Symposium on Advances in Small Hospital Care
Should Vascular Surgery Be Done in the Small Hospital? Charles Abernathy, M.D.*
There is but one standard for judging whether vascular surgery should be done in a small community hospital. Is it in the best interest of the patient? The vascular surgeon in a rural setting must decide what types of cases can be undertaken with acceptable morbidity and mortality in his own particular setting. The possibilities include: 1. Treating limb- or life-threatening vascular trauma only. This would usually include ruptured aortic aneurysms and other traumatic arterial lesions demanding more rapid care than the rural to urban medical evacuation system can provide. 2. The above with the addition of routine elective vascular operations dealing with obliterative and aneurysmal disease. Examples would include elective aortic aneurysms, peripheral aneurysms, extraanatomic and anatomic bypass procedures. Procedures that might be included in this category would be carotid endarterectomy, but probably not renal artery revascularization which would require additional diagnostic procedures. 3. All of the above with the addition of sophisticated vascular procedures, such as thoracic-abdominal aneurysms, complicated re-do surgery, high risk cerebral revascularization, and graft infections. A special category would be procedures requiring emergency microsurgery such as digit reimplantation. As satisfactory ancillary services such as blood banking, a noninvasive vascular laboratory, and arteriography were developed, a series of cases accumulated from categories one and two. This paper is a review of the results of the experience during 1977 and 1978 in peripheral vascular surgery performed by the two-man Montrose group (a third surgeon was added during the last year).
THE MONTROSE EXPERIENCE Approximately 1500 major general surgical operations were performed during the two year period of 1977 to 1978. Of these, 50 were ''Staff Surgeon, Montrose Memorial Hospital, Montrose, Colorado
Surgical Clinics of North America- Vol. 59, No. 3, June 1979
519
520
CHARLES ABERNATHY
Table 1. Profile of the Vascular Segment of a General Surgery Practice'' Total major cases done: approximately 1500 Total arterial vascular cases done: 50 Total postoperative (30 days) deaths: 2 (one ruptured aortic aneurysm, one aorto-bifemoral bypass) Total early (within three months) graft failure: 1 Average length of hospital stay in all vascular cases: 8.2 days Spectrum of Vascular Cases Ruptured aortic aneurysm: 3 Elective abdominal aortic aneurysm: 4 Aorto-bifemoral bypass: 5 Femoral popliteal bypass: 2 Femoral tibial bypass: 1 Peripheral aneurysm: 2 (brachial!, femoral 1) Profundaplasty: 1 Trauma Popliteal: 3 Brachial: 3 Femoral: Embolectomy: 7 Extra anatomic bypass Axillo-bifemoral: 4 Femoral-femoral: 5 Carotid-subclavian bypass: 3 Carotid endarterectomy: 7 Aorto-renal bypass: 1 *Two or three man group· practicing in a small community hospital (1977 to 1978).
arterial reconstructions. The spectrum of types of cases is seen in Table 1. The average hospital stay was 8.2 days. Ten patients were from category 1 (requiring emergency surgery); the remainder were from category 2. There were two deaths. One was caused by a ruptured aortic aneurysm. The patient had previously been refused elective surgery at a medical center because of supposed suprarenal involvement. This patient was presented in the emergency room in deep shock and was operated on immediately and found to have a large retroperitoneal hematoma as a result of the ruptured aneurysm. The aneurysm was resected successfully, but the patient died of irreversible shock in the immediate postoperative period. The other death was that of a patient who had had an aortobifemoral bypass six days previously. He had extensive immediate clotting of the blood vessels of both legs postoperatively, which was recalcitrant to anticoagulation. During surgery, precautions were taken to prevent distal atheroembolization, and the patient was heparinized. Autopsy failed to reveal the cause of the distal ischemia. One early graft occlusion occured one month after operation in a patient with a femoral-tibial graft done for salvage of the limb. The occlusion resulted in a below-the-knee amputation. Preoperative arteriography had shown no popliteal segment, and a Gore-Tex graft was
521
VASCULAR SURGERY
taken from the femoral artery to the distal posterior tibial artery. When the graft failed one month after the initial procedure, one attempt at embolectomy was done, and when this failed, the patient underwent amputation. During accumulation of the above highly selected series, several patients with other more complicated or higher risk lesions were referred to larger centers. Examples include a patient with a completely occluded carotid artery and a 95 per cent stenosis on the contralateral side who was sent to the medical center for evaluation and operation. Another example was a patient with renal vascular hypertension who was worked-up. at Montrose Memorial and found to have what appeared to be distal disease in the renal artery. This patient was sent to the university for repair of the lesions (including bench surgery). One of the patients with a ruptured aortic aneurysm who had renal failure in the postoperative period was referred to the medical center for dialysis.
