The endovascular performance spectrum of vascular surgery departments in Germany

Endovascular interventions have become part of the standard repertoire of vascular surgeons. For example, Sachs et al. [1] identified 563,143 patients in the nationwide inpatient sample (NIS), representing a sample of approximately 20 % of all hospitalizations in the USA who underwent interventions for intermittent claudication (IC) or critical limb ischemia (CLI) in the period between 1999 and 2007. Of these patients 218,655 (38.8 %) were treated by an endovascular procedure, i.e. percutaneous transluminal angioplasty (PTA) and stent, 280,021 underwent peripheral bypass graft (49.7 %), 36,307 (6.4 %) aortofemoral bypass and 5.1 % a hybrid procedure. The CRITISCH study [2], which was supported by the German Society for Vascular Surgery and Vascular Medicine (Deutsche Gesellschaft für Gefäßchirurgie und Gefäßmedizin, DGG), recently showed that endovascular treatment was the preferred approach in CLI, representing the treatment of first choice in 53.4 % of cases, followed by bypass surgery in 23.7 %. Finally, the endovascular approach plays a particularly important role in the treatment of abdominal aortic aneurysms (AAA). On the basis of the Medicare database (patients aged 67 years or older) for the period 2001–2008, Schermerhorn et al. [3] reported 128,598 patients who received elective treatment for AAA, 79,463 of whom underwent endovascular repair (61.8 %) and 49,135 open repair (OR). The percentage of endovascular procedures for the treatment of intact AAA (iAAA) has meanwhile continued to rise, totalling 72 % in the German Institute for Vascular Medicine Healthcare Research [4] (Deutsches Institut für Gefäßmedizinische Gesundheitsforschung, DIGG) register for 2014. Diagnosis-related groups hospital statistics released by the German Federal Statistical Office (Statistisches Bundesamt) permit an overview of inpatient endovascular treatment in Germany [5]. Table 1 provides some information on the procedures carried out in 2013. The statistics for 2013 also show 40,668 arteriograms of neck vessels, 77,140 of abdominal vessels, 138,860 of pelvic vessels, 159,990 of lower extremity vessels and 43,668 super-selective arteriograms, excluding coronary angiograms.

We conducted a survey to make a better assessment of the scope of services offered by vascular surgeons in Germany specifically in relation to endovascular treatment and the results of this survey are presented. At the same time, we have used the subject as an opportunity to provide an overview of the numbers reported for endovascular training in the literature.

Between 16 August and 23 October 2015 a total of 308 senior vascular surgeons were surveyed on departmental structure and scope of services using a 19-point questionnaire. To this end, more than 95 % of all senior departmental heads of vascular surgical units in Germany gained access to an online questionnaire. By checking and blocking IP addresses once questionnaires had been completed, it was largely possible to make access selective and preclude the possibility of responding twice. Responses were received from 223 vascular surgeons in total, representing a response rate of 72 %. The following information on questions and answers relates to this collective. In all 216 out of 223 respondents (96.8 %) held the qualification of vascular surgeons and 189 (84.8 %) the qualification of surgeon (Fig. 1). Of these 62.2 % reported an additional qualification as a DGG® endovascular surgeon and 43.5 % as a DGG® endovascular specialist. A total of 78.9 % had gained specialist knowledge of interventional radiology, 72.6 % of radiology and 10.7 % of computed tomography (CT) radiology. Of the respondents 30 (13.5 %) worked in university hospitals, 39 (17.5 %) in maximum care institutions, 83 (37.2 %) in specialized care institutions, 64 (28.7 %) in basic and standard care institutions, 5 (2.2 %) in specialist hospitals, 1 in an external physician department, and 1 in private practice.

In terms of departmental structure, 171 (76.7 %) specified a vascular surgery department, 47 (21.1 %) a unit within a general surgical department, and 5 (2.2 %) a unit within a cardiac surgery department. The number of staff per department was reported to include on average one chief physician, three senior physicians, one specialist vascular surgeon with no official position and three assistant physicians. Of the centers surveyed 57 % had no certification, 24 % were certified by the DGG alone, 12 % had triple certification and 7 % double certification. Table 2 lists the technical facilities available in the surveyed departments.

