A Comprehensive Guide to Evaluating Case Volume in Vascular Surgery Residency

Understanding Case Volume in Vascular Surgery Residency as a DO Graduate

Evaluating case volume is one of the most important—and most misunderstood—steps in choosing a vascular surgery residency, especially for a DO graduate navigating the osteopathic residency match (now fully integrated into the NRMP Match). For vascular surgery, where technical skill, judgment, and pattern recognition are developed in the operating room and angiography suite, case volume and variety directly shape your readiness for independent practice or fellowship.

This article breaks down how to assess residency case volume, what numbers actually matter, how to interpret surgical volume and procedure numbers at different programs, and specific considerations for DO applicants pursuing an integrated vascular program or fellowship pathway.

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1. Why Case Volume Matters So Much in Vascular Surgery

Vascular surgery is highly procedural. The breadth of operations—from carotid endarterectomy to fenestrated EVAR—means that your operative exposure will largely determine:

• How comfortable you are in the OR and endovascular suite
• Your readiness to practice independently on graduation
• Your competitiveness for academic jobs or complex aortic fellowships

The Three Dimensions of Case Volume

When you hear residents boast about being “busy,” you need to parse that into three dimensions:

1. Absolute case numbers (total surgical volume)

   • Total logged procedures as primary surgeon or first assistant
   • Breakdown of open vs. endovascular cases
   • Complexity: basic vs. advanced/complex procedures

2. Timing and progression

   • When you start doing cases (intern year vs. later)
   • How early you get primary surgeon experience
   • How quickly case complexity increases over PGY years

3. Quality and autonomy

   • Are you holding the knife or retracting?
   • Are attendings letting you make decisions, manage wires, deploy devices?
   • Are you practicing entire operations vs. just a step or two?

A program with “high case volume” where you mostly retract is far less valuable than a slightly lower-volume program where you consistently operate as primary surgeon.

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2. Core Case Volume Benchmarks in Vascular Surgery

To compare programs intelligently, you need a frame of reference. While specific minimums have evolved, there are widely recognized benchmarks for operative exposure by graduation.

Key Categories to Track

Use these as a mental checklist when you evaluate case logs, program websites, or talk to residents:

1. Endovascular interventions

   • EVAR, TEVAR
   • Iliac, femoral-popliteal, tibial angioplasty/stents
   • Thrombolysis, thrombectomy
     Typical robust experience by graduation:
   • 500–700+ endovascular procedures total
   • Significant experience being “primary operator” on diagnostic and straightforward interventions

2. Open aortic surgery

   • Open AAA repair
   • Aortobifemoral and aortoiliac reconstructions
   • Visceral and renal bypasses (less common in pure community programs)
     Solid training often includes:
   • 40–60+ open aortic cases (with a good portion as primary or co-surgeon)

3. Peripheral arterial surgery

   • Femoral endarterectomy
   • Fem-pop bypass (above and below knee)
   • Distal bypass and tibial/pedal procedures
     Competitive graduates often log:
   • 150–250+ open peripheral operations

4. Carotid and supra-aortic procedures

   • Carotid endarterectomy
   • Carotid stenting (CAS)
   • Subclavian, innominate, and arch branch work (often shared with CT surgery)
     Common ballpark:
   • 60–100 carotid operations (including a mix of open and endovascular)

5. Dialysis access

   • AV fistulas
   • AV grafts
   • Revision and thrombectomy
     Many high-volume training programs reach:
   • 100–200+ access procedures

6. Venous procedures

   • IVC filter placement/removal
   • Varicose vein ablation/stripping
   • Iliocaval stenting
     Numbers vary widely, but meaningful exposure is increasingly important with modern venous practice.

Example: What a Strong Graduating Case Log Might Look Like

A competitive graduate from a busy integrated vascular program might have:

• Total vascular cases: 900–1300+
• Endovascular: 600–800
• Open arterial: 250–400
• Open aortic: 50–70
• Carotid (open + CAS): 80–120
• Dialysis access: 150–250
• Venous interventions: 50–150

You don’t have to hit these exact numbers, but they’re a useful reference when comparing advertised program figures or ACGME case log averages.

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3. Evaluating Integrated Vascular Residency Programs as a DO

For a DO graduate, the shift to the single accreditation system means you’ll be applying alongside MDs to the same integrated vascular residencies. Your job is to determine which programs not only welcome DOs but also offer strong surgical volume and supportive training culture.

Step 1: Identify DO-Friendly Programs

When you review program websites and talk to residents, look for:

• Current or recent DO residents or fellows
  • Check resident lists; email a current DO trainee directly if possible
• Explicit mention of accepting COMLEX (even if USMLE is preferred or required)
• Evidence of DOs matching into the institution’s other surgical programs (general surgery, ortho, neurosurgery)
• Faculty who are DOs, especially in vascular or surgery departments

These indicators don’t guarantee high case volume, but they signal a more open mindset toward DO graduates within the surgical culture.

