs 42% for men). The most common reinforcing theme for trainees of both genders was preparation and planning (34.2% men; 24% women assessments), whereas the most common corrective feedback differed by gender. For men, efficiency was most common (25%), whereas for women, feedback regarding confidence was most common (27.5%). Given confidence reflects a personal characteristic rather than specific, actionable feedback, we explored this thematically. Thirty-two total SIMPL assessments discussed confidence. Over one-half were assessments of women trainees, despite women trainees comprising only 30% of the total cohort. Sixteen comments were corrective, with most (n = 12; 75%) directed toward women trainees, and all were provided by men faculty. Eleven comments were reinforcing, eight of which were for men trainees, and only three for women. When considering the associated autonomy and competency rating accompanying these comments, women tended to receive less positive and more negative feedback about confidence than men at any given level of autonomy and competency. Conclusions Women vascular trainees receive more agentic-themed operative feedback. Comments regarding lack of confidence are directed at women trainees and are exclusively from men faculty. Given that confidence is an intrinsic trait, rather than an actionable behavior, women trainees receive more low-quality negative feedback, disproportionately limiting their ability to improve operative performance. Attention to quality of faculty feedback is warranted to mitigate gender disparities in training.

PURPOSE:The Accreditation Council for Graduate Medical Education (ACGME) Milestone ratings in general surgery have the potential to be used as formative feedback to enhance trainee performance. This assumption rests on validity evidence, such as correlations with learning outcomes and early-career outcomes. This meta-analysis aims to estimate the effect size of the association between Milestone ratings and other performance measures in general surgery. METHOD:The authors conducted electronic database (search dates: August 9, 2023, March 25, 2024, and February 20, 2025) and forward and backward reference searching. A 3-level meta-analysis was performed to account for clustering and dependency of effect sizes. Overall effect size and heterogeneity statistics were estimated. Moderated analyses were conducted to examine whether any observed heterogeneity could be accounted for by training level, Milestones competency category, outcomes, and Milestones version. RESULTS:The authors extracted 445 effect sizes from 16 studies. Milestone ratings were statistically significantly correlated with Entrustable Professional Activities ( r = 0.59, P < .001) and American Board of Surgery In-Training Examination ( r = 0.39, P < .001) but not with United States Medical Licensing Examination ( r = 0.11, P = .20), social-emotional outcomes ( r = 0.14, P = .25), patient outcomes ( r = -0.08, P = .41), and residency application factors ( r = 0.07, P = .42). Training level, Milestones competency category, and Milestones version did not moderate effect size estimates. CONCLUSIONS:The ACGME Milestone ratings in general surgery correlate strongly with some indicators of performance, including Entrustable Professional Activity assessments and the American Board of Surgery In-Training Examination, but not for other outcomes, such as United States Medical Licensing Examination, social-emotional outcomes, residency application factors, or patient outcomes.

OBJECTIVE:Integrated vascular surgery residency and traditional fellowship training paradigms offer two unique pathways to independent vascular surgery practice and board eligibility. Although operative case requirements are equivalent in each, it is unknown whether operative competence achieved by graduates is comparable between paradigms. We sought to examine operative performance and autonomy achieved between vascular integrated residents (VIRs) and vascular surgery fellows (VSFs) in their final year of training. METHODS:Operative assessments were collected between 2018 and 2022 from a national cohort of vascular surgery training programs using the Society for Improving Medical Professional Learning (SIMPL) OR assessment application. Statistical analysis of intraoperative autonomy, performance, and case complexity was stratified by training paradigm. Generalized linear mixed models were conducted to compare assessments of autonomy and performance between VIRs and VSFs in their graduating year, controlling for case complexity and procedure type (open or endovascular). To account for the statistical dependency within the nested data, the random effects of trainee, faculty, program, and procedure were included. Separate analyses were conducted for faculty assessments and trainee self-assessments. Data were analyzed using R software. RESULTS:Twenty-five training programs (n = 12 residency; n = 13 fellowship) collected 4927 assessments (n = 2232 assessments by faculty; n = 2695 self-assessments by trainees) from 106 trainees and 94 faculty. There were no differences in faculty assessments or trainee self-assessments of operative performance (faculty: B = 0.06; P = .56; trainee: B = -0.15; P = .19) or autonomy (faculty: B = 0.06; P = .61; trainee: B = 0.03; P = .83) between VIRs and VSFs during the final year of training, even when corrected for case complexity and procedure type. Using the model, the predicted performance and autonomy ratings for VIRs and VSFs were estimated across postgraduate year and various case complexities for open and endovascular procedures, respectively. CONCLUSIONS:During the final year of vascular surgery training, VIR and VSF trainees achieve similar operative performance and autonomy for both endovascular and open procedures. Despite inherent differences in the training paradigms, equivalent operative competence and autonomy are achieved by graduation, suggesting similar preparedness for independent practice.

