SAIUNIVERSITY

GUIDELINES FOR COMPETENCY BASED POSTGRADUATE TRAINING PROGRAMME FOR M.Ch. IN VASCULAR SURGERY

Preamble

Incidence of vascular diseases - disorders of blood vessels and blood circulation in our body - is found to be increasing in India over the past decade. Atherosclerosis and allied causes like arteriopathies lead to involvement of aorta and arteries resulting in aneurismal or occlusive diseases with potential risk to limb, organ and or life. Advanced age, smoking habit, consumption of alcohol, over eating, obesity, physical inactivity coupled with diabetes and hypertension are found to enhance the disease process. Varicose veins and deep vein thrombosis with serious potential complications involving veins are also on the rise. Accidents with injury involving major vessel are rapidly increasing with socioeconomic changes in the community.

Beyond the current schedules for teaching and managing patients in select centres, the speciality needs to be revamped by Structured Programmes at national level to train super specialists for optimal healthcare delivery to scores of patients affected with vascular illnesses. Vascular surgery, an established speciality abroad, is still evolving and yet to come of age in our country. Vascular afflictions lead to enormous morbidity and mortality currently because of increased prevalence of risk factors along with demographic transition in our society. In addition, management of vascular trauma is attaining critical attention in view of the escalating accidents and injuries resulting in loss of young lives and man power. In a large country like ours, a concerted approach to train vascular surgeons at several centres is mandatory to meet the growing needs of our patients in future in order to provide quality of life and ability to pursue their profession.

Goal

The aim of Post graduate Medical Education shall be to produce competent specialists and Medical teachers who shall:

• recognize the health needs of the community, and carry out professional obligations ethically and in keeping with the objectives of the national health policy
• have mastered most of the competencies, pertaining to the speciality, that are required to be practiced at the secondary and the tertiary levels of the health care delivery system
• be aware of the contemporary advances and developments in the discipline concerned
• have acquired a spirit of scientific inquiry and is oriented to the principles of research methodology and epidemiology and
• have acquired the basic skills in teaching of the medical and paramedical professionals.

SCOPE OF VASCULAR SURGERY

Diseases concerning arteries, veins and lymphatics in the human body except those inside calvarium (brain) and pericardium (heart).

SUBJECT SPECIFIC OBJECTIVES

The objectives are:

• To have scientific approach to vascular illness to be able to decide on optimal therapeutic strategy ranging from the risk factor modifications, medical interventional and surgical options appropriately.
• To train to perform elective and emergent vascular surgery procedures – e.g embolectomy, peripheral vascular reconstructions, repair of abdominal aortic aneurysm, Carotid revascularization, surgery for venous insufficiency, endovascular therapies for occlusive, aneurismal diseases and AV malformations.
• To be able to develop interdisciplinary partnership with Neurologist, Cardiologist, Radiologist and Nephrologist.
• To have a broad background regarding vascular medical conditions e.g. Venous thromboembolic disorder and rationale of antiplatelet and anticoagulant therapy.
• To train specialists to handle common vascular illnesses, emergencies including vascular trauma, at respective institutions
• To update recent knowledge and to keep pace with rapid advances in the progress of Vascular Surgery and endovascular techniques.
• To sensitize the trainee to newer learning methods and research tools and to encourage clinical research.
• To plan and execute mass screening programmes and organise preventive methodology.
• To publish papers in indexed journals during the training period.

SUBJECT SPECIFIC COMPETENCIES

a) Cognitive domain (Knowledge)

The trainee should already possess knowledge of basic sciences and the training in general surgical skills. He /She will learn further the anatomy and physiology of arteries, the pathological changes in these and the effects on the end organs. The spectrum of pathologies to be mastered during the course are degenerative arterial disease arteriosclerosis, aneurysms, embolism and thrombosis, inflammatory arteriopathies, atheriovenous malformations (congenital and acquired), vasospastic disorders, diabetic angiopathy, sympathetic dystonia, extracranial cerebrovascular disease, splanchnic vascular disorders, thoracic outlet syndrome, varicose veins, venous thrombosis, post-thrombotic syndrome and lymphedema.

b) Clinical Diagnosis

The mainstay of vascular diagnosis is clinical examination and most of the time the symptoms dictate the therapy rather than the diagnostic tests. The art of clinical examination of vascular patients is simple and brisk, and should be rapidly learned by the students.