Step 2: Ask the Right Case Volume Questions

When evaluating an integrated vascular program, don’t just ask, “Are you busy?” Instead, ask targeted questions:

1. Case distribution and autonomy

   • “By the end of PGY-3, how many cases are residents typically logging as primary surgeon?”
   • “How are cases divided between integrated residents, fellows (if any), and general surgery residents?”
   • “Do juniors get early wire and catheter time in endovascular procedures?”

2. Open vs. endovascular balance

   • “Approximately what percentage of procedures are open vs. endovascular?”
   • “How many open aortic cases does a typical graduate log?”
   • “If open volume is limited, how does the program compensate (rotations at VA, affiliated hospitals, or visiting rotations)?”

3. Rotation structure

   • “What is the breakdown of vascular vs. non-vascular time each year?”
   • “Do integrated residents spend time on cardiac, critical care, and interventional radiology? How does that affect vascular case volume?”
   • “How are call responsibilities structured, and do they lead to increased emergency case exposure?”

4. Outcome metrics

   • “Have any graduates recently felt under-prepared in specific procedure types?”
   • “Where are recent graduates practicing—academic, private, hybrid—and do they feel their case volume was adequate?”

Step 3: Understand Case Volume in Context of Fellowships

Some programs have:

• Integrated residents only (no independent fellows)
• Both integrated residents and traditional vascular fellows
• Only independent vascular fellowships (not your primary target but relevant if you’re considering the general surgery → fellowship route)

When both integrated residents and fellows train together, ask specifically:

• “How are complex cases divided between integrated residents and fellows?”
• “Do integrated residents get adequate exposure to complex aortic and advanced endovascular work, or is that predominantly fellow territory?”

A program can be extremely high-volume on paper, but if you are always second in line to fellows, your personal procedure numbers may not reflect that.

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4. Comparing Programs: Beyond the Raw Procedure Numbers

Relying solely on how many cases a program advertises is risky. Two programs could each report 1,000 cases per resident, yet deliver very different experiences.

A. Open vs. Endovascular Balance

As modern practice shifts heavily toward endovascular solutions, it’s tempting to prioritize angioplasty and stent numbers. You absolutely need strong endovascular skills, but:

• High-level vascular surgeons consistently emphasize the value of open training for:
  • Understanding anatomy in 3D
  • Managing complications of endovascular interventions
  • Tackling complex redo or infection cases

If a program’s open case volume (especially open aortic and distal bypass) is extremely low, talk to graduates: do they feel clinically and technically ready?

B. Case Volume per Resident (Not Just Hospital Volume)

Hospital vascular volume alone is misleading. Focus on:

• Number of vascular surgeons and trainees
  • If there are many fellows and integrated residents for a limited attending group, case competition may be intense
• Division of labor
  • Who staffs the VA? The main hospital? Satellite hospitals?
  • Are residents spread thin across multiple sites so they “see everything but fully own nothing,” or is time structured to allow ownership?

Ask residents:

• “In the average week, how many cases are you scrubbed into?”
• “Of those, in how many do you function as true primary surgeon or primary operator?”

C. Graduated Responsibility

High case volume is only valuable if your role evolves:

• PGY-1–2: exposure + learning anatomy + basic skills (suturing, exposure, wire handling)
• PGY-3–4: becoming primary operator on routine cases; gaining confidence in judgment and planning
• PGY-5–7 (for integrated programs): leading major cases with attending backup; managing complications; making perioperative decisions

Ask for concrete examples:

• “Can you give examples of cases where a chief resident runs most of the case?”
• “By what PGY level do residents usually perform carotid endarterectomies as primary surgeon?”

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5. A DO Graduate’s Strategy for Evaluating Case Volume

As a DO applicant, you may feel additional pressure to prove you belong in a highly technical field like vascular surgery. A thoughtful, data-driven approach to case volume evaluation not only helps you pick the right program, it also demonstrates maturity to interviewers.

Step 1: Research Before Application Submission

Create a spreadsheet that includes:

• Program name and location
• Current or recent DO residents (yes/no and names if known)
• Published case log summaries (if provided)
• Program size (number of integrated positions/year, any fellows)
• Affiliated hospitals (e.g., VA, private, county) and their vascular volume reputation

Use:

• Program websites
• ACGME public data (when available)
• Residency / integrated vascular program review forums (interpret with caution)
• Direct emails to coordinators for case volume snapshots or “average graduate case reports”

Step 2: Focus on Red Flags and Green Flags

Red flags related to case volume:

• Vague responses like “we’re very busy” with no approximate numbers
• Residents struggling to recall open volume specifics (“we don’t do that many open aortas anymore”)
• Multiple trainees quietly mentioning they wish they had more operative autonomy or open exposure
• Heavy reliance on peripheral clinics at the expense of operative time

