Cadaver Simulation is Associated with Increased Comfort in Performing Open Vascular Surgery Among Integrated Vascular Surgery (0+5) Residents and Recent Graduates


      With the evolution in vascular surgery toward increased endovascular therapy and decreased open surgical training, comfort with open procedures by current trainees is declining. A proposed method to improve this discomfort is simulator training. We hypothesized that open, cadaver, and endovascular surgery simulation would be associated with increased self-perceived comfort in performing corresponding procedures.


      Integrated (0 + 5) vascular surgery residents and recent graduates in the United States were asked to complete a survey quantifying comfort via a Likert scale with procedures and experience with simulation training. Simulation groups were then matched using coarsened exact matching. Ordinal logistic regression assessed the association between simulation experience and comfort in performing procedures.


      Surveys were completed by 68 trainees and 20 attending surgeons in their first 5 years of practice. On unmatched analyses, there were no significant differences in comfort in performing any open or endovascular aorto-mesenteric or peripheral vascular procedures between respondents who reported experience with open or endovascular simulation, respectively. However, respondents who reported cadaver simulation experience (58%, 51/88) had a significantly higher reported comfort score performing open juxtarenal aortic repair (2.4 vs. 1.7), superior mesenteric artery thrombectomy or bypass (2.5 vs. 1.9), inferior vena cava or iliac vein repair (2.2 vs. 1.7), axillary-femoral artery bypass (3.4 vs. 2.5), femoral-popliteal artery bypass (3.7 vs. 2.8), and inframalleolar artery bypass (2.8 vs. 2.1; all P < 0.05). After matching on training level, number of abdominal cases completed, and number of open vascular cases completed, ordinal logistic regression demonstrated that previous cadaver simulation was significantly associated with increased comfort in performing open aortic repairs, venous repair, visceral revascularization, and peripheral bypasses.


