title: A prospective observational study to assess the impact of operator seniority on outcome following arteriovenous fistula formation.
abstract: OBJECTIVE
  Arteriovenous fistula (AVF) surgery affords an excellent opportunity for junior surgeons to learn key vascular techniques. However, implementation of the European Working Time Directive has reduced trainee surgeon's working hours, leading to concerns regarding a possible effect on patient outcomes. Given high early postoperative failure rates and limited AVF sites, it has been proposed that AVF surgery should be performed by Consultants and senior trainees only. This prospective observational study aimed to establish how seniority impacts upon AVF surgery outcomes.
  
  
  METHODS
  All patients referred for AVF formation were considered for inclusion. Demographic data, comorbidities, medications and previous access history were recorded. Surgery was performed by a Consultant Vascular Surgeon or a junior surgeon. Clinical review was undertaken 30 days postoperatively to assess patency and record any complications.
  
  
  RESULTS
  Seventy-seven patients underwent AVF formation. About 63.6% procedures were carried out by a junior surgeon. The groups were well matched for demographics, comorbidities and medications. There was no difference in anatomical site of formation between groups operated on by consultant versus juniors (p = 0.373). More general anaesthetic procedures were undertaken by Consultant surgeons, for example basilic vein transposition when compared with juniors (p = 0.039). There was no significant difference in terms of early AVF failure (p = 0.710), complication rates (p = 0.139) or requirement for re-intervention (p = 0.256) between the groups. Patency rates were also equivocal between the groups.
  
  
  CONCLUSIONS
  The seniority of the operating surgeon does not appear to impact on outcomes following AVF formation. A greater proportion of general anaesthetic cases were undertaken by a Consultant, which may introduce bias. Junior surgeons with appropriate training and modest experience can perform access surgery without detriment to patients patient detriment.
authors.affiliation: Academic Department of Vascular Surgery, Hull and East Yorkshire NHS Trust/Hull York Medical School, Hull - UK.
authors.forename: Rachel
authors.initials: R
authors.lastname: Barnes
authors.forename: George E
authors.initials: GE
authors.lastname: Smith
authors.forename: Ian C
authors.initials: IC
authors.lastname: Chetter
mesh_terms: D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects / Q000193:education*; D002983:Clinical Competence; D004503:Education, Medical, Graduate; D006801:Humans; D011183:Postoperative Complications / Q000209:etiology; D011446:Prospective Studies; D006435:Renal Dialysis; D012307:Risk Factors; D066231:Surgeons / Q000193:education*; D013997:Time Factors; D016896:Treatment Outcome; D014654:Vascular Patency