The results of the survey revealed a high level of endovascular expertise among vascular surgeons in Germany. This applied not only to the scope of endovascular activities in diagnosis and treatment but also to the number of estimated annual procedures. Nowadays, experience in endovascular techniques is required of all vascular surgeons working in western countries [6]. In a survey of members of the Society for Vascular Surgery (SVS) conducted by Matthews et al. [7], 37.8 % of respondents reported that endovascular procedures accounted for 51–75 % of the case volume. Of these respondents, 20 % estimated that they performed open procedures as frequently as endovascular procedures and only 20 % reported that endovascular interventions accounted for less than 25 % of the activities. As many as 12 % of respondents stated that endovascular procedures accounted for even more than 75 % of the case volume. An age dependence was seen in this survey: 89.9 % of younger vascular surgeons (aged below 50 years) reported that endovascular procedures made up half of the workload, while this proportion was reported by only 62 % of vascular surgeons aged over 50 years. Harkin et al. [8] surveyed 450 vascular surgeons in the UK on their activities and 352 surgeons responded (78 % response rate). Over 90 % of vascular surgeons performed the index operations open aneurysm repair, carotid endarterectomy, infrainguinal bypass and amputation, while 84 % performed standard endovascular aortic repair (EVAR). More complex endovascular procedures, such as thoracic EVAR (TEVAR, 39 %), fenestrated EVAR (35 %) and branched EVAR (24 %) were performed less frequently. Peripheral angioplasty belonged to the repertoire of 31 % of vascular surgeons. Only 20 % of surgeons performed complex open thoracoabdominal aortic surgery and 43 % renal access surgery. The lower density of vascular surgeons in the UK (7 surgeons per 1 million population at the time of the survey) needs to be taken into account in the description of this field of activity.

Endovascular interventions in the lower extremities are performed by a number of different specialists. Wallace et al. [9] analyzed routine data from the Florida Agency for Health Care Administration including 15,398 hospitalized patients between 2005 and 2009 not undergoing concomitant surgical procedures. The percentage of procedures performed by vascular surgeons from all endovascular interventions rose steadily during this period from 28 % to 48 % in 2009, while the percentage of interventional cardiologists dropped from 47 % to 33 % and interventional radiologists from 25 % to 20 %; however, as the majority of these interventions are performed in an outpatient setting in the USA, the quota of individual disciplines in relation to the total case volume should be estimated with caution. A study conducted by Harris et al. [10] based on data from the Centers for Medicare & Medicaid Services (CMS) in the USA is potentially better suited to this end. The CMS database contained all procedure-related invoices for this patient population (patients over 65 years). According to this study, growth was seen in all disciplines (i.e. radiology, cardiology and vascular surgery) for the code 37205 (transcatheter placement of an intravascular stent in a vessel, excluding coronary, carotid and vertebral arteries) between 2000 and 2007, the highest growth being seen in vascular surgery; however, the percentage performed by vascular surgeons was still smaller than those performed by radiologists and cardiologists. Calculated on the basis of 100,000 Medicare insurees, vascular surgeons performed 54 of these interventions in 2007, cardiologists 95 and radiologists 67. The highest growth in vascular surgery was also registered for the code 75962 (transluminal balloon angioplasty, peripheral arteries), whereby the percentage performed by vascular surgeons went on to exceed that of radiologists: looking at a population of 100,000 Medicare insurees, 64 of these interventions were carried out by vascular surgeons, 78 by cardiologists and 58 by radiologists in 2007.

The study by Wallace et al. [9] highlighted that vascular surgeons dealt with the more serious cases, treating 50 % of all patients with CLI, while interventional cardiologists, in contrast, treated 57 % of all patients with IC. This confirms the results of an earlier study by Vogel et al. [11] who analyzed a total of 1887 percutaneous transluminal angioplasty (PTA) on lower extremities, 1021 performed by vascular surgeons and 866 by cardiologists. Here again, the vascular surgical patients were significantly more severely diseased. The percentage of patients with IC in the vascular surgical patient population was 60.7 % but 80.7 % in the cardiology population. In contrast, patients with at resting pain accounted for 16.0 % of vascular surgical patients and gangrene patients for 23.3 %. The corresponding figures for cardiologists were 6.2 % and 13.1 %. Vogel et al. [11] also calculated the cost of resources under North American billing conditions. According to their calculation, treatment in vascular surgical departments was significantly more cost-effective than in cardiology departments but with comparable outcomes. Reasons for this included the fact that vascular surgeons utilized fewer resources and hence worked more cost-effectively compared with cardiologists (in terms of the number of catheters used and technical equipment/medical supplies/number of consultations). Particularly with regard to EVAR for AAA, the leading expertise of the vascular surgeon is undisputed. This was demonstrated by an analysis of the NIS in the USA for the period 2001–2009 that included 28,094 EVAR procedures, 97 % of which were for non-ruptured AAA [12]. In this collective, 92.2 % of all EVAR procedures were performed by surgeons (not further differentiated) and 7.8 % by interventionalists (also not further differentiated). Patients treated by surgeons exhibited lower hospital mortality (2.0 % vs. 4.3 %) and, as a gauge for complications, shorter average hospital stays (3.69 vs. 5.88 days); however, this benefit for surgery did not reach clinical significance when only therapists with large case volumes were compared.

