Author's Reply to: “Comment on: What is the Best Training for Vascular Access Surgery?”

Dear Editor,

We have read with interest the letter by Aitken et al and we appreciate their constructive views as many of them are in agreement with our concepts expressed in our recent article on training in vascular access (1). However we believe they misunderstood our point regarding the effect of juniors’ training on outcome. We have never stated in our article that “training impacts negatively the service provision,” on the contrary we have proved that arteriovenous (AV) fistula creation is safe and of equal quality when delivered by residents. We came to this conclusion performing meta-analysis of all existing studies comparing the outcomes of AV fistulas created by consultants vs. trainees and getting no statistically significant results (1).

Additionally we agree heartily with the concept expressed in Aitken et al's letter that AV fistulae can be effectively performed by any surgeon interested and trained in this type of surgery. On the other hand we totally understood experts’ vote in the questionnaire that vascular surgeons should be those that more effectively create access, because vascular surgeons are those most familiar with both surgical and interventional techniques, using them in their everyday practice in hybrid suites and in various areas of the body. This view is supported by the fact that treatment of access thromboses in the UK is mainly carried out by vascular surgeons (2).

Finally regarding the ideal facility for access creation that obviously interferes with training, Aitken et al support centralization of services. The latter is consistent with studies demonstrating the hospital volume–outcome effect in other areas of vascular surgery as aneurysm and carotid surgery (3, 4). Centralization in access is also recommended by many, but there are no quantitative data, in contrast to aneurysm and carotid surgery, demonstrating its success or justifying the existence of access centers (5). In our discussion we emphasized the pros and cons of centralization and although the evidence of centralization appears robust, it might not be as simple as that. There is a clear trade-off between advantages associated with a high-volume center and difficulties caused by prolonged travel times for patients and relatives and such centralization has been debated even for aneurysm surgery (6). These negative effects of centralization are known as “distance decay.” From the patients’ perspective there may be benefits to local service including convenience and continuity of care with familiar physicians, especially as complications and subsequent revisions in access surgery are more frequent than in any other area of vascular surgery. In our view centralization in access surgery remains a controversial issue.