Advanced Practice - Venous —
Training activity: 9

Details

Assess the suitability of veins for use as a bypass graft

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• Patient centred care and support
• Vein measurements
• Patient communication
• Clinical history
• Image optimisation
• Vein patency
• Anatomy and physiology
• Local, national and international guidelines
• Multidisciplinary working
• Documentation and record keeping

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

What does success look like?

• Identify what is expected of you in relation to successfully assessing the suitability of veins for bypass grafting.
• Consider how the learning outcomes apply, specifically in relation to assessing venous insufficiency and reviewing relevant national guidelines.
• Discuss with your training officer to gain clarity of what is expected of you in relation to specific measurements (e.g., diameter) and detailed anatomical mapping required for successful pre-operative vein assessment.

What is your prior experience of this activity?

• Think about what you already know about venous anatomy relevant to grafting, vessel diameter requirements, and the role of ultrasound in pre-operative vein mapping.
• Consider possible challenges you might face during the activity, such as scanning tortuous or small calibre vessels, accurately measuring vein diameter under different physiological states, or identifying previous venous pathology (e.g., chronic DVT, valve damage).
• Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example for challenging anatomical variations or when equivocal findings might significantly impact surgical planning.
• Acknowledge how you feel about embarking on this vein graft assessment activity.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as precise venous mapping (e.g., marking skin), accurate diameter measurements, and detailed anatomical documentation.
• Identify the specific insights you hope to gain into the surgical considerations for bypass grafting and the critical importance of accurate pre-operative mapping.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of detailed anatomical mapping or precise measurements.
• Identify important information you need to consider before embarking on the activity, such as patient’s surgical history, indication for bypass, and specific mapping protocols (e.g., required segment lengths).

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst assessing the suitability of veins for use as a bypass graft?
• Are you encountering situations such as:
  • The primary target vein segment falls unexpectedly below the minimum required diameter for grafting, challenging the preliminary assessment of suitability?
  • Unexpected signs of previous venous pathology (e.g., recanalised thrombus or valve damage) are identified in the potential graft segment, complicating the final suitability assessment?

How are you reacting to the unexpected development?

• How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to detailed anatomical documentation and re-measurement?
• Consider the steps you are taking in the moment, such as:
  • Immediately documenting the precise vein diameter measurements in multiple segments and confirming accuracy to establish the longest suitable segment.
  • Halting the assessment to systematically check for signs of chronic DVT or valve incompetence in adjacent segments.
• How are you feeling in that moment? For instance, are you finding it difficult to adapt the assessment to unexpected anatomy? Is it affecting your confidence in making a reliable pre-operative recommendation?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully measuring and documenting the required vein characteristics (patency, diameter, segment length)? Or are you needing support when anatomical variations severely limit the required length of suitable vein, requiring surgical liaison for an alternative plan?
• What are you learning as a result of the unexpected development? For example, are you mastering precise pre-operative vein mapping techniques? Or gaining insight into the critical quality parameters required by the surgical team?

On action

What happened?

• Begin by summarising the key steps you took when assessing veins for bypass graft suitability, including the specific measurements (e.g., vein diameter) and criteria you evaluated.
• Consider specific events, actions, or interactions which felt important during the assessment, such as identifying a diseased segment, accurately assessing vein calibre under different conditions, or dealing with patient factors affecting the scan.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately revising the assessment protocol when a previously unknown DVT or anatomical variant was encountered.
• How did you feel during this experience, e.g., did you feel focused on meticulous scanning or stressed by the impact of the unexpected finding on graft suitability?

How has this experience contributed to your developing practice?

• Identify what learning you can take from assessing veins for bypass grafts. What strengths did you demonstrate, e.g., meticulous scanning or accurate application of specific measurement techniques?
• What skills and/or knowledge gaps were evident, e.g., unfamiliarity with the specific minimum diameter required for different surgical teams or difficulty assessing valve integrity accurately?
• Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in applying specific measurement criteria for graft suitability?
• Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding an unusual finding that severely impacted suitability or escalating a complex case to ensure assessment accuracy, and how you reacted to this.

What will you take from the experience moving forward?

• Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to improving the precision and thoroughness of vein graft suitability assessment.
• What will you do differently next time you approach a vein graft assessment, for instance, by proactively confirming the specific required measurements and anatomical details with the surgical team before the scan.
• Do you need to practise any aspect of the activity further, such as detailed anatomical mapping or key learning outcomes related to applying specific diameter measurement techniques?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences of assessing veins for bypass grafts since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, how an instance where a subsequent graft required meticulous identification of valve integrity and potential segments of subclinical thrombus forced you to re-evaluate the thoroughness of your initial diameter measurement methodology you applied during your first attempt at suitability assessment.
• Considering what you understand about vein diameter criteria, anatomical mapping precision, and surgical requirements now, were the actions or considerations you identified after your initial reflection on this training activity sufficient? How have you since implemented or adapted improvements in your graft suitability assessment technique based on further learning and experiences? For example, how you proactively reviewed and integrated the specific minimum diameter criteria required by the vascular surgery team to ensure assessment consistency, demonstrating you have adapted improvements based on further learning.
• Has discussing complex vein mapping issues (e.g., unexpected small diameter, complex anatomical variations) or the impact of inaccurate assessment on surgical outcomes with peers or colleagues changed how you now view your initial experience in this training activity? For example, how professional storytelling with a vascular surgeon about a vein that was unsuitable due to previously unidentified valve damage refined your understanding of the critical nature of meticulous pre-operative anatomical assessment.

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent graft suitability assessment experiences, contributed to your overall confidence and competence in assessing the suitability of veins for use as a bypass graft, particularly in preparing for assessments like DOPS? For example, how your accumulated ability in precise venous mapping now enables you to confidently perform detailed venous assessment for graft suitability during a DOPS assessment.
• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to assessing veins for bypass grafts? How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation? For example, how your evolved approach means you now routinely seek advice immediately when the vein is borderline unsuitable (e.g., small diameter or chronic changes), recognising this requires senior surgical liaison and input.
• Looking holistically at your training journey, how has this initial graft suitability assessment experience, revisited with your current perspective, contributed to your development in meeting the objectives related to assessing venous insufficiency and appraising the impact of national guidelines? For example, how this foundational experience has supported your development in enhancing detailed anatomical measurement skills.

Relevant learning outcomes

#	Outcome
# 3	Outcome Assess venous insufficiency using ultrasound.
# 9	Outcome Appraise the impact of research evidence on national guidelines.