OBJECTIVE:Practice patterns regarding the surgical management of aortic pathologies have evolved over time, with a shift in care toward endovascular interventions and increasingly complex endovascular techniques. This raises concern for inadequate experience with aortic surgery, both open and endovascular, in vascular surgery training. Although numerous studies have explored trends in the volume of aortic cases completed during training, none have examined graduating proficiency in aortic surgery. We sought to examine the competence and autonomy of graduating vascular surgery trainees performing aortic operations using a multi-institutional sample of trainees. METHODS:Operative performance and autonomy ratings of post-graduate year 4-5 residents and all fellows performing aortic interventions from the Society for Improving Medical Professional Learning application database were collected for vascular surgery participating institutions from 2018 to 2023. 'Supervision only' and 'passive help' ratings were coded as 'autonomous,' whereas 'exceptional performance' and 'practice ready' were coded as 'competent.' Descriptive statistics were calculated for open and endovascular abdominal aortic aneurysm repair. Mixed effects logistic regressions were conducted to estimate the predictive association between procedure type and graduating trainee proficiency for all aortic procedures. RESULTS:A total of 54 trainees and 50 faculty from 19 programs completed 579 assessments (n = 394 endovascular; n = 185 open). For infrarenal aortic aneurysm repair, in the final year of training residents and fellows were assessed as 'autonomous' for 60.9% of endovascular and 21.1% of open procedures and were assessed as competent for independent practice in 50% of endovascular and 22.2% of open procedures. Regarding all aortic procedures, trainees were assessed as autonomous for 58.0% of endovascular and 41% of open procedures, and competent for 49.0% of endovascular and 37.0% of open procedures in their final year. There were no differences when comparing graduating integrated residents and fellows. However, trainees were less likely to achieve autonomous and competent ratings for open, as compared with endovascular, cases by graduation on both faculty (odds ratio, 0.25; 95% confidence interval, 0.11-0.53) and trainee self-assessment (odds ratio, 0.39; 95% confidence interval, 0.19-0.77). CONCLUSIONS:Vascular surgery trainees are more likely to achieve proficient levels of autonomy and competence in endovascular aortic cases by graduation, regardless of training paradigm. Trainees are also more likely to perceive themselves as achieving higher levels of proficiency than their faculty assessors rate them in open aortic procedures. These findings highlight the importance of developing innovative solutions to enhance aortic surgical skills in training.

BACKGROUND:As principles of competency-based medical education are implemented into graduate medical education [GME] programs, it is imperative that the assessments employed are reliable and valid. Internal structure is a core component of validity evidence that has been under studied. In this study, we examined elements of the internal structure for the American Board of Surgery In-Training Examination [ABSITE]. METHODS:This national retrospective cohort study utilized performance data for general surgery residents from 2018 to 2023 to determine aspects of the internal structure for the ABSITE. The item difficulty, item discrimination, internal consistency, and dimensionality of the exam were calculated. RESULTS:55,986 unique test results were obtained in the study. The ABSITE exhibits strong reliability, (Cronbach's alpha >0.9), and appropriate item difficulty (0.66) and item discrimination index (>0.2) for a formative examination. Results of the exploratory factor analysis reveals that the ABSITE is unidimensional. CONCLUSIONS:The ABSITE is a unidimensional examination with strong reliability. Furthermore, the item difficulty and item discrimination levels of the exam are appropriate for a formative test. Future studies utilizing consensus methods could be employed to determine what specific construct is measured by the ABSITE.

Vice Chairs of Education (VCE) are responsible for ensuring faculty in their department deliver high-quality education to the next generation of physicians. However, there is a paucity of tools available to assess faculty performance as educators. The Accreditation Council for Graduate Medical Education (ACGME) developed the Clinician Educator Milestones (CEM) as a formative assessment tool for faculty educators, but they have yet to be widely implemented. We sought to explore the feasibility and utility of the CEM for both VCEs and faculty educators. Participants included VCEs and faculty from multiple clinical departments at a single academic institution. Faculty performed a CEM self-assessment and VCEs used the CEM to assess faculty. Subsequently, faculty and VCEs were instructed to meet, using their completed CEM as a framework for discussion about faculty development, including strengths, weaknesses, and goals for growth. After 6 months, the VCEs and faculty repeated the assessment/self-assessment using the CEM and met a second time for discussion. We used a convergent parallel mixed methods approach, including quantitative surveys and qualitative focus groups, analyzed with descriptive statistics and thematic analysis respectively. Fifteen faculty and 6 VCEs from 6 clinical departments participated (survey response rates were 93.3