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total publications, consisting of 39 systematic reviews, 33 meta-analyses and 97 randomised control trials (RCTs). Among the publications, the most popular vascular topic is thoracoabdominal aortic pathologies (24%), primarily consisting of aneurysmal disease, trauma-related presentations and occlusive aortic disease. This is followed by peripheral arterial disease (15%) and carotid artery disease (9%). A total of 10% of articles are not able to be categorised into a major vascular topic and 20% are unrelated to vascular surgery. A chronological depiction of the research output, stratified by topic (Figure 2), allows identification of trends within the literature. It is important to note that the data for 2018 are complete only until July and therefore figures for 2017 is used for comparison. Collectively, the academic productivity of vascular surgeons has doubled over the past two decades, from 74 publications in 1998 to 148 in 2017. While the quantity of published articles for thoracoabdominal aortic conditions has remained relatively stagnant over this time, there is a clear trend showing increasing literature regarding peripheral arterial disease. The vascular surgical technique with the largest representation is endovascular surgery (24%), which is a collective category encompassing peripheral arterial angiograms, endoluminal aortic repairs, carotid stenting, endovascular embolisation and endovenous procedures. Open surgery is not far behind, accounting for 21% of articles. More than a quarter (26%) of publications describe non-vascular surgical techniques, and 14% are unrelated to treatment. Chronological analysis shows that the number of endovascular surgical publications have gradually increased over the past 20 years, while open surgical research has been relatively stable. Importantly, it is evident that the literature regarding hybrid vascular surgical techniques (combining both endovascular and open surgery) has seen significant growth, particularly over the last decade. Depict a comparative analysis of the top 10 (5%) authors, as measured by h-index, compared to the remainder of the group. The top authors account disproportionately for 41% of all publications and 49% of all citations. They are also responsible for double the total number of level I evidence articles than the rest of the cohort, and published a significantly higher number of median publications in all evidence categories (p < 0.05). In addition, analysis of the data shows that the top 10 authors have a significantly longer median publication age (years from first publication to present) than the remaining authors (p < 0.05). Research output by Australian and New Zealand vascular surgeons has been steadily on the rise over the past 20 years. This is consistent with previously published studies in other medical specialties, both locally6,20 and worldwide.10,21 This bibliometric analysis highlights the quality of research output based on level of evidence, patterns in publication topics and the distribution of author productivity. Despite the large volume of research produced by Australasian vascular surgeons in the past 20 years, the distribution of levels of evidence also suggests scope for improvement. This propensity towards publishing observational studies such as case reports, audits and narrative reviews in preference to RCTs and guidelines is not unique and has been previously reported in many other medical cohorts.20,22,23 There are a number of explanations for why there is such a high prevalence of low-level evidence research among surgeons. Higher quality research almost universally places greater demands on funding and time, resources that are not readily available to all surgeons. Limited research funding from both commercial and academic sources is therefore a major deterrent to many authors who may wish to undertake a large-scale or high-level evidence research project. In addition, there are constraints to conducting experimental studies, such as RCTs, for surgical procedures. Logistical issues, such as recruitment and blinding, have to be factored in to the process and can come at a significant financial cost.24 Furthermore, ethics approvals can be time-consuming and difficult to obtain, leading to delays in
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