Decreasing prevalence of centers meeting the Society for Vascular Surgery abdominal aortic aneurysm guidelines in the United States.

Based on data supporting a volume-outcome relationship in elective aortic aneurysm repair, the Society of Vascular Surgery (SVS) guidelines recommend that endovascular aortic repair (EVAR) be localized to centers that perform ≥10 operations annually and have a perioperative mortality and conversion-to-open rate of ≤2% and that open aortic repair (OAR) be localized to centers that perform ≥10 open aortic operations annually and have a perioperative mortality ≤5%. However, the number and distribution of centers meeting the SVS criteria remains unclear. This study aimed to estimate the temporal trends and geographic distribution of Centers Meeting the SVS Aortic Guidelines (CMAG) in the United States. The SVS Vascular Quality Initiative was queried for all OAR, aortic bypasses, and EVAR from 2011 to 2019. Annual OAR and EVAR volume, 30-day elective operative mortality for OAR or EVAR, and EVAR conversion-to-open rate for all centers were calculated. The SVS guidelines for OAR and EVAR, individually and combined, were applied to each institution leading to a CMAG designation. The proportion of CMAGs by region (West, Midwest, South, and Northeast) were compared by year using a χ2 test. Temporal trends were estimated using a multivariable logistic regression for CMAG, adjusting by region. Overall, 67,865 patients (49,264 EVAR; 11,010 OAR; 7591 aortic bypasses) at 336 institutions were examined. The proportion of EVAR CMAGs increased nationally by 1.7% annually from 51.6% (n = 33/64) in 2011 to 67.1% (n = 190/283) in 2019 (β = .05; 95% confidence interval [CI], 0.01-0.09; P = .02). The proportion of EVAR CMAGs across regions ranged from 27.3% to 66.7% in 2011 to 63.9% to 72.9% in 2019. In contrast, the proportion of OAR CMAGs has decreased nationally by 1.8% annually from 32.8% (n = 21/64) in 2011 to 16.3% (n = 46/283) in 2019 (β = -.14; 95% CI, -0.19 to -0.10; P < .01). Combined EVAR and OAR CMAGs were even less frequent and decreased by 1.5% annually from 26.6% (n = 17/64) in 2011 to 13.1% (n = 37/283) in 2019 (β = -.12; 95% CI, -0.17 to -0.07; P < .01). In 2019, there was no significant difference in regional variation of the proportion of combined EVAR and OAR CMAGs (P = .82). Although an increasing proportion of institutions nationally meet the SVS guidelines for EVAR, a smaller proportion meet them for OAR, with a concerning downward trend. These data question whether we can safely offer OAR at most institutions, have important implications about sufficient OAR exposure for trainees, and support regionalization of OAR.

Ramirez JL ，Matthay ZA ，Lancaster E ，Smith EJT ，Gasper WJ ，Zarkowsky DS ，Doyle AJ ，Patel VI ，Schanzer A ，Conte MS ，Iannuzzi JC ... -  《-》

Center volume and failure to rescue after open or endovascular repair of ruptured abdominal aortic aneurysms.

