Vascular training and sub-specialization in mainland China

The history of development of vascular surgery in China dates back to 1950s, with the first vascular operation being a homograft replacement of a gigantic syphilitic aneurysm of the innominate artery (with a diameter of 18 cm) by Fu Pei-Bin¹ at Guang-Ci Hospital of Shanghai Second Medical College in 1955. Dong Fang-Zhong² performed the first surgical repair of abdominal aortic aneurysm with homograft replacement at Ren-Ji Hospital of Shanghai Second Medical College in 1956. In 1957, Gu Kai-Shi³ performed the first aortic aneurysm repair using vascular prosthesis at Shanghai Chest Hospital, and later reported their initial experience of 17 patients with aortic aneurysms in 1961. During this period, Feng You-Xian and Cui Zhi-Yi from Zhong-Shan Hospital of Shanghai First Medical College invented the silk prosthetic vascular graft and used for reconstruction of lower limb aneurysms.^{4, 5} In 1958, Lin Chun-Ye⁶ reported the first thrombectomy for aortic saddle embolism, and Gao Jun-Guang⁷ performed a popliteal aneurysm resection and autogenous long saphenous vein transplantation at Guizhou Provincial Hospital in 1960. Chen Zhong-Wei and Qian Yun-Qing⁸ retransplanted successfully a completely amputated forearm with microvascular surgery at Shanghai Sixth Hospital in 1963. The first carotid endarterectomy was performed by Wang Zhong-Gao⁹ at Peking Union Medical College Hospital in 1983. In the same year, Wang Zhong-Gao introduced a new endovascular treatment for Budd-Chiari syndrome using a stiff catheter to penetrate the web in the inferior vena cava in a young female patient and significantly improved the patient's symptoms.^{10, 11} The first endovascular repair of abdominal aortic aneurysm was performed by Jing Zai-Ping¹² at Changhai Hospital of The Second Military University in 1997. The majority of the early reports on vascular surgery were published in the Chinese language, and although these vascular surgeons worked tirelessly and were well-respected in China, their successful landmark cases were mostly unknown to the Western world until the 1980s.

In China, the medical practice and training is under the control of the Chinese Medical Association. In 1993, the Chinese Society of Vascular Surgery was founded as a subgroup of the General Surgery Branch of the Chinese Medical Association.¹⁰ The missions of the Chinese Society of Vascular Surgery are to instruct and educate the vascular surgeons in clinical practice, and promote and develop academic exchange of vascular surgery.¹³ The past two to three decades have witnessed a rapid development of vascular surgery in China. Due to a high demand of vascular services in China in view of the vast aging population, it was estimated that 1000 surgeons were actively working in vascular surgery in 2015.¹⁰ The majority of these vascular surgeons worked exclusively in the field of vascular surgery. Many hospitals still do not have trained vascular surgeons, and the vascular patients are treated by interventional radiologists, cardiologists or cardiovascular surgeons. According to the survey from 114 cardiovascular centres, the number of endovascular aortic procedures done by cardiovascular surgeons was 9948 in 2019.¹⁴ There has been an international trend toward independent certification in vascular surgery in the past decades.^{15, 16} However, in China, vascular surgery has not been recognized as an independent surgical specialty, and is still being considered as a component of general surgery. In 2019, the Vascular Surgeon Association was established under the Chinese Medical Doctor Association,¹⁷ and more than 1100 national delegates attended this meeting. This is a further step toward independent specialty certification in vascular surgery in mainland China. The vascular service has been recognized, many hospitals have set up independent Vascular Surgery Specialist Clinics and Divisions.

The two earliest Chinese textbooks of vascular surgery in China were published by Lan Xi-Chun from Shanghai Second Medical College in 1963 and Feng You-Xian from Shanghai First Medical College in 1980.^{10, 13} At present, education of vascular surgery is incorporated into a 3-year basic general surgery training after graduation from a 5-year undergraduate program. Training is only conducted at major regional hospitals and trainees are certified on the basis of examination. The examination at the end of the 3-year training is composed of a national standard written exam and a surgical skill test organized by provincial Health Commission, and trainees will get certification from provincial Health Commission for completion of the training. Most vascular diseases (such as deep vein thrombosis, peripheral arterial disease and aortic pathologies) do not feature in the training curriculum syllabus of general surgery, and therefore opportunities and exposure for vascular trainees vary widely between institutions. After general surgical training, vascular trainees are encouraged to engage in further advanced vascular training, together with higher post-graduate degrees such as Master of Surgery or PhD program at the vascular high-ranking educational institutions. They need to pass a national written examination and interview by individual vascular institution for post-graduate degrees. In addition, most of the aspiring vascular surgeons will be encouraged to attend overseas training. Junior surgeons may get advanced vascular and endovascular skill training at reputed centres in big cities, such as Beijing, Shanghai, Guangzhou, Wuhan, Hangzhou and Changsha, where most of the vascular surgeons have their apprentice training at their own institutions.¹⁸ Vascular surgeons need to be qualified for some complex interventional procedures, including endovascular aortic repair, carotid stenting and atherectomy for peripheral arterial disease, training on these endovascular skills are conducted at several major accredited hospitals. No examinations are required for these advanced training, and vascular surgeons are certificated by provincial Health Commission after participation of certain number of interventional procedures. For example, in Guangdong province, vascular surgeons are required to complete a period of 6 months training and participate in more than 50 aortic and peripheral interventional procedures.

More structured specialist training programs were officially launched since 2018 by national Health Commission in China. It has been conducted at some pilot regional hospitals. There is no vascular specialist training program at national or provincial level, as vascular is still recognized as a part of general surgery. For specialized trainees, they may apply for a 2–4 years' specialist training in a designated training centre after completion of their 3 years' basic general surgery training.¹⁹ In the general surgery specialist training program in Shanghai, the period of exposure to vascular surgery is only 4 months.²⁰ After specialist training, trainees may choose vascular surgery as a sub-specialty in a hospital set up with division of vascular surgery. However, it is rather competitive to stay at the regional reputed vascular centres due to the limited positions.

With the aging Chinese population and the ever increasing and more complex vascular work-load, there is an urgent need for development of standardized vascular training to guarantee a certain standard of treatment for the vascular patients. As such, the recognition of vascular surgery as an independent subspecialty with standardized training, education, and accreditation is necessary.