Objectives and Curriculum
The integrated residency is aimed at successful graduates of an accredited medical or osteopathic school who wish to specialize in the field of vascular surgery. The program is 6 clinical years in length, and includes 2 years of core surgical training and 3 years of intensive vascular training. In keeping with our mission of training future leaders in vascular surgery, we have a mandatory academic development year between the third and fourth year. The curriculum stresses core education in the management of surgical patients with complex illnesses, and advanced education to develop competency in the diagnosis and treatment of patients with vascular disease.
The two teaching hospitals that form the basis for the vascular surgery residency are Yale-New Haven Hospital (YNHH) and the VA Connecticut Healthcare, West Haven (VA). The Yale General Surgery Residency program provides rotations in general surgery to all vascular surgery residents at the PGY-1 through PGY-5 levels. There is great opportunity at both hospitals for clinical training and research.
The core surgery education provide the PGY 1-3 vascular surgery resident with adequate exposure to the basic science of surgery, the basic principles of perioperative patient assessment and management, and the fundamentals of surgery techniques and procedures. The essential components of the core curriculum include preoperative assessment, perioperative physiology and hemodynamics, coagulation physiology, principles of infectious disease, wound healing, and nutrition. The minimum core technical skills acquired include airway management, invasive hemodynamic monitoring and AV access, soft tissue management, and basic thoracic, abdominal and surgical trauma techniques. The experience are of sufficient breadth to allow the vascular surgery resident to assess and manage common surgical conditions, perform common surgical procedures and to recognize and manage common surgical complications.
Vascular surgical residents receive clinical experiences in gastrointestinal surgery, trauma surgery, surgical critical care, plastic surgery, cardiothoracic surgery, and transplantation surgery. These clinical experiences provide the vascular surgery resident with the opportunity to evaluate and manage patients with multiple traumatic injuries, gastrointestinal tract pathology (malignancy, bleeding, obstruction, bowel ischemia/infarction, ileus, rectal diseases), the acute abdomen, pulmonary pathology (malignancy, hemothorax and pneumothorax), hernias (inguinal, ventral), end-stage organ failure (liver, kidney), and soft tissue defects.
Since patients with vascular disease commonly have associated co-morbidities, the vascular surgery resident also obtain experience in the management of diabetes, myocardial ischemia, renal insufficiency, hypertension and pulmonary disease as related to the preoperative preparation and postoperative management of the surgical patient. The vascular surgery resident have primary responsibility for and experience in all elements of preoperative and postoperative patient care including hemodynamic management (including arterial and central venous monitoring, interpretation of EKGs), respiratory care, ventilation management and pain management. These are acquired through the general surgery rotations as well as anesthesia and critical care. The assigned inpatient and outpatient cardiology rotations allow the vascular resident to become very familiar with the medical management of hypertension, elevated lipids and atherosclerotic vascular disease. A thorough understanding of platelet physiology and antiplatelet therapy is also required of these rotations.
The vascular surgery resident also learn the assessment of commonly performed diagnostic imaging studies as they pertain to the surgical patient. Special attention to vascular imaging techniques including CT angiography and MRA scans is expected to be achieved through an abdominal imaging rotation in Radiology during the PGY-1 year. Familiarity with scanning techniques and 2D and 3D image reconstructions as well as their advantages for specific vascular exams are expected.
The cardiac and thoracic surgery rotations provide understanding of the anatomy of the heart, aortic arch and branches as well as the thoracic aorta, understanding of bypass techniques, pump principles and the management of pleural collections, common lung and cardiac diseases and the presentations and principles of management of emergency thoracic aortic diseases.
The PGY-4 and PGY-5 years are designed to provide a more independent and “senior” experience on vascular services. They provide experience at the senior level in the more complex type of vascular problems, both elective and emergency. These years are spent entirely in the main sponsoring institution hospitals (YNHH and VA) where tertiary care is provided in addition to the common standard vascular procedures.