      In this nationally representative sample, cadaver, but not open or endovascular, simulation was associated with increased comfort in performing open vascular surgery. Providing cadaver simulation to trainees may help to improve comfort levels in performing open surgery. Integrated vascular surgery training programs should consider implementing these experiences into their curriculum.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Annals of Vascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • O'Donnell T.F.X.
        • Patel V.I.
        • Deery S.E.
        • et al.
        The state of complex endovascular abdominal aortic aneurysm repairs in the vascular quality initiative.
        J Vasc Surg. 2019; 70: 369-380
        • Baba T.
        • Ohki T.
        • Maeda K.
        Current status of endovascular treatment for thoracoabdominal aortic aneurysms.
        Surg Today. 2019; 50: 1343-1352
        • Popplewell M.A.
        • Davies H.O.B.
        • Narayanswami J.
        • et al.
        A comparison of outcomes in patients with infrapopliteal disease randomised to vein bypass or plain balloon angioplasty in the bypass vs. angioplasty in severe ischaemia of the leg (BASIL) trial.
        Eur J Vasc Endovasc Surg. 2017; 54: 195-201
        • Menard M.T.
        • Farber A.
        • Assmann S.F.
        • et al.
        Design and rationale of the best endovascular versus best surgical therapy for patients with critical Limb Ischemia (BEST-CLI) trial.
        J Am Heart Assoc. 2016; 5: e003219
        • Smith M.E.
        • Andraska E.A.
        • Sutzko D.C.
        • et al.
        The decline of open abdominal aortic aneurysm surgery among individual training programs and vascular surgery trainees.
        J Vasc Surg. 2020; 71: 1371-1377
        • Dua A.
        • Koprowski S.
        • Upchurch G.
        • et al.
        Progressive shortfall in open aneurysm experience for vascular surgery trainees with the impact of fenestrated and branched endovascular technology.
        J Vasc Surg. 2017; 65: 257-261
        • Greenwood V.
        • Shames B.
        • Tanious A.
        • et al.
        Trends in open abdominal exposure among vascular surgery trainees.
        J Vasc Surg. 2017; 66: 947-951.e2
        • Tanious A.
        • Wooster M.
        • Jung A.
        • et al.
        Open abdominal surgical training differences experienced by integrated vascular and general surgery residents.
        J Vasc Surg. 2017; 66: 1280-1284
        • Ullery B.W.
        • Nathan D.P.
        • Jackson B.M.
        • et al.
        Qualitative impact of the endovascular era on vascular surgeons' comfort level and enjoyment with open and endovascular AAA repairs.
        Vasc Endovascular Surg. 2012; 46: 150-156
        • Macsata R.A.
        • Fernandez S.
        A comparison of the knowledge base and surgical skills of integrated versus independent vascular surgery trainees.
        J Vasc Surg. 2016; 64: 514-519
        • Woo K.
        • Rowe V.L.
        • Weaver F.A.
        • et al.
        The results of a needs assessment to guide a vascular surgery skills simulation curriculum.
        Ann Vasc Surg. 2012; 26: 198-204
        • Pandey V.A.
        • Wolfe J.H.
        Expanding the use of simulation in open vascular surgical training.
        J Vasc Surg. 2012; 56: 847-852
        • Mitchell E.L.
        • Sevdalis N.
        • Arora S.
        • et al.
        A fresh cadaver laboratory to conceptualize troublesome anatomic relationships in vascular surgery.
        J Vasc Surg. 2012; 55: 1187-1194
        • Chaer R.A.
        • Derubertis B.G.
        • Lin S.C.
        • et al.
        Simulation improves resident performance in catheter-based intervention: results of a randomized, controlled study.
        Ann Surg. 2006; 244: 343-352
        • Drudi L.
        • Hossain S.
        • Mackenzie K.S.
        • et al.
        A national survey on teaching and assessing technical proficiency in vascular surgery in Canada.
        Ann Vasc Surg. 2016; 33: 220-226
        • Iacus S.M.K.G.
        • Porro G.
        Causal inference without balance checking: coarsened exact matching.
        Polit Anal. 2012; 20: 1-24
        • Shin S.H.
        • Tang G.L.
        • Shalhub S.
        Integrated residency is associated with an increase in women among vascular surgery trainees.
        J Vasc Surg. 2020; 71: 609-615
        • Tanious A.
        • Wooster M.
        • Jung A.
        • et al.
        Comparison of the integrated vascular surgery resident operative experience and the traditional vascular surgery fellowship.
        J Vasc Surg. 2017; 66: 307-310
        • Duran C.
        • Bismuth J.
        • Mitchell E.
        A nationwide survey of vascular surgery trainees reveals trends in operative experience, confidence, and attitudes about simulation.
        J Vasc Surg. 2013; 58: 524-528
        • Robinson W.P.
        • Doucet D.R.
        • Simons J.P.
        • et al.
        An intensive vascular surgical skills and simulation course for vascular trainees improves procedural knowledge and self-rated procedural competence.
        J Vasc Surg. 2017; 65: 907-915.e3
        • Faizer R.
        • Singal A.
        • Ojo C.
        • et al.
        Development of a pulsatile cadaver-based simulation for training of open abdominal vascular surgery skills.
        J Vasc Surg. 2020; 72: 1076-1086
        • Fletcher B.
        • De La Ree J.
        • Drougas J.
        Development of a pulsatile, tissue-based, versatile vascular surgery simulation laboratory for resident training.
        J Vasc Surg Cases Innov Tech. 2017; 3: 209-213
        • Sarkar A.
        • Kalsi R.
        • Ayers J.D.
        • et al.
        Continuous flow perfused cadaver model for endovascular training, research, and development.
        Ann Vasc Surg. 2018; 48: 174-181
        • Nesbitt C.
        • Tingle S.J.
        • Williams R.
        • et al.
        A pulsatile fresh frozen human cadaver circulation model for endovascular training: a trial of face validity.
        Ann Vasc Surg. 2018; 46: 345-350
        • Nesbitt C.I.
        • Tingle S.J.
        • Williams R.
        • et al.
        Educational impact of a pulsatile human cadaver circulation model for endovascular training.
        Eur J Vasc Endovasc Surg. 2019; 58: 602-608
        • Vento V.
        • Cercenelli L.
        • Mascoli C.
        • et al.
        The role of simulation in boosting the learning curve in EVAR procedures.
        J Surg Educ. 2018; 75: 534-540
        • Aho P.
        • Vikatmaa L.
        • Niemi-Murola L.
        • et al.
        Simulation training streamlines the real-life performance in endovascular repair of ruptured abdominal aortic aneurysms.
        J Vasc Surg. 2019; 69: 1758-1765
        • Gosling A.F.
        • Kendrick D.E.
        • Kim A.H.
        • et al.
        Simulation of carotid artery stenting reduces training procedure and fluoroscopy times.
        J Vasc Surg. 2017; 66: 298-306
        • Robinson 3rd, W.P.
        • Schanzer A.
        • Cutler B.S.
        • et al.
        A randomized comparison of a 3-week and 6-week vascular surgery simulation course on junior surgical residents' performance of an end-to-side anastomosis.
        J Vasc Surg. 2012; 56 (discussion 80-1): 1771-1780
        • Sigounas V.Y.
        • Callas P.W.
        • Nicholas C.
        • et al.
        Evaluation of simulation-based training model on vascular anastomotic skills for surgical residents.
        Simul Healthc. 2012; 7: 334-338
        • Hicks C.W.
        • Kernodle A.
        • Abularrage C.J.
        • et al.
        A national resident survey about the current state of venous education in vascular surgery training programs.
        J Vasc Surg Venous Lymphat Disord. 2017; 5: 897-904.e2
        • Lee J.T.
        • Son J.H.
        • Chandra V.
        • et al.
        Long-term impact of a preclinical endovascular skills course on medical student career choices.
        J Vasc Surg. 2011; 54: 1193-1200
        • Bartline P.B.
        • O'Shea J.
        • McGreevy J.M.
        • et al.
        A novel perfused porcine simulator for teaching aortic anastomosis increases resident interest in vascular surgery.
        J Vasc Surg. 2017; 66: 642-648.e4
        • Robinson W.P.
        • Baril D.T.
        • Taha O.
        • et al.
        Simulation-based training to teach open abdominal aortic aneurysm repair to surgical residents requires dedicated faculty instruction.
        J Vasc Surg. 2013; 58: 247-253.e1-2