Centers with Vascular Surgery Training Programs Are More Likely to Utilize Vein Mapping and Autologous Vein for Infrainguinal Bypass.

Abstract

Objective: The Society for Vascular Surgery (SVS) recommends preoperative vein mapping (PVM) and the use of autologous vein (AV) conduits when available for infrainguinal bypass (IIB). This study aims to evaluate the association between the presence of a vascular surgery (VS) training program at a medical center and the utilization of PVM and AV conduits in IIB procedures.

Methods: Patients undergoing an elective IIB for peripheral artery disease (PAD) between 2016 and 2022 were identified in a prospective, statewide, multicenter observational registry. Hospital rates of PVM and AV utilization were calculated. Patients were then classified based on whether the medical center in which they were treated had an Accreditation Council for Graduate Medical Education (ACGME) certified VS training program or not. Both integrated vascular surgery residencies (0+5) and vascular surgery fellowships (5+2) were considered as VS training programs. Bayesian mixed effects logistic regressions were performed to study the independent association of VS training programs with the primary outcomes of PVM and AV utilization.

Results: A total of 37 centers performing IIB were included, of which 24% (9/37) had a VS training program and 76% (28/37) did not. Hospital rates of PVM ranged from 10.2% to 81.7% with a median rate of 40.5% (IQR, 24.4%-61.9%), whereas that of AV utilization as an IIB conduit varied between 16.5% and 88.1% with a median rate of 43.8% (IQR, 33.3%-56.0%). A strong linear correlation between hospital rates of PVM and hospital rates of AV utilization was observed (R² = 0.956). A total of 5,951 patients met the inclusion criteria, of whom 36.9% (2,196/5,951) underwent IIB at centers with a VS training program and 63.1% (3,755/5,951) underwent IIB at centers without a VS training program. Patients treated at centers with a VS training program were less likely to undergo an IIB for claudication (47.0% vs 63.5%, p<0.001) and more likely to undergo preoperative ABI testing (68.9% vs 55.2%, p<0.001). Moreover, centers with a VS training program were more likely to perform PVM (57.7% vs 39.0%, p<0.001) and utilize an AV conduit (60.0% vs 45.3%, p<0.001) in IIB. On multivariate logistic regression analysis, centers with a VS training program were more than twice as likely to utilize PVM (OR 2.23, 95% CI 1.04-4.88) and nearly twice as likely to utilize AV as a conduit (OR 1.84, 95% CI 1.07-3.17) in patients undergoing IIB compared to centers without a VS training program.

Conclusion: The overall utilization of PVM and AV conduits in IIB remains below 50%, highlighting a significant concern in the national effort to improve PAD care. Centers with a VS training program demonstrate higher rates of PVM and AV utilization in IIB, reflecting greater adherence to SVS guidelines for the management of PAD. Future strategies and quality improvement initiatives should aim to enhance adherence to PAD guidelines within vascular surgery, regardless of practice setting.