Measuring competence development for performing high flow extracranial-to-intracranial bypass

We report our experience with competence development in the performance of high flow extracranial-to-intracranial (HF EC–IC) bypass surgery because of the infrequency of, and hence potential exposure to, this challenging surgery. We reviewed the National Hospital Morbidity Database for the incidence of EC-IC bypass surgery as well as a prospectively collected database (institutional experience). The following were recorded from the institutional experience: graft occlusion, stenosis, disruption, distal ischaemia, surgical complications of the bypass leading to a modified Rankin Scale (mRS) score >2, and intraoperative cross-clamping time. The cross-clamping time was considered the total time that circulation may have been impaired, which included both the distal and proximal cross-clamping periods. The Australian national EC–IC bypass rate (of all bypass types) averaged 1.9 cases per 1,000,000 head of population annually. The institutional experience (170 cases) of high flow EC–IC bypass in this series was associated with 14.7% (95% confidence interval [CI] 10.1-20.9) of graft complications. Graft-specific complications leading to a mRS score >2 were 5.9% (95% CI 3.1-10.6). For the 83 patients where the cross-clamping time was known, the time of cross-clamping was 44 ± 14 min. We concluded that HF EC–IC bypasses are rarely performed procedures that challenge the development of surgical competence. Novel ways of developing and maintaining surgical skills are necessary, including simulation and laboratory experience.