DISCUSSION In surveying the literature on vascular surgery in an attempt to determine the caseload per year of the average vascular surgeon in various settings in the United States, one is quickly confronted with a lack of data. The reports from university hospitals are suspect, because one is unable to find how many staff surgeons, residents, visiting surgeons, and so on were involved in the management of the reported cases. Reproduced in Table 2 are the data presented by Dr. DeWeese in his presidential address to the Society for Vascular Surgery.2 DeWeese held that experience was responsible for the decreased mortality rates in vascular surgery. He analyzed the mortality rate in elective surgery for abdominal aortic aneurysm in small hospitals versus large hospitals. The table would seem to indicate that an overall mortality rate of 11.1 per cent in small hospitals is inferior to the 8.5 Table 2. Elective Repair of Abdominal Aortic Aneurysms: The Mortality Rate in Professional Study Activity Hospitals in 1976* DEATHS SIZE OF HOSPITAL
NUMBER OF HOSPITALS
TOTAL OPERATIONS
Number
Per Cent
Smallt Medium! Large§ ToTAL
551 1083 243 1877
414 3191 3160 6765
46 292 270 608
11.1 9.2 8.5 9.0
*From DeWeese, J. A.: Vascular surgery-Is it different? Surgery, 84:733, 1978, with permission. tTotal annual discharges less than 5,000 patients (usually less than 100 beds). !Total annual discharges 5,001 to 14,999 patients (usually 100 to 400 beds). §Total annual discharges greater than 15,000 patients (usually more than 400 beds).
522
CHARLES ABERNATHY
per cent mortality rate in large hospitals. Actually, these percentages are not statistically significant. In fact, one could argue that these numbers support the thesis that a high caseload may not be necessary. For example, the data cite a large center doing 1000 operations with a mortality rate of 7 per cent. Another hospital had a mortality rate of 4 per cent in 100 operations. In DeWeese's study there were 551 small hospitals reporting a total of 414 aneurysmectomies. This is less than one aneurysmectomy per year per hospital. One would doubt that a surgeon who performed only one vascular operation every two or three years for aortic aneurysm could do so successfully. Similarly, in no way are we suggesting that the concept of the "occasional" vascular surgeon should be condoned. Nowhere in the data presented is the caseload of the individual surgeon related to the mortality rate in elective surgery for aneurysm. Only the size of the hospital was considered. The more pertintent question is: "What is the minimum caseload of arterial reconstructive surgery required of a surgeon each year in order to maintain his competence?" Rich and Spencer have recently published a useful volume on vascular trauma. 5 In this the wealth of vascular experience in Vietnam is reported. It is interesting to note that the caseload per surgeon performing arterial repairs in Vietnan1 was, in fact, quite low. Rich reports: "In Vietnam a large number of surgeons have successfully repaired injured arteries. Rich and Hughes found that at least 159 surgeons were involved in treating 500 patients, and only 20 surgeons were identified who performed more than five major arterial repairs each. 4 In subsequent follow-up through the registry, the number of surgeons performing vascular repairs in Vietnam was found to be more than 500. Although this information is not ideal, it clearly indicates that the general principles of vascular surgery have been successfully carried out by young surgeons from a wide variety of training programs." The outstanding results of repairs of arterial injuries are well documented in that registry. One would wonder whether or not the same group of general surgeons would have been able to obtain such outstanding results had they not been recently graduated from their residencies and instead had been in the private practice of general surgery for 15 to 20 years during which time they had not been performing any peripheral vascular surgery. Miller and Welch clearly defined the influence of time lag from injury to repair in extremity ischemia. 3 Survival of the limb was optimal when the arterial repair was done within six hours. In 225 vascular injuries seen in Vietnam, most patients reached the hospital within 1.5 hours; an average time from wounding to operation was 2. 75 hours, significantly contributing to the outstanding results in arterial repair seen in the Vietnam War. Rich and Spencer note that in civilian injuries, an average time lag of approximately four hours is desirable and is usually obtainable. A four hour time lag would not be possible in our isolated setting if transfer to a tertiary care facility is necessary. 5
523
VASCULAR SURGERY
We are fortunate in Colorado to have excellent air alllbulance (fixed wing and helicopter) service to our tertiary care center (Denver). However, many bitter lessons have been learned about the difference between theoretical transportation time and what is practical. This is not because the response time is slow; nor is it because the aircraft are too slow. Triage and assessment of injuries in severely injured patients take time, particularly if the injury must be subsegmentalized into a definite category as specific as vascular surgery before the decision to transfer is made. The time lag is longer for many of the emergency lesions of peripheral vascular surgery such as ruptured abdominal aortic anuerysms, ischemic limbs due to arterial injuries, and intra-abdominal bleeding from major vessel injuries, as these problems are often subtle and somewhat occult. This makes the evaluation more difficult and timeconsuming, in marked contrast to a severe head injury, an enucleated eye, severe bleeding from a laceration, or a number of less subtle injuries that demand urgent care even to the incognescenti. The chain of events prior to the decision to transfer to the tertiary care medical center is more streamlined in these more obvious injuries. In the article on management of popliteal artery injuries elsewhere in this volume, we report a series of seven popliteal artery injuries. As can be seen by comparison with other urban centers (Table 3), the incidence is quite high in our rural area, and the results are comparable to the series with the best results.
