Operative confidence in open and endovascular procedures among vascular surgery graduates reflects procedural exposure during training

Objective The shift toward minimally invasive techniques has transformed vascular surgery practice and training. As endovascular procedures replace many traditional open operations, concerns have emerged about whether current training adequately prepares graduates for independent practice, particularly in complex open procedures. Methods A web-based survey was distributed to recent graduates of Accreditation Council for Graduate Medical Education-accredited vascular surgery training programs from 2022 and 2024. The survey assessed demographics, program characteristics, estimated case volumes, and confidence in 22 core vascular operations using a five-point Likert scale. Mann-Whitney U and Kruskal-Wallis tests, as well as multivariable logistic regression, identified factors associated with confidence. Results Sixty-seven respondents (11.5%) completed the survey. Participants reported high confidence in routine procedures. In contrast, only 30% felt confident performing open thoracoabdominal aortic aneurysm repair (TAAA), and 63% for open repair of ruptured abdominal aortic aneurysm (AAA). Univariable analysis identified several associations between respondent characteristics and confidence. Male sex was associated with greater confidence in carotid-subclavian bypass ( P = .0134), whereas age >36 years correlated with higher confidence in thoracic endovascular aneurysm repair ( P = .0196) and TAAA repair ( P = .0207). University-based training correlated with greater confidence in extremity thromboembolectomy ( P = .0204). Program size affected confidence in elective endovascular aneurysm repair (EVAR) ( P = .0296) and extremity thromboembolectomy ( P = .0393). No associations were seen with training pathway, region, or simulation exposure. Higher open abdominal case volume was significantly associated with greater confidence in open ruptured AAA, elective AAA, TAAA, aortobifemoral bypass, visceral bypass, and superior mesenteric artery embolectomy (all P < .05). No associations were found between case volume and confidence in endovascular, open cerebrovascular, or open peripheral procedures. Confidence was markedly higher for endovascular compared with open counterparts across multiple matched pairs: elective EVAR vs open AAA, thoracic endovascular aneurysm repair vs TAAA, aortoiliac stenting vs aortobifemoral bypass, and visceral stenting vs visceral bypass (all P < .0001). Multivariable analysis showed male sex independently predicted confidence in thoracic outlet decompression ( P = .0271), and age >36 years was associated with confidence in carotid-subclavian bypass ( P = .0203). Higher abdominal case volume independently predicted confidence in open ruptured AAA, elective AAA, TAAA, and aortobifemoral bypass. Only 3% of respondents expressed interest in additional training after graduation. Conclusions Vascular surgery trainees report strong confidence in routine procedures but limited confidence in complex open abdominal operations. To preserve operative competence, reforms in surgical education should prioritize simulation, regional training rotations, early mentorship, and competency-based assessment.