The correlation between center volume and elective abdominal aortic aneurysm (AAA) repair outcomes is well established; however, these effects for either endovascular aneurysm repair (EVAR) or open aneurysm repair (OAR) of ruptured AAA (rAAA) remains unclear. Notably, the capacity to either avert or manage complications associated with postoperative mortality is an important cause of outcome disparities after elective procedures; however, there is a paucity of data surrounding nonelective presentations. Therefore, the purpose of this analysis was to describe the association between annual center volume, complications, and failure to rescue (FtR) after EVAR and OAR of rAAA. All consecutive endovascular and open rAAA repairs from 2010 to 2020 in the Vascular Quality Initiative were examined. Annual center volume (procedures/year per center) was grouped into quartiles: EVAR-Q1 (<14), 3.4%; Q2 (14-23), 12.8%; Q3 (24-37), 24.7%; and Q4 (>38), 59.1%; OAR-Q1 (<3), 5.4%; Q2 (4-6), 12.8%; Q3 (7-10), 22.7%; and Q4 (>10), 59.1%. The primary end point was FtR, defined as in-hospital death after experiencing one of six major complications (cardiac, renal, respiratory, stroke, bleeding, colonic ischemia). Risk-adjusted analyses for intergroup comparisons were completed using multivariable logistic regression. The unadjusted in-hospital death rate was 16.5% and 28.9% for EVAR and OAR, respectively. Complications occurred in 45% of EVAR (n = 1439/3188) and 70% of OAR (n = 1366/1961) patients with corresponding FtR rates of 14% (EVAR) and 26% (OAR). For OAR, Q4-centers had a 43% lower FtR risk (odds ratio [OR], 0.57; 95% confidence interval [CI], 0.4-0.9; P = .017) compared with Q1 centers. Centers performing fewer than five OARs/year had a 43% lower risk (OR, 0.57; 95% CI, 0.4-0.7; P < .001) of FtR and this decreased 4% for each additional five procedures performed annually (95% CI, 0.93-0.991; P = .013). However, there was no significant relationship between center volume and FtR after EVAR. The risk of FtR was strongly associated with a greater number of complications for both procedures (OR multiplied by 6.5 for EVAR and 1.5 for OAR for each additional complication; P < .0001). Among OAR patients with a single recorded complication, return to the operating room for bleeding had highest risk of in-hospital mortality (OR, 4.1; 95% CI, 1.1-4.8; P = .034), whereas no specific type of complication increased FtR risk after EVAR. FtR occurs commonly after EVAR and OAR of rAAA within Vascular Quality Initiative centers. Importantly, increasing center volume was associated with decreased FtR risk after OAR, but not EVAR. Complication pattern and frequency predicted FtR after either repair strategy. For stable patients, especially those deemed anatomically ineligible for EVAR, these findings emphasize the need to improve the coordination of regional referral networks that centralize rAAAs to high-volume centers. Moreover, hospitals that treat rAAA should invest in resources that develop protocols targeting specific complications to mitigate risk of preventable postoperative death.

D'Oria M ，Scali ST ，Neal D ，DeMartino R ，Beck AW ，Mani K ，Lepidi S ，Huber TS ，Stone DH ... -  《-》

Outcomes after elective abdominal aortic aneurysm repair in obese versus nonobese patients.

Obesity is a worldwide epidemic, particularly in Western society. It predisposes surgical patients to an increased risk of adverse outcomes. The aim of our study was to use a nationally representative vascular database and to compare in-hospital outcomes in obese vs nonobese patients undergoing elective open aortic repair (OAR) and endovascular aneurysm repair (EVAR). All patients undergoing elective abdominal aortic aneurysm repair were identified in the Vascular Quality Initiative database (2003-2017). Obesity was defined as body mass index ≥30 kg/m2. Univariable (Student t-test and χ2 test) and multivariable (logistic regression) analyses were implemented to compare in-hospital mortality and any major complications (wound infection, renal failure, and cardiopulmonary failure) in obese vs nonobese patients. We identified a total of 33,082 patients undergoing elective OAR (nonobese, n = 4605 [72.4%]; obese, n = 1754 [27.6%]) and EVAR (nonobese, n = 18,338 [68.6%]; obese, n = 8385 [31.4%]). Obese patients undergoing OAR and EVAR were relatively younger compared with nonobese patients (mean age [standard deviation], 67.55 [8.26] years vs 70.27 [8.30] years and 71.06 [8.22] years vs 74.55 [8.55] years), respectively; (both P < .001). Regardless of approach, obese patients had slightly longer operative time (OAR, 259.02 [109.97] minutes vs 239.37 [99.78] minutes; EVAR, 138.27 [70.64] minutes vs 134.34 [69.98] minutes) and higher blood loss (OAR, 2030 [1823] mL vs 1619 [1642] mL; EVAR, 228 [354] mL vs 207 [312] mL; both P < .001). There was no significant difference in mortality between the two groups undergoing OAR and EVAR (OAR, 2.9% vs 3.2% [P = .50]; EVAR, 0.5% vs 0.6% [P = .76]). On multivariable analysis, obese patients undergoing OAR had 33% higher odds of renal failure (adjusted odds ratio [OR], 1.33; 95% confidence interval [CI], 1.09-1.63; P = .006) and 75% higher odds of wound infections (adjusted OR, 1.75; 95% CI, 1.11-2.76; P = .02) compared with nonobese patients. However, in patients undergoing EVAR, no association was seen between obesity and any major complications. A significant interaction was found between obesity and surgical approach in the event of renal failure, in which obese patients undergoing OAR had significantly higher odds of renal failure compared with those in the EVAR group (ORinteraction, 1.36; 95% CI, 1.05-1.75; P = .02). Using a large nationally representative database, we demonstrated an increased risk of renal failure and wound infections in obese patients undergoing OAR compared with nonobese patients. On the other hand, obesity did not seem to increase the odds of major adverse outcomes in patients undergoing EVAR. Further long-term prospective studies are needed to verify the effects of obesity after abdominal aortic aneurysm repair and the implications of these findings in clinical decision-making.