SUGGESTIONS AND CONCLUSIONS Vascular surgery can be performed well in small community hospitals. It is best done when experienced supporting services including blood bank, angiography, and vascular laboratory capabilities are present. In addition, surgeons must take advantage of every case that comes up for vascular operation in the community. If only 20 or 50 cases per year occur, he must be the primary or assisting surgeon on every one. It is particularly important in the rural setting that the opportunities for vascular surgery not be diluted among several surgeons. Rather two or three surgeons should attempt to be involved
Table 3. Amputation Rates Following Popliteal Artery Repair YEARS OF
Montrose Denver Houston New Orleans
SERIES
CASES
AMPUTATION
4 10 10 7
7 14
2
11
16
2 6
PER CENT
14.3 14.3 18.2 38.0
Modified from Rich, N. M., and Spencer, F. C.: Vascular Trauma. Philadelphia, W. B. Saunders Co., 1978.
524
CHARLES ABERNATHY
Table 4.
Suggestions for Maximizing Skill Maintenance
Each surgeon should perform at least 20 to 25 arterial reconstructive cases per year. Two surgeons should be designated, both to participate in all vascular cases. Every surgeon should obtain a minimum of eight hours per year of postgraduate education in vascular surgery. A mini-residency in vascular surgery should be undertaken every 2 to 3 years. Surgeons should participate in case reviews through a regional vascular society or medical center.
consistently in the management of every case of elective or emergency vascular surgery. This is usually not difficult to arrange, and it is one of the ways that rural surgeons can bolster their skills in a low volume setting. Other methods of skill enhancement that we have used are listed in Table 4. In fact, in many teaching and referral centers, the vascular surgeon dilutes his experience more than is realized by tuming over his cases to residents and fellows or being absent at meetings when referred vascular operations are being performed on his service or even in his name. Furthermore, traumatic and emergency vascular repairs clearly are properly performed when trained surgeons have maintained their skills and supporting equipment is available. It is recognized that the greater the time and distance from a vascular center, the more necessary it is to do the repair locally. Penetrating or blunt trauma to lifesustaining arteries must be performed locally. This may even be true of ruptured aneurysms. However, some stable patients with ruptured aneurysms may best be transferred to nearby centers. Elective cases must be individualized. Our data indicate that proper selection of cases for local repair is possible. These cases may include carotid endarterectomies, aorto-iliac bypass procedures, and revascularization of the leg. When there are major complications, coexisting disease, or an obviously poor run off into the distal arterial bed, referral may be preferable to local surgical repair. By adopting these criteria, we maintain a level of vascular operative expertise to be ready to care for the vascular emergencies thrust upon us. One positive step that could be taken to improve results in rural hospitals is the formation of vascular registries similar to the one that Avellone et al. formed in Cleveland. 1 Perhaps even a national registry would be feasible, with surgeons voluntarily submitting data on their vascular cases. An analysis would be done periodically and then the question of case load versus results could be answered. Most surgeons performing vascular surgery in the high volume large hospital settings today did not have specialized training in vascular surgery. On the contrary, they were, for the most part, graduates of excellent quality general surgical programs in which the vascular portion had not been splintered away. The underlying question that keeps cropping up is whether a few super-surgeons with highly specialized training in vascular surgery are needed, or whether many good ones could perform as
525
VASCULAR SURGERY
well. Some would suggest that we should be training all of our peripheral vascular surgeons to perform the complicated multi-limbed aortic replacement grafts involving both the chest and abdominal aorta. In fact, if the economic factor alone is considered, it is easy to demonstrate that it makes much more economic sense for the patient to have his elective vascular procedure close to home rather than have the patient be evaluated, operated upon, and followed up 250 miles away, usually with the accompanying family. The second suggestion is frequently made that the evaluation could be done at the local level; the operation done at the referral center; and then the patient returned back home for his follow-up. The fallacy inherent in this system is often seen by the isolated small hospital surgeon or other practitioner who is not allowed to participate in the operative management of a patient, and yet is expected to provide quality evaluation and follow-up care including early recognition of complications and week-to-week management outside of the operating room. This method of patient care, with much of the care being done many miles distant from the operating surgeon, is an essence a form of itinerant surgery.
