Vascular Acute Care Surgery (VACS) Services: A New Model for the Future and a Solution to the Emerging Vascular Surgery Coverage Crisis

  • M. Aizpuru
  • A. P. Sweeney
  • J. D. Watson
  • D. G. Harris
  • C. B. Drucker
  • J. J. Diaz
  • R. S. CrawfordEmail author
Vascular Surgery (R. S. Crawford, Section Editor)
Part of the following topical collections:
  1. Vascular Surgery


Purpose of Review

The following is a comprehensive review of the current practice of Vascular Surgery, highlighting the existing gaps in vascular surgical care and delivery and providing evidence-based suggestions for improvements moving forward.

Recent Findings

Recent data demonstrate that a shift of many vascular surgical procedures from extensive, high-risk, inpatient operations toward minimally invasive, endovascular, same-day surgeries has created a gap in the ability of the community-based vascular surgeon to adequately care for acute vascular events.


The trends towards outpatient vascular surgery, coupled with the increasing demands of acute vascular surgical expertise for less-common open and high-risk procedures have created a crisis in the field. When the field of General Surgery was at a similar crossroads in the early 2000s, the community responded with the development of Acute Care Surgery (ACS) services to manage resource-intensive emergencies. Vascular surgery should learn from the ACS experience and consider the development of Vascular Acute Care Surgery (VACS) services responsible for the care of acute vascular patients.


Vascular surgery Acute care surgery Vascular acute care surgery 



The editors would like to thank Dr. Anne Fischer for taking the time to review this manuscript.