c) Non-invasive Vascular Laboratory

It is an indispensable part of vascular diagnosis and many times, supersedes the more invasive and sophisticated techniques. The use of duplex scan (Combination of B mode and Doppler Ultrasound) is an essential part of training of vascular surgeons. The trainee should be taught the use of hand held Doppler, principles of physiological testing and ABI.

d) Specific Imaging Modalities

• Computed Tomography (CT) is the commonest and useful special investigation for delineation of nearly all vascular diseases.
• Magnetic Resonance Imaging (MRI) is an alternative investigatory method in vascular practice.
• Digital Subtraction Angiography (DSA) is mostly performed prior to endovascular procedures and as complimentary treatment modality with or following open surgical procedures.

e) Prevention of vascular diseases

Vascular surgeons should be actively involved in risk factor modification of their patients, to prevent progression or recurrence of the diseases namely cessation of smoking, control of diabetes and modifications of food habits. Appropriate footwear has not only been preventive but also of therapeutic value.

f) Vascular Surgical Techniques/Open vascular Procedures

The spectrum involves repair of all blood vessels of the body with the exception of intracranial vessels, the heart and the aorta up to the arch. The student should learn the exposure of all vessels, the basic vascular suturing techniques and use of various types of grafts in elective and emergency situations. He should be adept in handling of vascular trauma, techniques of thrombectomy, embolectomy, ‘bypass’ to small infrapopliteal/ pedal arteries, treatment of venous disorders from simple varicose veins to deep vein reconstruction. He should be familiar in the management of extracranial vascular diseases, vascular access procedures in renal failure patients and non-vascular procedures like sympathectomy, thoracic outlet syndromes and amputation. With increasing prevalence of diabetes in society he should acquire thorough knowledge of management of diabetic foot.

g) Endovascular Surgery/Intervention

Vascular surgeons should learn this rapidly progressive, minimally invasive surgery. Many diseases, which are treated surgically, might be treated by Endovascular procedures in future and vascular judgement is essential in performing these procedures. Every trainee should be conversant with basic procedures like iliac/ femoral angioplasties and stenting, placement of IVC filters etc. They should also possess at least theoretical knowledge of advanced procedures like stent grafting of aneurysm, use of rotablator, IVUS and other emerging modalities of Endovascular therapies.

h) Vascular Medicine & General Management

Vascular surgery is unique in that there is no medical counterpart (like Cardiology - Cardiac Surgery, Neurology - Neurosurgery). Hence, vascular surgeons should be trained in the use of pharmacotherapeutic agents like anticoagulants, thrombolytic and haemorrheologic agents, antiplatelet drugs, use of drugs in inflammatory vasculopathies, evaluation and therapy of thrombophilic states, use of lipid lowering and anti- atherogenic drugs etc. Vascular surgeons should also learn to supervise physical therapy exercise programmes and possess knowledge of various available prosthesis.

II. Affective Domain

The student:

• Should be able to function as a part of a team, develop an attitude of cooperation with colleagues, and interact with the patient and the clinician or other colleagues to provide the best possible diagnosis or opinion.
• Always adopt ethical principles and maintain proper etiquette in dealings with patients, relatives and other health personnel and to respect the rights of the patient including the right to information and second opinion.
• Develop communication skills to word reports and professional opinion as well as to interact with patients, relatives, peers and paramedical staff, and for effective teaching.

III. Psychomotor domain - Subject specific practical competencies

The post graduate student should acquire the following practical competencies:

• To diagnose and work-up outpatients cases.
• To plan and prepare inpatients for major surgical procedures.
• To conduct interactive ward rounds and to assess the trainee with regard to clinical skills
• Objective in the operating room is to infuse confidence and impart surgical skills in a graded manner.
• The first year post graduate student would be trained to operate on minor surgical procedures.
• The second and third year post graduate students would be trained to assist critical procedures and finally to independently operate major procedures under supervision of Senior Professor/faculty.
• To recognize early signs of untoward events in clinical practice and operating room in particular.
• Writing research articles
• Training in research methodology, medical ethics and medico-legal aspects

Currently vascular therapy includes both open surgical operations and endovascular interventions. Therefore, vascular surgeons/trainees in addition to expertise in open surgery have to learn to perform endovascular procedures often alone as well as along with radiologists as team. This evolution is expected to strengthen in the coming years resulting in the creation of Vascular Specialist.