SUMMARY This article presents our successful experience with vascular surgery at the Montrose Memorial Hospital . Before a decision is made to ban vascular operations from all but referral hospitals, hard data from additional small community hospitals concerning their experience must be obtained. Surgeons from small community hospitals should be urged to analyze and objectively report their results with vascular procedures before national guidelines are formed.
REFERENCES 1. Avellone, J. C., Beven, E. G., Hertzer, N. R., et al.: A regional specialty society as a
model to monitor surgical care. J.A.M.A. 240:2177, 1978. 2. DeWeese, J. A.: Vascular surgery- Is it different? Surgery, 84:733, 1978. 3. Miller, H. H., and Welch, C. S.: Quantitative studies on time factors in arterial injuries. Ann. Surg., 130:428, 1949. 4. Rich, N. M., and Hughes, C. W.: Vietnam vascular surgery: A preliminary report. Surgery, 63:218, 1969. 5. Rich, N. M., and Spencer, F. C.: Vascular Trauma. Philadelphia, W. B. Saunders Co., 1978. Montrose Memorial Hospital 800 South Third Street Montrose, Colorado 81401
Should Vascular Surgery Be Done in the Small Hospital? Charles Abernathy, M.D.*
There is but one standard for judging whether vascular surgery should be done in a small community hospital. Is it in the best interest of the patient? The vascular surgeon in a rural setting must decide what types of cases can be undertaken with acceptable morbidity and mortality in his own particular setting. The possibilities include: 1. Treating limb- or life-threatening vascular trauma only. This would usually include ruptured aortic aneurysms and other traumatic arterial lesions demanding more rapid care than the rural to urban medical evacuation system can provide. 2. The above with the addition of routine elective vascular operations dealing with obliterative and aneurysmal disease. Examples would include elective aortic aneurysms, peripheral aneurysms, extraanatomic and anatomic bypass procedures. Procedures that might be included in this category would be carotid endarterectomy, but probably not renal artery revascularization which would require additional diagnostic procedures. 3. All of the above with the addition of sophisticated vascular procedures, such as thoracic-abdominal aneurysms, complicated re-do surgery, high risk cerebral revascularization, and graft infections. A special category would be procedures requiring emergency microsurgery such as digit reimplantation. As satisfactory ancillary services such as blood banking, a noninvasive vascular laboratory, and arteriography were developed, a series of cases accumulated from categories one and two. This paper is a review of the results of the experience during 1977 and 1978 in peripheral vascular surgery performed by the two-man Montrose group (a third surgeon was added during the last year).
THE MONTROSE EXPERIENCE Approximately 1500 major general surgical operations were performed during the two year period of 1977 to 1978. Of these, 50 were ''Staff Surgeon, Montrose Memorial Hospital, Montrose, Colorado
Surgical Clinics of North America- Vol. 59, No. 3, June 1979
519
520
CHARLES ABERNATHY
Table 1. Profile of the Vascular Segment of a General Surgery Practice'' Total major cases done: approximately 1500 Total arterial vascular cases done: 50 Total postoperative (30 days) deaths: 2 (one ruptured aortic aneurysm, one aorto-bifemoral bypass) Total early (within three months) graft failure: 1 Average length of hospital stay in all vascular cases: 8.2 days Spectrum of Vascular Cases Ruptured aortic aneurysm: 3 Elective abdominal aortic aneurysm: 4 Aorto-bifemoral bypass: 5 Femoral popliteal bypass: 2 Femoral tibial bypass: 1 Peripheral aneurysm: 2 (brachial!, femoral 1) Profundaplasty: 1 Trauma Popliteal: 3 Brachial: 3 Femoral: Embolectomy: 7 Extra anatomic bypass Axillo-bifemoral: 4 Femoral-femoral: 5 Carotid-subclavian bypass: 3 Carotid endarterectomy: 7 Aorto-renal bypass: 1 *Two or three man group· practicing in a small community hospital (1977 to 1978).