Locham S ，Rizwan M ，Dakour-Aridi H ，Faateh M ，Nejim B ，Malas M ... -  《-》

Temporal Trends and Outcomes of Abdominal Aortic Aneurysm Care in the United States.

Gilmore BF ，Scali ST ，D'Oria M ，Neal D ，Schermerhorn ML ，Huber TS ，Columbo JA ，Stone DH ... -  《Circulation-Cardiovascular Quality and Outcomes》

Open aortic surgery volume experience at a regionalized referral center and impact on Accreditation Council for Graduate Medical Education trainees.

The objective of this study was to review our institute's open aortic surgery volume experience and its impact on Accreditation Council for Graduate Medical Education trainees. A review was conducted of the vascular surgery department's operative database for all cases that underwent aortic aneurysm repair, whether open aortic repair (OAR), endovascular aneurysm repair (EVAR), or fenestrated EVAR (FEVAR). We also reviewed our graduating trainees' case logs. In the setting of our regionalized referral center, all patients who underwent open or endovascular aortic intervention between 2010 and 2014 at our main campus were included. The total number of aortic procedures performed by our graduation trainees was determined. All aortic aneurysm interventions, both open and endovascular (both EVAR and FEVAR), were included. The main outcome measures were the total number of aortic interventions, any change in trends of intervention, and the total number of open aortic cases that our graduation trainees had. During the 5-year period analyzed, a total of 1389 abdominal aortic aneurysm repair procedures were performed by OAR, EVAR, and FEVAR. Of those, 462 were OARs, representing 33.2% of the total; 440 were EVARs, representing 31.6%; and 487 were FEVARs, representing 35.2%. For all OAR procedures, there was a significant increase in the proportion of these cases over time (P = .014). The total number of EVAR and FEVAR cases performed annually during this time did not change, whereas the number of OAR cases has increased. Of the OARs, 59.3% were performed for juxtarenal aneurysms, whereas 22.9% involved type IV thoracoabdominal aortic aneurysms. On average, graduating vascular surgery trainees performed 23.1 OARs before graduation (range, 19-26). In contrast to the documented national trend of decreased OAR, our institute continues to see increased OAR relative to EVAR and FEVAR. Moreover, we theorized that the preservation of OAR volume in our program and other similar institutions might offer a practical solution to the challenge of addressing vascular surgery training in aortic surgery by OAR, EVAR, and FEVAR. Inclusive discussions at the national and international levels are needed to reach consensus regarding the future of vascular surgery training and key issues, such as additional, mandatory, subspecialized training in OAR and FEVAR for both residents and fellows who wish to receive certification in OAR; creation of centers of excellence for open aortic surgery that would centralize OAR and direct trainees to those centers for their needed training; and possibly development of new training strategies whereby single cases can be shared among trainees with alternating roles as exposure and closure vs repair.

El-Arousy H ，Lim S ，Batagini NC ，Azim AA ，Bena J ，Clair DG ，Kirksey L ... -  《-》