Compliance with Ethics Guidelines

Conflict of interest

Matthew Aizpuru, Aidan P. Sweeney, J. Devin Watson, Donald G. Harris, Charles B. Drucker, Jose J. Diaz, and Robert S. Crawford each declare no potential conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Martin MJ, Long WB. Vascular trauma: epidemiology and natural history. In: Cronenwett JL, Johnston KW, editors. Rutherford’s vascular surgery. 8th ed. New York: Saunders, an imprint of Elsevier Inc.; 2014. p. 2422–37.Google Scholar
  2. 2.
    Schneider PA. The future of vascular surgery. J Vasc Surg. 2015;61(5):1357–65. Scholar
  3. 3.
    Tefera G. Vascular surgery and endovascular therapy. Surg Clin North Am. 2013;93(4):xvii–xix. Scholar
  4. 4.
    Levin DC, Rao VM, Parker L, Frangos AJ, Sunshine JH. Endovascular repair vs open surgical repair of abdominal aortic aneurysms: comparative utilization trends from 2001 to 2006. J Am Coll Radiol. 2009;6(7):506–9. Scholar
  5. 5.
    Matthews MAB, Satiani B, Lohr JM. Trends in a changing vascular practice environment for members of the Society for Vascular Surgery. J Vasc Surg. 2013;57(2):586–592.e2. Scholar
  6. 6.
    Dosluoglu HH, Lall P, Blochle R, Harris LM, Dryjski ML. Ambulatory percutaneous endovascular abdominal aortic aneurysm repair. J Vasc Surg. 2014;59(1):58–64. Scholar
  7. 7.
    Jones WS, Mi X, Qualls LG, et al. Trends in settings for peripheral vascular intervention and the effect of changes in the outpatient prospective payment system. J Am Coll Cardiol. 2015;65(9):920–7. Scholar
  8. 8.
    Forrester JD, Weiser TG, Maggio P, et al. Trends in open vascular surgery for trauma: implications for the future of acute care surgery. J Surg Res. 2016;205(1):208–12. Scholar
  9. 9.
    •• Harris DG, Herrera A, Drucker CB, et al. Defining the burden, scope, and future of vascular acute care surgery. J Vasc Surg. 2017;66(5):1511–7. This paper quanitfies the burden of vascular acute care surgery patients, describing a trend towards increased inpatient admissions of acute vascular patients. CrossRefPubMedGoogle Scholar
  10. 10.
    Richards T, Pittathankal A, Kahn P, Magee T, Lewis M, Galland R. Vascular surgical emergencies: how will future surgeons be trained? Ann R Coll Surg Engl. 2006;88(7):646–9. Scholar
  11. 11.
  12. 12.
    American Medical Association. History of Medicare Conversion Factors. 2018.
  13. 13.
    Yan H, Maximus S, Kim JJ, et al. General surgery resident vascular operative experience in the era of endovascular surgery and vascular fellowships. Am Surg. 2015;81(10):1093–6.PubMedGoogle Scholar
  14. 14.
    Krafcik BM, Sachs TE, Farber A, et al. Assessment of open operative vascular surgical experience among general surgery residents. J Vasc Surg. 2016;63(4):1110–5. Scholar
  15. 15.
    Fonseca AL, Reddy V, Longo WE, Gusberg RJ. Are graduating surgical residents confident in performing open vascular surgery? Results of a national survey. J Surg Educ. 2015;72(4):577–84. Scholar
  16. 16.
    Yan H, Maximus S, Koopmann M, et al. Vascular trauma operative experience is inadequate in general surgery programs. Ann Vasc Surg. 2016;33:94–7. Scholar
  17. 17.
    Strumwasser A, Grabo D, Inaba K, et al. Is your graduating general surgery resident qualified to take trauma call? A 15-year appraisal of the changes in general surgery education for trauma. J Trauma Acute Care Surg. 2017;82(3):470–80. Scholar
  18. 18.
    Dua A, Upchurch GR, Lee JT, Eidt J, Desai SS. Predicted shortfall in open aneurysm experience for vascular surgery trainees. J Vasc Surg. 2014;60(4):945–9. Scholar
  19. 19.
    Sachs T, Schermerhorn M, Pomposelli F, Cotterill P, O’Malley J, Landon B. Resident and fellow experiences after the introduction of endovascular aneurysm repair for abdominal aortic aneurysm. J Vasc Surg. 2011;54(3):881–8. Scholar
  20. 20.
    Sullivan TM, Taylor SM, Blackhurst DW, et al. Has endovascular surgery reduced the number of open vascular operations performed by an established surgical practice? J Vasc Surg. 2002;36(3):514–9.CrossRefGoogle Scholar
  21. 21.
    Hirsch AT, Criqui MH, Treat-Jacobson D, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA. 2001;286(11):1317–24.CrossRefGoogle Scholar
  22. 22.
    Swor R, Lucia V, McQueen K, Compton S. Hospital costs and revenue are similar for resuscitated out-of-hospital cardiac arrest and ST-segment acute myocardial infarction patients. Acad Emerg Med. 2010;17(6):612–6. Scholar