Green flags:

• Programs readily share aggregate residency case volume data by PGY level
• Chief residents express confidence in managing both open and endovascular emergencies independently
• Built-in rotations at high-volume open centers if home base is more endovascular-heavy
• Regular simulation, cadaver labs, and structured technical skills curricula that complement real case volume

Step 3: Ask “DO-Specific” Questions Tactfully

You never want to frame questions in a way that suggests insecurity about being a DO, but you can explore culture and opportunity:

• “How are residents supported when they enter with different medical school backgrounds (MD vs. DO vs. international)?”
• “Have DO graduates in recent years had any difficulty achieving targeted operative numbers or fellowship placements?”
• “How does the program ensure consistent case access and progression for every resident, regardless of background?”

When DOs have historically thrived at a program, attendings and residents are usually happy to share that.

Step 4: Interpret Volume Claims Against Accreditation Standards

While you might not have every detail of ACGME thresholds, you can still ask:

• “Do your graduates consistently exceed the ACGME minimums for case categories?”
• “In which categories do residents typically have the strongest surplus over minimums (e.g., peripheral bypass, endovascular, dialysis access)?”

Programs that can answer this confidently tend to be more deliberate about resident education rather than just service coverage.

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6. Balancing Case Volume with Lifestyle, Culture, and Career Goals

High surgical volume is not everything. An environment that is toxic, disorganized, or unsupportive of DO graduates can erode your learning regardless of case numbers.

Fit Matters as Much as Numbers

As you evaluate programs, consider:

• Teaching culture

  • Do attendings enjoy teaching, or are they just trying to get through the list?
  • Are residents comfortable asking questions during cases?

• Feedback and assessment

  • Are technical skills evaluated regularly with formal feedback?
  • Do residents get clear guidance on what they need to improve to handle more complex cases?

• Career outcomes

  • Are graduates going directly into practice, advanced fellowship, or academic jobs similar to what you envision?
  • If your goal is high-end academic or complex aortic work, does the program’s case mix support that?

Example Scenarios for a DO Graduate

1. Scenario A: Medium-size academic program, strong open volume

   • 1 integrated vascular resident per year, no fellows
   • High open aortic and peripheral volume due to limited endovascular resources
   • Graduates feel technically independent in open procedures, slightly less in complex endovascular
   • For a DO seeking strong foundational skills and community/academic hybrid practice, this may be ideal.

2. Scenario B: Large quaternary center, massive endovascular volume

   • Integrated residents plus multiple vascular fellows
   • Robust complex endovascular program (fenestrated/branched EVAR, complex TEVAR)
   • Open volume sufficient but diluted across many trainees
   • For a DO aiming at advanced endovascular or academic jobs, this can be excellent—if you confirm real access to complex cases.

3. Scenario C: Community-based integrated program with moderate volume

   • 1 integrated resident/year, heavy clinical workload, modest case numbers
   • Mostly bread-and-butter endovascular and standard bypasses
   • If your goal is smaller community practice and lifestyle balance, this may meet your needs, but check that you still clear necessary case thresholds.

Your ideal program is where case volume, case mix, culture, and your long-term goals intersect.

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FAQs: Case Volume Evaluation for DO Graduates in Vascular Surgery

1. As a DO, do I need higher case volume to “prove myself” compared to MDs?
No. ACGME requirements and board expectations are the same for MD and DO graduates. What you want is sufficient and well-distributed case volume to become a competent, confident vascular surgeon. Being a DO does not change the minimums you need; it may simply make you more attentive to choosing an environment that offers equitable case access and real support.

2. How do I compare programs if they won’t give exact case numbers?
Look for approximate ranges and qualitative descriptors supported by examples. Ask residents how many cases they scrub into in a typical week and how often they are primary operator. Ask about open aortic and endovascular exposure separately. If everyone is evasive or vague, consider that a warning sign.

3. Should I prioritize open or endovascular case volume when choosing a program?
You need both. For long-term practice, especially in the United States, you will do a lot of endovascular work—but strong open training is critical for complication management, complex disease, and durability in your skillset. Prioritize programs where your open and endovascular volumes are both solid, with a case mix that matches your envisioned future practice.

4. Is a lower-volume program ever a good choice?
Yes, if the lower operative volume is still above accreditation minimums, provides balanced open and endovascular exposure, offers high autonomy, and aligns with your career goals and desired lifestyle. A supportive culture, strong mentorship, and clear graduated responsibility can sometimes outweigh sheer numbers—especially if volume is adequate and not dangerously low.

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For a DO graduate pursuing vascular surgery, you are not just searching for “the busiest place.” You are searching for an environment where your residency case volume, autonomy, and mentorship position you to become a thoughtful, technically excellent vascular surgeon. Use numbers as a lens, not a destination—and let your evaluation of programs reflect the complexity of the field you are entering.