arterial reconstructions. The spectrum of types of cases is seen in Table 1. The average hospital stay was 8.2 days. Ten patients were from category 1 (requiring emergency surgery); the remainder were from category 2. There were two deaths. One was caused by a ruptured aortic aneurysm. The patient had previously been refused elective surgery at a medical center because of supposed suprarenal involvement. This patient was presented in the emergency room in deep shock and was operated on immediately and found to have a large retroperitoneal hematoma as a result of the ruptured aneurysm. The aneurysm was resected successfully, but the patient died of irreversible shock in the immediate postoperative period. The other death was that of a patient who had had an aortobifemoral bypass six days previously. He had extensive immediate clotting of the blood vessels of both legs postoperatively, which was recalcitrant to anticoagulation. During surgery, precautions were taken to prevent distal atheroembolization, and the patient was heparinized. Autopsy failed to reveal the cause of the distal ischemia. One early graft occlusion occured one month after operation in a patient with a femoral-tibial graft done for salvage of the limb. The occlusion resulted in a below-the-knee amputation. Preoperative arteriography had shown no popliteal segment, and a Gore-Tex graft was
521
VASCULAR SURGERY
taken from the femoral artery to the distal posterior tibial artery. When the graft failed one month after the initial procedure, one attempt at embolectomy was done, and when this failed, the patient underwent amputation. During accumulation of the above highly selected series, several patients with other more complicated or higher risk lesions were referred to larger centers. Examples include a patient with a completely occluded carotid artery and a 95 per cent stenosis on the contralateral side who was sent to the medical center for evaluation and operation. Another example was a patient with renal vascular hypertension who was worked-up. at Montrose Memorial and found to have what appeared to be distal disease in the renal artery. This patient was sent to the university for repair of the lesions (including bench surgery). One of the patients with a ruptured aortic aneurysm who had renal failure in the postoperative period was referred to the medical center for dialysis.
DISCUSSION In surveying the literature on vascular surgery in an attempt to determine the caseload per year of the average vascular surgeon in various settings in the United States, one is quickly confronted with a lack of data. The reports from university hospitals are suspect, because one is unable to find how many staff surgeons, residents, visiting surgeons, and so on were involved in the management of the reported cases. Reproduced in Table 2 are the data presented by Dr. DeWeese in his presidential address to the Society for Vascular Surgery.2 DeWeese held that experience was responsible for the decreased mortality rates in vascular surgery. He analyzed the mortality rate in elective surgery for abdominal aortic aneurysm in small hospitals versus large hospitals. The table would seem to indicate that an overall mortality rate of 11.1 per cent in small hospitals is inferior to the 8.5 Table 2. Elective Repair of Abdominal Aortic Aneurysms: The Mortality Rate in Professional Study Activity Hospitals in 1976* DEATHS SIZE OF HOSPITAL
NUMBER OF HOSPITALS
TOTAL OPERATIONS
Number
Per Cent
Smallt Medium! Large§ ToTAL
551 1083 243 1877
414 3191 3160 6765
46 292 270 608
11.1 9.2 8.5 9.0
*From DeWeese, J. A.: Vascular surgery-Is it different? Surgery, 84:733, 1978, with permission. tTotal annual discharges less than 5,000 patients (usually less than 100 beds). !Total annual discharges 5,001 to 14,999 patients (usually 100 to 400 beds). §Total annual discharges greater than 15,000 patients (usually more than 400 beds).