  23. 23.
    Ouriel K, Shortell CK, DeWeese JA, et al. A comparison of thrombolytic therapy with operative revascularization in the initial treatment of acute peripheral arterial ischemia. J Vasc Surg. 1994;19(6):1021–30.CrossRefGoogle Scholar
  24. 24.
    Singh IM, Holmes DR. Myocardial Revascularization by Percutaneous Coronary Intervention: past, present, and the future. Curr Probl Cardiol. 2011;36(10):375–401. Scholar
  25. 25.
    Kereiakes DJ. Specialized centers and systems for heart attack care. Am Heart Hosp J. 2008;6(1):14–20.CrossRefGoogle Scholar
  26. 26.
    Henry TD, Atkins JM, Cunningham MS, et al. ST-segment elevation myocardial infarction: recommendations on triage of patients to heart attack centers: is it time for a national policy for the treatment of ST-segment elevation myocardial infarction? J Am Coll Cardiol. 2006;47(7):1339–45. Scholar
  27. 27.
    Earnshaw JJ, Whitman B, Foy C. National Audit of Thrombolysis for Acute Leg Ischemia (NATALI): clinical factors associated with early outcome. J Vasc Surg. 2004;39(5):1018–25. Scholar
  28. 28.
    Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: executive summary. Vasc Med. 2017;22(3):NP1–43. Scholar
  29. 29.
    Vemulapalli S, Curtis LH. Putting the vascular back into cardiovascular research: ST-segment-elevation myocardial infarction as a blueprint for improving care in patients with acute limb ischemia. Circulation. 2013;128(2):89–91. Scholar
  30. 30.
    Wang SK, Murphy MP, Gutwein AR, et al. Perioperative outcomes are adversely affected by poor pretransfer adherence to acute limb ischemia practice guidelines. Ann Vasc Surg. 2018;50:46–51. Scholar
  31. 31.
    Williams K, Schneider B, Lajos P, Marin M, Faries P. Supply and demand: will we have enough vascular surgeons by 2030? Vascular. 2016;24(4):414–20. Scholar
  32. 32.
    • Singh TM. Present vascular surgery challenges are magnified in our emergency rooms. Vasc Spec. 2016. This paper was the first to describe the vascular surgery coverage crisis in U.S. Emergency Departments.
  33. 33.
    Campbell B, Chester J. Emergency vascular surgery. BMJ. 2002;324(7347):1167–8.CrossRefGoogle Scholar
  34. 34.
    Kutcher ME, Peitzman AB. A history of acute care surgery (emergency surgery). Acute Care Surgery Handbook. Cham: Springer; 2017. p. 19–37.CrossRefGoogle Scholar
  35. 35.
    Lynge DC, Larson EH, Thompson MJ, Rosenblatt RA, Hart LG. A longitudinal analysis of the general surgery workforce in the United States, 1981-2005. Arch Surg. 2008;143(4):345–50. (discussion 351).CrossRefPubMedGoogle Scholar
  36. 36.
    Borman KR, Vick LR, Biester TW, Mitchell ME. Changing demographics of residents choosing fellowships: longterm data from the American Board of Surgery. J Am Coll Surg. 2008;206(5):782–8. (discussion 788-9).CrossRefPubMedGoogle Scholar
  37. 37.
    Beretvas RI, Brody F. Ambulatory laparoscopic surgery. Semin Laparosc Surg. 1999;6(1):17–20.PubMedGoogle Scholar
  38. 38.
    Bian J, Morrisey MA. Free-standing ambulatory surgery centers and hospital surgery volume. Inquiry. 2007;44(2):200–10. Scholar
  39. 39.
    Institute Of Medicine. IOM report: the future of emergency care in the United States health system. Acad Emerg Med. 2006;13(10):1081–5. Scholar
  40. 40.
    Santry HP, Madore JC, Collins CE, et al. Variations in the implementation of acute care surgery: results from a national survey of university-affiliated hospitals. J Trauma Acute Care Surg. 2015;78(1):60–7. (discussion 67-8).CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Zhu X, Ullrich F, Mueller KJ, et al. Trends in hospital network participation and system affiliation, 2007-2012. Rural Policy Brief. 2014;6:1–5.Google Scholar
  42. 42.
    Miller PR, Wildman EA, Chang MC, Meredith JW. Acute care surgery: impact on practice and economics of elective surgeons. J Am Coll Surg. 2012;214(4):531–5. Scholar
  43. 43.
    Michailidou M, Kulvatunyou N, Friese RS, et al. Time and cost analysis of gallbladder surgery under the acute care surgery model. J Trauma Acute Care Surg. 2014;76(3):710–4. Scholar
  44. 44.
    Austin MT, Diaz JJ, Feurer ID, et al. Creating an emergency general surgery service enhances the productivity of trauma surgeons, general surgeons and the hospital. J Trauma. 2005;58(5):906–10.CrossRefGoogle Scholar
