Infrapopliteal bypass surgery in the endovascular era.

Background: Over the past decade the increasing adoption of endovascular-first strategies has significantly altered the landscape in the treatment of peripheral arterial disease (PAD), raising concerns about the continuation and future development of high-quality surgical training, particularly in regard to tibial and pedal bypass procedures. This study aims to assess the current surgical and endovascular experience among the community of German vascular surgery program directors. Materials and methods: This study consisted of a questionnaire-based survey among German vascular surgeons who are licensed to provide further training in vascular surgery (in 2024). The aim was to assess participant's clinical experience, technical approaches to bypass surgery, decision making algorithms to revascularization procedures, and perceived adequacy of training in vascular surgery. Results: A total of 272 (77.7%) of the 350 invited surgeons responded, including 19 females (7.0%). The majority of the participants worked at academic teaching hospitals (79.8%), while 9.2% were in university hospitals and 11.0% worked at non-teaching hospitals. The median number of below-the-knee bypasses performed per career was 524 (IQR 286-1002), including 57 (IQR 20-129) pedal bypasses. Academic teaching hospitals reported the highest number of bypasses (601 vs. 300 in university hospitals) and non-teaching hospitals reported the highest number of endovascular procedures (786 vs. 301). Although the majority reported high confidence levels in performing said procedures, a considerable heterogeneity existed in technical aspects such as intraoperative anticoagulation, clamping technique, and post-surgical quality control. There was no association between institution type and technical aspects. One-third of respondents were over 60 years of age and therefore close to retirement age. Conclusions: This survey provided valuable insights into the delivery of vascular surgery programs in Germany, revealing a high variability in surgical experience, techniques, and training exposure. With an aging workforce and the further evolution of endovascular techniques, structured mentorship programs and standardized training curricula are essential to tackle the challenge of ensuring vascular surgeons remain proficient in tibial and pedal bypass surgery.