522
CHARLES ABERNATHY
per cent mortality rate in large hospitals. Actually, these percentages are not statistically significant. In fact, one could argue that these numbers support the thesis that a high caseload may not be necessary. For example, the data cite a large center doing 1000 operations with a mortality rate of 7 per cent. Another hospital had a mortality rate of 4 per cent in 100 operations. In DeWeese's study there were 551 small hospitals reporting a total of 414 aneurysmectomies. This is less than one aneurysmectomy per year per hospital. One would doubt that a surgeon who performed only one vascular operation every two or three years for aortic aneurysm could do so successfully. Similarly, in no way are we suggesting that the concept of the "occasional" vascular surgeon should be condoned. Nowhere in the data presented is the caseload of the individual surgeon related to the mortality rate in elective surgery for aneurysm. Only the size of the hospital was considered. The more pertintent question is: "What is the minimum caseload of arterial reconstructive surgery required of a surgeon each year in order to maintain his competence?" Rich and Spencer have recently published a useful volume on vascular trauma. 5 In this the wealth of vascular experience in Vietnam is reported. It is interesting to note that the caseload per surgeon performing arterial repairs in Vietnan1 was, in fact, quite low. Rich reports: "In Vietnam a large number of surgeons have successfully repaired injured arteries. Rich and Hughes found that at least 159 surgeons were involved in treating 500 patients, and only 20 surgeons were identified who performed more than five major arterial repairs each. 4 In subsequent follow-up through the registry, the number of surgeons performing vascular repairs in Vietnam was found to be more than 500. Although this information is not ideal, it clearly indicates that the general principles of vascular surgery have been successfully carried out by young surgeons from a wide variety of training programs." The outstanding results of repairs of arterial injuries are well documented in that registry. One would wonder whether or not the same group of general surgeons would have been able to obtain such outstanding results had they not been recently graduated from their residencies and instead had been in the private practice of general surgery for 15 to 20 years during which time they had not been performing any peripheral vascular surgery. Miller and Welch clearly defined the influence of time lag from injury to repair in extremity ischemia. 3 Survival of the limb was optimal when the arterial repair was done within six hours. In 225 vascular injuries seen in Vietnam, most patients reached the hospital within 1.5 hours; an average time from wounding to operation was 2. 75 hours, significantly contributing to the outstanding results in arterial repair seen in the Vietnam War. Rich and Spencer note that in civilian injuries, an average time lag of approximately four hours is desirable and is usually obtainable. A four hour time lag would not be possible in our isolated setting if transfer to a tertiary care facility is necessary. 5
523
VASCULAR SURGERY
We are fortunate in Colorado to have excellent air alllbulance (fixed wing and helicopter) service to our tertiary care center (Denver). However, many bitter lessons have been learned about the difference between theoretical transportation time and what is practical. This is not because the response time is slow; nor is it because the aircraft are too slow. Triage and assessment of injuries in severely injured patients take time, particularly if the injury must be subsegmentalized into a definite category as specific as vascular surgery before the decision to transfer is made. The time lag is longer for many of the emergency lesions of peripheral vascular surgery such as ruptured abdominal aortic anuerysms, ischemic limbs due to arterial injuries, and intra-abdominal bleeding from major vessel injuries, as these problems are often subtle and somewhat occult. This makes the evaluation more difficult and timeconsuming, in marked contrast to a severe head injury, an enucleated eye, severe bleeding from a laceration, or a number of less subtle injuries that demand urgent care even to the incognescenti. The chain of events prior to the decision to transfer to the tertiary care medical center is more streamlined in these more obvious injuries. In the article on management of popliteal artery injuries elsewhere in this volume, we report a series of seven popliteal artery injuries. As can be seen by comparison with other urban centers (Table 3), the incidence is quite high in our rural area, and the results are comparable to the series with the best results.
SUGGESTIONS AND CONCLUSIONS Vascular surgery can be performed well in small community hospitals. It is best done when experienced supporting services including blood bank, angiography, and vascular laboratory capabilities are present. In addition, surgeons must take advantage of every case that comes up for vascular operation in the community. If only 20 or 50 cases per year occur, he must be the primary or assisting surgeon on every one. It is particularly important in the rural setting that the opportunities for vascular surgery not be diluted among several surgeons. Rather two or three surgeons should attempt to be involved
Table 3. Amputation Rates Following Popliteal Artery Repair YEARS OF
Montrose Denver Houston New Orleans
SERIES
CASES
AMPUTATION
4 10 10 7
7 14
2
11
16
2 6
PER CENT
14.3 14.3 18.2 38.0
Modified from Rich, N. M., and Spencer, F. C.: Vascular Trauma. Philadelphia, W. B. Saunders Co., 1978.