  45. 45.
    Earley AS, Pryor JP, Kim PK, et al. An acute care surgery model improves outcomes in patients with appendicitis. Ann Surg. 2006;244(4):498–504. Scholar
  46. 46.
    Cubas RF, Gómez NR, Rodriguez S, Wanis M, Sivanandam A, Garberoglio CA. Outcomes in the management of appendicitis and cholecystitis in the setting of a new acute care surgery service model: impact on timing and cost. J Am Coll Surg. 2012;215(5):715–21. Scholar
  47. 47.
    Murphy PB, DeGirolamo K, Van Zyl TJ, et al. Meta-analysis on the impact of the acute care surgery model of disease- and patient-specific outcomes in appendicitis and biliary disease. J Am Coll Surg. 2017;225(6):763–777.e13. Scholar
  48. 48.
    Mehta M, Taggert J, Darling RC, et al. Establishing a protocol for endovascular treatment of ruptured abdominal aortic aneurysms: outcomes of a prospective analysis. J Vasc Surg. 2006;44(1):1–8. Scholar
  49. 49.
    Mehta M. Endovascular aneurysm repair for ruptured abdominal aortic aneurysm: the Albany Vascular Group approach. J Vasc Surg. 2010;52(6):1706–12. Scholar
  50. 50.
    Cull DL, Langan EM, Taylor SM, Carsten CG, Tong A, Johnson B. The influence of a Vascular Surgery Hospitalist program on physician and patient satisfaction, resident education, and resource utilization. J Vasc Surg. 2013;58(4):1123–8. Scholar
  51. 51.
    Harris DG, Olson SB, Rosen CB, et al. Early treatment at a referral center improves outcomes for patients with acute vascular disease. Ann Vasc Surg. 2018;50:52–9. Scholar
  52. 52.
    • Manzur MF, Ham SW, Elsayed R, et al. Vascular surgery: an essential hospital resource in modern health care. J Vasc Surg. 2017;65(6):1786–92. This analysis of vascular surgery consults found that they are often unplanned, and require prompt surgical intervention.CrossRefPubMedGoogle Scholar
  53. 53.
    Leithead CC, Matthews TC, Pearce BJ, et al. Analysis of emergency vascular surgery consults within a tertiary health care system. J Vasc Surg. 2016;63(1):177–81. Scholar
  54. 54.
    McMackin K, Lombardi J, Carpenter J, Alexander J, Trani J, Caputo F. PC130 development and implementation of a level one vascular emergency program. J Vasc Surg. 2017;65(6):174S–5S. Scholar
  55. 55.
    Pieracci FM, Stahel PF. Organization of an acute care surgery service and patient safety management. Acute care surgery handbook. Cham: Springer; 2017. p. 55–67.CrossRefGoogle Scholar
  56. 56.
    Graham KJ, Strauss CE, Boland LL, et al. Has the time come for a national cardiovascular emergency care system? Circulation. 2012;125(16):2035–44. Scholar
  57. 57.
    He JC, Clancy K, Schechtman D, Conrad-Schnetz KJ, Claridge JA. Traumatic vascular injuries: who are repairing them and what are the outcomes? Am J Surg. 2016;211(3):619–25. Scholar
  58. 58.
    Shackford SR, Kahl JE, Calvo RY, et al. Limb salvage after complex repairs of extremity arterial injuries is independent of surgical specialty training. J Trauma Acute Care Surg. 2013;74(3):716–23. Scholar
  59. 59.
    Villamaria CY, Eliason JL, Napolitano LM, Stansfield RB, Spencer JR, Rasmussen TE. Endovascular skills for trauma and resuscitative surgery (ESTARS) course. J Trauma Acute Care Surg. 2014;76(4):929–36. Scholar
  60. 60.
    Zettervall SL, Schermerhorn ML, Soden PA, et al. The effect of surgeon and hospital volume on mortality after open and endovascular repair of abdominal aortic aneurysms. J Vasc Surg. 2017;65(3):626–34.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • M. Aizpuru
    • 1
  • A. P. Sweeney
    • 1
  • J. D. Watson
    • 2
  • D. G. Harris
    • 3
  • C. B. Drucker
    • 4
  • J. J. Diaz
    • 5
  • R. S. Crawford
    • 6
    Email author
  1. 1.Emory University School of MedicineAtlantaUSA
  2. 2.Heart, Lung, and Vascular CenterDavid Grant Medical Center, Travis AFBFairfieldUSA
  3. 3.Department of SurgeryUniversity of WisconsinMadisonUSA
  4. 4.Department of SurgeryUniversity of Maryland Medical CenterBaltimoreUSA
  5. 5.Division of Acute Care SurgeryUniversity of Maryland School of Medicine, R Adams Cowley Shock Trauma CenterBaltimoreUSA
  6. 6.Division of Vascular & Endovascular SurgeryEmory University School of Medicine, Emory St. Joseph’s HospitalGeorgiaUSA

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