So you want to be a vascular surgeon. You want to spend all your time operating on varicose veins and be the surgeon all other surgeons turn to to save the day. Well—not quite.
Let’s debunk the public perception myths and give it to you straight. This is the reality of vascular surgery.
Welcome to our next installment in So You Want to Be. In this series, we highlight a specific specialty within medicine to help you decide if it’s a good fit for you. You can find the other So You Want to Be guides here on the Med School Insiders website as well as our YouTube playlist.
Subscribe to the Med School Insiders YouTube channel to vote on upcoming polls on what specialties to cover next.
What Is Vascular Surgery?
Vascular surgery is the medical specialty that involves the surgical and medical management of arterial and venous diseases.
Vascular surgeons care for patients with pathology involving all arteries and veins, except those of the heart and brain, which are managed by their own respective specialists, cardiothoracic surgeons and neurosurgeons. A vascular surgeon operates all over the body and is incredibly knowledgeable about a patient’s vascular anatomy, as well as the non-vascular anatomy that must be avoided when exposing the vessel of interest.
Common conditions that vascular surgeons treat include carotid artery disease, aortic aneurysms, peripheral arterial disease of the arms and legs, venous insufficiency, varicose veins and blood clots, and hemodialysis access creation and maintenance, to name a few.
Vascular surgeons must also always be available to other surgical specialties in the event that catastrophic bleeding occurs, which, of course, must be controlled.
Open Surgery vs. Endovascular Surgery
The speciality can be categorized based on the area of pathology that the surgeon specializes in.
Vascular surgery involves two paradigms of surgical management for various conditions; open surgery and endovascular surgery.
Open surgery involves making an incision to access the blood vessel of interest and operating on it directly.
One example of open vascular surgery is a carotid endarterectomy, in which the carotid artery, which is in the neck and supplies oxygen to the brain, is opened to allow for removal of the plaque that is causing the patient’s symptoms, which could include weakness, dizziness, vision loss, severe headaches, and difficulty speaking.
Another example would be an open abdominal aortic aneurysm repair, in which a bulging of the aortic wall is replaced with an artificial tube graft to prevent the aneurysm from rupturing, which is often fatal.
One more example would be a peripheral bypass, commonly from the femoral artery to the popliteal artery to treat the symptoms of impaired blood flow in the legs.
Conversely, endovascular surgery is the minimally invasive approach that utilizes catheters, wires, balloons, and stents to treat the same conditions. Using the previous examples, a needle can be used to access the femoral artery to deliver a stent to the internal carotid artery, a stent graft to the aorta, or a balloon to open up a blockage in the arteries of the leg.
Vascular surgery, particularly endovascular aortic surgery, often involves creative solutions to treat complex aneurysms.
The decision on whether to pursue open versus endovascular surgery is often complex and patient specific; however, a good vascular surgeon will have all these options in their toolkit.
Private vs. Academic Medicine
Vascular surgeons can have either private or academic practices; however, given the direction that medicine is going, private practices are more and more difficult to sustain given the high overhead costs and perpetually decreasing reimbursement.
Generally, in academic practices, vascular surgeons work with residents and fellows, whereas in private practice, they work with PAs, NPs, or RN first assists in the OR.
Private practice providers will tend to lean more heavily towards treating PAD and venous insufficiency mostly via minimally invasive procedures, which can be done in an office setting, allowing the patient to return home the same day.
Again, while not absolute, academic vascular surgeons will likely perform bigger, more complicated surgeries that require inpatient admission plus or minus ICU monitoring.
Misconceptions About Vascular Surgery
Let’s clear up a common misconception about vascular surgery.
A common misconception is that vascular surgeons operate on varicose veins. While this is certainly true, it is a very small part of their job. Most vascular surgery procedures are major surgery, often with high-risk involved.
Unlike many other surgical specialties that rarely deviate from established, routine treatments, vascular surgery requires you to be able to quickly adapt to different clinical situations. Many other surgeons depend on vascular surgeons to be able to perform their procedures safely.
For example, certain spine surgeries require access to the spinal column, which is very close to major blood vessels, and injury to them could be fatal. In this case, a vascular surgeon would meticulously expose the spine for the spine surgeon, taking care to protect the nearby vascular structures.
Trauma surgeons will sometimes call in their vascular surgery colleagues for help when major bleeding is encountered, either for control or reconstruction of the particular blood vessel that is bleeding. Many of these collaborative relationships exist in the operating suite, and a vascular surgeon must be on staff for a hospital to safely offer surgery.
How to Become a Vascular Surgeon
There are currently two training paths to become a vascular surgeon.
The first is an integrated residency, where you match directly from medical school. This residency option lasts 5 years, though it could last up to 7 years, depending on research requirements.
The alternative is a vascular surgery fellowship after completing either a general surgery, which lasts 5 years, or a cardiothoracic surgery residency or fellowship, the former being 6 years and the latter 2-3 years after a general surgery residency. The vascular fellowship is an additional two years.
