SS08 - Entrustment Differences between Carotid Revascularization Techniques among a National, Multi-Institutional Cohort of Graduating Vascular Surgery Trainees

Objectives: Recent findings from the CREST-2 trial suggest patients with asymptomatic high-grade carotid artery stenosis (CAS) benefit from carotid artery stenting in addition to medical management over medical management alone. Therefore, understanding the adequacy of training provided to vascular surgery trainees for all carotid revascularization techniques is paramount. The proficiency of graduating vascular surgery trainees in performing carotid revascularization techniques, however, has not been examined. We sought to determine the proficiency of graduating trainees in performing endovascular and open carotid revascularization.

Methods: Faculty assessments and trainee self-assessments of intra-operative autonomy, competence, and entrustment of vascular surgery residents and fellows in their final two years of training were collected from a national sample of accredited training programs from 2018-2024. 'Supervision only' and 'passive help' ratings were coded as 'autonomous’, 'exceptional performance' and 'practice ready' were coded as 'competent’. Autonomous and competent assessments and practice-ready entrustment ratings were coded as ‘entrustable’. Descriptive statistics were calculated for open (endarterectomy) and endovascular (transcarotid/transfemoral stent) carotid revascularization procedures. Mixed effects logistic regressions were conducted to estimate the predictive association between procedure type and graduating trainee proficiency, accounting for post-graduate year of trainee, week of year during which the assessment was performed, and complexity of the case.

Results: Seventy-seven faculty and 69 trainees(n=30 residents, n=39 fellows) across 32 institutions and 38 programs(n=18 residency, n=20 fellowship) submitted assessments. In the final year of training both faculty assessments and trainee self-assessments demonstrated higher levels of competence for open, as compared to endovascular, procedures(Faculty: open=71% vs endo=36%, p=0.04; Trainee: open=62% vs endo=26%, p=0.02). Autonomy was similar on faculty assessment(open=74% vs endo=53%, p=0.19), but higher for open on trainee self-assessment(open=81% vs endo=38%, p=0.002). Entrustment was also higher for open, as compared to endovascular, procedures on both faculty and trainee assessment(Faculty: open=60% vs endo=27%, p=0.03; Trainee: open=44% vs endo=27%, p=0.09). Predicted probability of achieving an ‘entrustable’ rating by graduation was higher for open, as compared to endovascular, procedures on both faculty(OR 3.12 [CI 1.05-9.27]) and trainee(OR 4.84 [CI 1.52-15.48]) assessments. (Figure)

Conclusions: Vascular surgery graduates are more likely to achieve ‘entrustable’ ratings in open, as compared to endovascular, carotid revascularization procedures regardless of training paradigm. Faculty perceive similar levels of autonomy given for open and endovascular cases, while trainees perceive greater autonomy allowed in open cases. These findings highlight the importance of focusing efforts to ensure vascular surgery trainees graduate with the skills necessary to competently offer carotid artery stenting to appropriately selected patients.