Cerebrovascular Surgical Training in the Era of Neuroendovascular Interventions: The Chief Resident Experience

Background: Cerebrovascular surgical training faces a daunting challenge: training neurosurgeons to competently perform complex open cerebrovascular procedures in the era of neuroendovascular interventions. As advancements in neuroendovascular interventions continue, newer techniques emerge and indications widen. This in turn decreases the number of cases that are treated in open fashion. Consequently, open cerebrovascular cases

Methods: In this study, we investigated the effect that residency program size related factors like procedures scrubbed into, vascular procedural volume encountered, and procedures personally done, could have an impact in shaping the decision-making process for neurosurgery residents to become future neuroendovascular surgeons. We conducted a survey-based study among chief residents of Accreditation Council for Graduate Medical Education (ACGME) recognized neurosurgery residency programs to investigate the impact of program size on residents' exposure to endovascular procedures and their likelihood of choosing a career in endovascular surgery. To summarize the data, we used descriptive statistics. We calculated a correlation matrix for key variables, including program size, the number of anterior circulation aneurysms clipped at the institution, the number of cases where the chief resident assisted, and the number of cases where the chief microdissected and/or clipped the aneurysm. Additionally, we used multivariate regression models to assess how these variables impacted the chief resident's comfort level with clipping anterior circulation aneurysms and their decision to pursue further training in vascular and/or skull base surgery. We also performed a Kruskal–Wallis test to check for discrepancies among different program sizes. If a discrepancy was found, we used the Wilcoxon rank test to determine if the difference was statistically significant.

Results: Of the 80 neurosurgery programs surveyed, program size did not significantly influence the exposure to interventional procedures or the likelihood of residents choosing a career in endovascular surgery. While larger programs tended to have higher academic productivity and board pass rates, differences in clinical exposure among program sizes were not significant.

Conclusion: Our study showed that the differences that come with program size, including the number of interventional procedures a resident is exposed too, number of cases scrubbed into, and the total amount of surgeries resident perform personally, aren’t playing a deterministic effect on influencing the attitudes of neurosurgery fellows when it comes to ESN. Our findings suggest that factors beyond program size play a more significant role in shaping residents' training experiences and career choices in endovascular surgery. Initiatives aimed at promoting interest in endovascular surgery among neurosurgery residents should focus on other factors such as dedicated training pathways, mentorship programs, and exposure to advanced endovascular techniques. Future studies should explore the multifaceted aspects of residency program characteristics and their impact on training outcomes and career trajectories, with careful consideration of the potential loss of neurosurgeons to other specialties if endovascular surgery is not embraced ([Fig. 1]).