Training, regardless of which pathway, is rigorous, which is similar to many other surgical specialties. This will include long hours in the hospital and long, complicated surgeries.
Based on our Specialty Competitiveness Index, which you can download, vascular surgery is the 9th most competitive medical specialty.
For the 2024 match cycle, there were 143 applicants for 84 positions, or 1.7 applicants per spot, and those who were successful had an average Step 2 score of 247. Research in the field with relevant publications and presentations is expected.
In fact, those who match into vascular surgery now have an average of 12.8 research items in 2024, up from 10.5 in 2020, and this number is only expected to grow each year. Publications consistently play a huge role in a candidate’s ability to match into their desired program.
Despite how important it is, so many premed and medical students still find research daunting and difficult to make headway on. That’s why we created The Med School Insiders Ultimate Research Course, which distills the tactics I used to gain over 60 research items.
Learn to publish more in less time, build a research team around you, confidently present your work, and much more using advanced tactics you won’t find anywhere else because we innovated them.
Additional Training Options
The vast majority of vascular surgeons do not pursue additional training upon completion, as vascular surgery is already quite specialized.
A vascular surgeon can choose to subspecialize in aortic surgery and, therefore, must be comfortable with both the open and endovascular management of aortic aneurysms. Alternatively, they can choose to specialize in peripheral arterial disease and opt to treat patients with impaired circulation to their hands and feet.
Some will opt for training in cardiothoracic surgery, which will allow for additional open surgery of the ascending aorta and aortic arch, which falls under their purview. This would mean an additional 2 to 3 years of training, depending on the program.
Vascular surgeons are commonly referred to as the firemen or firewomen of the operating room, as they’re usually called when someone is in trouble and needs rescuing. Further training in vascular surgery can, however, include traveling to a center with a particular investigational device exemption to learn an advanced endovascular technique on a device in trial that is not yet available to the broader market.
But this is not the norm, as most vascular surgeons enter practice after their residency or fellowship.
What You’ll Love About Vascular Surgery
There’s a lot to love about vascular surgery.
First, vascular surgeons have the ability to operate all over the body, performing a combination of both open and endovascular surgery.
Additionally, operating on minuscule arteries requires technical precision and a high degree of dexterity. The hands-on approach to medicine can be quite appealing. This is one of the reasons I was so drawn to surgery when I was choosing my medical specialty. Vascular surgery is a great option for those who love working with their hands, are meticulous, and pay close attention to minor details.
Vascular surgery patients typically follow with their surgeons for the rest of their lives, as the nature of atherosclerosis is progressive, with most procedures turning back the clock rather than curing the disease.
Compensation is also on the higher end of the spectrum. Vascular surgery is among the 10 highest paying medical specialties, coming in 8th above radiology at number nine and below cardiology at number seven. Vascular surgeons make over $550,000 a year.
What You Won’t Love About Vascular Surgery
But of course, vascular surgery isn’t for everyone.
If you are someone who needs structure and has a hard time deviating from plan A, then vascular surgery will be a challenge. Oftentimes, vascular surgeons are called in the middle of the night or on weekends for emergencies that are limb and life threatening. So while the compensation is excellent, the work-life balance of a vascular surgeon leaves much to be desired.
It’s also a challenging specialty to match into.
Of course, if you don’t match into an integrated program, you could do a 5-year general surgery residency and then pursue a vascular surgery fellowship, which lasts 2 years. But again, although the compensation is excellent, 5 to 7 years of training on top of 4 or more years of medical school means it will take a long time before you see that $550K salary.
Another less glamorous part of vascular surgery is the wound care and amputations that sometimes must be performed on unsalvageable limbs. While these surgeries are not very glamorous, they are a necessary part of the job, particularly in a limb salvage program.
Finally, since many procedures are done via endovascular means, using fluoroscopy, there is a great deal of radiation exposure. This is done in either a hybrid operating room or angio suite with a C-arm centered over the area of interest and the operators typically standing right next to it. Although physicians wear protective shielding, it does theoretically increase the lifetime risk for certain malignancies.
Should You Become a Vascular Surgeon?
So, should you become a vascular surgeon?
If you are detail oriented and enjoy caring for high-risk, medically complex patients, you will likely thrive in the field. Good hands are necessary, but this is a skill that most can hone with practice.
However, while the compensation is one of highest of all medical specialties, if you prioritize a healthy work-life balance, vascular surgery does not provide this. You could be called in for an emergency surgery at any time of day and on weekends.
To become a vascular surgeon, you’ll need to do well in medical school, thrive at standardized tests, stand out in your clerkship training, and craft a stellar residency application so that you can match into this competitive surgical specialty. And before all of that, you’ll need to get into medical school, which is a long, complex, and tedious process.
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