A survey conducted by Dalsing et al. [13] of vascular surgery residents in training demonstrated where the focus of interest lies among trainee vascular surgeons in the USA today: the teaching faculty and endovascular facilities were the most important factors in their ranking of a training program, with 68.8 % and 60 %, respectively, rating these as very important. These were followed by case volumes in open aortic surgery (43.8 %), open carotid surgery (40.0 %) and thoracic aortic interventions (37.6 %) in the ranking of importance for the choice of training program. Residents were also asked about their levels of competence (self-grading) and graded own endovascular competence as high with 78.1 % who considered themselves very competent in general endovascular techniques and 68.8 % in EVAR and TEVAR; however, only 38.7 % considered themselves highly competent in carotid stenting and familiarity with lytic therapy was also lower at 56.3 %. The number who graded themselves as very competent in carotid endarterectomy (CEA) was 78.1 %, in lower extremity revascularization 71.9 % and in open abdominal aortic surgery 46.9 %. How the scope of vascular surgical practice has changed in recent decades was strikingly demonstrated by a comparison of the 10 most common procedures reported by applicants for the vascular surgery recertification examination in the USA in 1995 vs. 2009 ([14]; Table 4).

In 2010 Fitridge et al. [15] proposed an international core curriculum for endovascular surgical training, which set 100 diagnostic angiograms, 50 angioplasties/stents (20 aortoiliac, 15 femoral above-knee popliteal and 15 infragenicular), as well as 20 EVAR as the minimal requirements for specialist recognition. Can a trainee vascular surgeon achieve this case log on a 1-2 year training program and where does the focus lie? Schanzer et al. [16] sought answers to these questions and according to their analysis, open procedures accounted for approximately 48 %, diagnostic endovascular procedures 20 % and therapeutic endovascular procedures 32 % of the 519 major vascular surgical procedures performed on average by graduating trainees in 2007. Approximately 50 EVAR were set against 41 open aortic procedures, 42 CEA, and 36 open peripheral bypasses, to mention the most common. Schanzer et al. [16] found a significant increase in the mean number of procedures performed by trainees between 2001 and 2007, from 298 to 519, attributable almost entirely to the substantially increased case volume in 2007 compared with 2001. Parallel to this increase in endovascular procedures, only 65 % of trainee vascular surgeons questioned in another US survey believed that they would leave their training program with competence levels that prepared them well for open vascular surgery in their future practice, whereas 84 % felt confident that they could provide the full range of endovascular surgical procedures [17].

With their survey Reed et al. [18] set out to ascertain the extent to which vascular surgical departments in the USA have the capacity to adequately train vascular surgery resident trainees in interventional techniques. In all 191 out of 240 trainees who had been trained in 91 hospitals with special training programs responded. In 2008 it was possible to learn interventional techniques largely (over 80 %) in vascular surgical institutions, most commonly with EVAR (99 %), suprainguinal (94.8 %) and infrainguinal (92.7 %) PTA/stenting and least commonly with carotid artery stenting (CAS, 82.2 %). Trainees additionally received training in interventional techniques in cardiology (more rarely) and interventional radiology (more frequently). When asked about the percentage accounted for by the individual departments in terms of their training in interventional techniques, 38.5 % of respondents estimated that 75–100 % of their training had been obtained in the vascular surgical department, 30.8 % put this figure at 51–75 % and a further 30.8 % at 26–50 %. A UK survey of 217 trainee vascular surgeons, of which 153 (71 %) responded, painted a very different picture [19]. At the time of the survey 80 of these 153 (52 %) were working in posts that offered no endovascular training and 88 % (123/153) had performed less than 10 peripheral angiograms and/or angioplasties with or without supervision in the previous 12 months. A total of 63 % (96/153) reported that they had never performed a procedure of this kind. The majority of trainees (104/153) had performed less thatn10 EVAR (partially or completely, with or without supervision) in the previous 12 months. Furthermore, no experience with endovenous laser therapy, radiofrequency ablation or foam sclerotherapy for varicose vein treatment was reported by 33 %, 49 %, and 46 %, respectively. This survey demonstrates, in terms of individual vascular surgical department capacity to offer further training, the range of endovascular services available and the opportunities offered to endovascular guest students, among other factors that at least endovascular training opportunities in Germany for trainee vascular surgeons in vascular surgical departments are significantly broader. Finally, a further and particular aspect of endovascular activity requires mention, i. e. radiation exposure. Kirkwood et al. [20] showed that providing surgeons with training in techniques aimed at reducing radiation exposure during endovascular procedures is an important factor in reducing radiation doses in the interventional context. In our survey 72.6 % of respondents reported having specialist knowledge of radiology, while 78.9 % reported specialist knowledge of interventional radiology. To what extent these rates can be improved on remains open.