524
CHARLES ABERNATHY
Table 4.
Suggestions for Maximizing Skill Maintenance
Each surgeon should perform at least 20 to 25 arterial reconstructive cases per year. Two surgeons should be designated, both to participate in all vascular cases. Every surgeon should obtain a minimum of eight hours per year of postgraduate education in vascular surgery. A mini-residency in vascular surgery should be undertaken every 2 to 3 years. Surgeons should participate in case reviews through a regional vascular society or medical center.
consistently in the management of every case of elective or emergency vascular surgery. This is usually not difficult to arrange, and it is one of the ways that rural surgeons can bolster their skills in a low volume setting. Other methods of skill enhancement that we have used are listed in Table 4. In fact, in many teaching and referral centers, the vascular surgeon dilutes his experience more than is realized by tuming over his cases to residents and fellows or being absent at meetings when referred vascular operations are being performed on his service or even in his name. Furthermore, traumatic and emergency vascular repairs clearly are properly performed when trained surgeons have maintained their skills and supporting equipment is available. It is recognized that the greater the time and distance from a vascular center, the more necessary it is to do the repair locally. Penetrating or blunt trauma to lifesustaining arteries must be performed locally. This may even be true of ruptured aneurysms. However, some stable patients with ruptured aneurysms may best be transferred to nearby centers. Elective cases must be individualized. Our data indicate that proper selection of cases for local repair is possible. These cases may include carotid endarterectomies, aorto-iliac bypass procedures, and revascularization of the leg. When there are major complications, coexisting disease, or an obviously poor run off into the distal arterial bed, referral may be preferable to local surgical repair. By adopting these criteria, we maintain a level of vascular operative expertise to be ready to care for the vascular emergencies thrust upon us. One positive step that could be taken to improve results in rural hospitals is the formation of vascular registries similar to the one that Avellone et al. formed in Cleveland. 1 Perhaps even a national registry would be feasible, with surgeons voluntarily submitting data on their vascular cases. An analysis would be done periodically and then the question of case load versus results could be answered. Most surgeons performing vascular surgery in the high volume large hospital settings today did not have specialized training in vascular surgery. On the contrary, they were, for the most part, graduates of excellent quality general surgical programs in which the vascular portion had not been splintered away. The underlying question that keeps cropping up is whether a few super-surgeons with highly specialized training in vascular surgery are needed, or whether many good ones could perform as
525
VASCULAR SURGERY
well. Some would suggest that we should be training all of our peripheral vascular surgeons to perform the complicated multi-limbed aortic replacement grafts involving both the chest and abdominal aorta. In fact, if the economic factor alone is considered, it is easy to demonstrate that it makes much more economic sense for the patient to have his elective vascular procedure close to home rather than have the patient be evaluated, operated upon, and followed up 250 miles away, usually with the accompanying family. The second suggestion is frequently made that the evaluation could be done at the local level; the operation done at the referral center; and then the patient returned back home for his follow-up. The fallacy inherent in this system is often seen by the isolated small hospital surgeon or other practitioner who is not allowed to participate in the operative management of a patient, and yet is expected to provide quality evaluation and follow-up care including early recognition of complications and week-to-week management outside of the operating room. This method of patient care, with much of the care being done many miles distant from the operating surgeon, is an essence a form of itinerant surgery.
SUMMARY This article presents our successful experience with vascular surgery at the Montrose Memorial Hospital . Before a decision is made to ban vascular operations from all but referral hospitals, hard data from additional small community hospitals concerning their experience must be obtained. Surgeons from small community hospitals should be urged to analyze and objectively report their results with vascular procedures before national guidelines are formed.
REFERENCES 1. Avellone, J. C., Beven, E. G., Hertzer, N. R., et al.: A regional specialty society as a
model to monitor surgical care. J.A.M.A. 240:2177, 1978. 2. DeWeese, J. A.: Vascular surgery- Is it different? Surgery, 84:733, 1978. 3. Miller, H. H., and Welch, C. S.: Quantitative studies on time factors in arterial injuries. Ann. Surg., 130:428, 1949. 4. Rich, N. M., and Hughes, C. W.: Vietnam vascular surgery: A preliminary report. Surgery, 63:218, 1969. 5. Rich, N. M., and Spencer, F. C.: Vascular Trauma. Philadelphia, W. B. Saunders Co., 1978. Montrose Memorial Hospital 800 South Third Street Montrose, Colorado 81401