At the end of the intensive training the graduate is expected to have the skills necessary to diagnose and define abnormalities of the vascular system, formulate a treatment plan based on available medical and surgical therapeutic options and perform all various surgical and endovascular reconstructive procedures necessary. The graduating vascular surgeon will also have an in-depth understanding of the pathophysiology of vascular disease, especially in areas of hemodynamics, predisposing factors for atherosclerotic disease and knowledge of the pharmacokinetics of drugs used in the treatment of vascular pathology.
Considerable clinical information is covered in a range of conferences held on Monday morning. The didactic lecture schedule is meant to encompass those clinical topics that are not routinely seen by the VS resident in the out-patient or in-patient setting. The senior resident, under supervision of an assigned full-time faculty member, is responsible for setting the schedule. The topics are related to anatomy, microbiology, infectious disease, vascular physiology and pathology especially as they relate to the diagnosis and management of vascular lesions. General information such as management of complications, occurs in Mortality and Morbidity sessions. Specific topics are addressed by the faculty in the vascular teaching conferences to draw on experiences and impart this material to the vascular resident in the clinical arena. The monthly multi-disciplinary peripheral vascular interventions conferences, the bimonthly multidisciplinary carotid management conference, and the Journal Club provide opportunities to address unique clinical topics not seen or discussed in routine patient care. The residents are also encouraged to visit the Association of Program Directors of Vascular Surgery website to review the cases that are installed on a monthly basis.
Non-invasive vascular laboratory techniques and study interpretation
A number of talks on the physics, mechanics and physiologic interpretation of various non-invasive laboratory techniques are given by Dr. Leslie Scoutt, Chief of Ultrasound. The VS residents attends the out-patient clinics at both YNHH and VA. In the vascular rotations, Physiologic and duplex vascular testing are conducted on-site. The resident participates directly in the evaluation of the patient and assists in the interpretation of the test results. A specific one month rotation in the vascular diagnostic laboratory is provided in PGY1 rotation.
Training in endovascular surgery occurs during all years of VS resident training but the bulk of activity for the VS resident is during the 4th and 5th year. Since 2002, there has been a formal affiliation between the Interventional Radiology group and the Vascular Surgery Service. In addition, we have PV faculty members who perform procedure in the IR suite. Dr. Bart Muhs had formal training in endovascular procedures during his VS training as well as an additional year of post-fellowship experience. He was a Marco Polo Fellow and spent six months in Utrecht, Netherlands, training on fenestrated aortic grafts. He works two full days in the IR suites. Dr. Jeff Indes is a recent fellowship trained surgeon who also works in the IR suite doing peripheral arterial and venous procedures. Dr. Cassius Chaar joined the faculty in September 2011 and also completed formal vascular surgery training and is skilled in open and catheter directed vascular interventions. The VS resident is therefore trained in catheter and guidewire skills by both IR and VS faculty. In the first three years, the vascular resident will be exposed to endovascular surgery with rotations on the vascular surgery and medicine services amounting to 9 months, and one month at the VA vascular service. In the final two years, the resident will spend half of PGY4 in clinical vascular surgery rotations where endovascular surgery will be taught as appropriate to patient care, and the entire PGY5 year in clinical vascular surgery rotations. They learn to perform diagnostic angiography, angioplasty and stenting of appropriate lesions and repair of abdominal aortic aneurysms with stent-graft. These procedures are done both in the IR suites and OR by both interventional radiologists and vascular surgeons. Senior VS residents are intimately involved in the pre-operative planning of the procedures, including indications, imaging assessment, measurement of aortic characteristics and selection of appropriate device. At least one of the VS residents is scrubbed for aneurysm or carotid procedures and is involved in catheter selection, guidewire advancement, device deployment, and confirmatory angiography. VS residents are involved in the post-operative follow-up of the patients with regards to the interpretation of follow-up CT scans and the detection of endo-leaks in aneurysm patients.
Finally, at our twice monthly vascular teaching conference, and our monthly multi-disciplinary endovascular conference, endovascular surgery is discussed in all of its aspects.
Timur Paul Sarac, M.D.
Yale University School of Medicine
333 Cedar Street, FMB 137
PO Box 208062
New Haven, Connecticut 06520-8062