Clinical Services and Teams
The Vascular Surgery Service is organized around four care groups, with each headed on a rotating basis by a trainee service chief. The trainee service chief is either one of the four vascular surgery fellowship trainees or a PGY-V level general surgery trainee. These separate care teams allow for a single point of contact for all of the decisions related to the patients managed on that service. Four of the services are based at the Barnes-Jewish/St. Louis Children’s/Washington University Medical Center Complex (BJH/WUSM). The fifth rotation is held at the Barnes-Jewish West County Hospital. In July of 2012, we enrolled our first resident into the Integrated Program in Vascular Surgery (0+5).
The four teams based at BJH/WUSM share two mid-level general surgery residents (PGY-II or PGY-III) and two PGY-I residents who fully and actively participate in the educational and clinical activities of the vascular service. The four teams also share two nurse practitioners who assist with the in-hospital care of the vascular patients.
The trainees actively participate in the outpatient clinic of the respective attending(s) to evaluate patients and provide the follow-up of patients for whom they were involved in the preoperative, operative and in-hospital postoperative care. All senior-level trainees are assigned as the initial contact for new patients to provide them with the experience of preoperative assessment, including differential diagnoses, as well as developing a management plan that they discuss with the respective vascular surgery faculty.
A conference schedule is organized by Dr. Brian Rubin and the program director based on a 2-year cycle. The conference schedule is organized to cover areas of basic and clinical science of vascular diseases, and is presented by experts from a variety of specialties. The fellows are also assigned topics in vascular surgery for review and presentation at the conference. Besides the didactic conference, there is a bimonthly Morbidity and Mortality Conference, case presentations and review of key studies in the recent literature. The selection of cases presented is monitored by the program director and vascular surgery faculty to make certain all areas of vascular diseases are appropriately covered. A Journal Club meets twice a month to review seminal publications in the medical literature.
In addition to the routine evaluation of clinical radiographs associated with patient management, intensive experience in the details of CT and MR imaging techniques are integrated into the Barnes-Jewish West County Hospital (BJWCH) rotation. The fellows work directly with Mallinckrodt Institute radiologists who are experts in vascular imaging and interpretation. We have also added a concentrated experience in venous thrombolysis, angioplasty and stenting under the tutelage of Dr. Suresh Vedantham (Professor of Radiology and national principal investigator of the NIH-funded ATTRACT trial*) and other colleagues in Vascular Interventional Radiology.
*Acute Venous Thrombosis: Thrombus Removal With Adjunctive Catheter-Directed Thrombolysis
The Noninvasive Vascular Laboratory provides an abundance of clinical material for educational purposes in conferences and daily rounds. All laboratory locations (CAM, BJH, South County Office, BJWCH) are accredited by the Inter-Societal Commission for the Accreditation of Vascular Laboratories (ICAVL). Vascular surgery residents learn interpretation of vascular laboratory studies from clinical patients during clinical care, rounds and conferences. In compliance with the forthcoming requirements from the Vascular Surgery Board (starting in 2014), all vascular surgery trainees will have the necessary interpretive experience required to sit for the RPVI examination before completion of their training. They will work closely with the vascular laboratory supervisor for their training.
The vascular surgery trainees gain expertise in the preoperative, operative and postoperative care of patients with vascular diseases. Residents obtain an extensive experience in arterial, venous and lymphatic circulatory system diseases. The program director and vascular surgery faculty carefully monitor a vast and balanced experience for residents in open and endoluminal procedures in all anatomic sites. The Vascular Surgery Service currently uses 4 operating rooms 5 days a week, with overflow into other rooms as needed.
Washington University vascular surgeons have a mature practice of endovascular techniques for treatment of all appropriate vascular disease. The program is also actively involved in a variety of clinical studies involving leading endovascular techniques and technology. Trainees participate in all endovascular procedures. The large volume of endovascular procedures at our institution allows the vascular surgery residents, as well as residents in general surgery (PGY-III’s and PGY-V’s), to participate in a wide variety of endovascular procedures.
All operating rooms are designed to support portable intraoperative imaging, and one of the operating rooms is a hybrid operating room with a Siemens fixed-fluoroscopy unit used for hybrid procedures and complicated branched/fenestrated endograft interventions. There is also a dedicated room in the Heart and Vascular Institute outpatient suite (Philips fixed unit) dedicated for the vascular service on a daily basis.
The endovascular experience is large and broad. Vascular surgeons perform about 200 endovascular treatments of abdominal and thoracic aortic aneurysms yearly. They have performed almost 400 carotid stent procedures since September 2003 with excellent published results. Similar extensive endovascular experience exists in the aortoiliac, renal artery and lower extremity anatomic sectors.
Open Vascular Training
In addition to the vast endovascular training, vascular surgery trainees maintain a strong experience in open vascular procedures. In addition to endovascular aneurysm repair, the fellows participate in about 80 open (thoracoabdominal, suprarenal and infrarenal) aneurysm repairs on a yearly basis. There are another 50 abdominal obstructive (aortofemoral, mesenteric or renal bypasses) procedures each year.
On-call Coverage/Vacation Stipend
Vascular surgery trainees (four fellows and PGY-V resident) prepare the on-call schedule every two months. There is no in-house call, but the trainee is available to work with the in-house, mid-level general surgery residents to provide emergent vascular care. The Vascular Surgery Service is in full compliance with the work-hours regulations as established by the ACGME. Moonlighting during training is prohibited. Additional information on vacation, stipend, and health benefits can be found at the WU/BJH Graduate Medical Education Consortium website.