Elias J. Arous

Endovascular treatment of ruptured abdominal aortic aneurysms in the United States (2001-2006): A significant survival benefit over open repair is independently associated with increased institutional volume

OBJECTIVE Endovascular aortic repair (EVAR) has gained wide acceptance for the elective treatment of abdominal aortic aneurysms (AAA), leading to interest in similar treatment of ruptured abdominal aortic aneurysms (RAAA). The purpose of this study was to evaluate national outcomes after EVAR for RAAA and to assess the effect of institutional volume metrics. METHODS The Nationwide Inpatient Sample was used to identify patients treated with open or EVAR for RAAA, 2001-2006. Procedure volume was determined for each institution categorizing hospitals as low-, medium-, and high-volume. The primary outcome was in-hospital mortality. Secondary outcomes related to resource utilization. Multivariable logistic regression models were used to determine independent predictors of EVAR usage and mortality. RESULTS From 2001 to 2006, an estimated 27,750 hospital discharges for RAAA occurred; 11.5% were treated with EVAR. EVAR utilization increased over time (5.9% in 2001 to 18.9% in 2006, P < .0001) while overall RAAA rates remained constant. EVAR had a lower overall in-hospital mortality than open repair (31.7% vs 40.7%, P < .0001), an effect which amplified when stratified by institutional volume. On multivariable regression, open repair independently predicted mortality (odds ratio [OR] 1.56; 95% confidence interval [CI] 1.29-1.89). EVAR usage for RAAA increased with age (>80 years) (OR 1.58; 95% CI 1.30-1.93), high elective EVAR volume (>40/y) vs medium (19-40/y) (OR 2.65; 95% CI 1.86-3.78) and low (<19/y) (OR 5.37; 95% CI 3.60-8.0). EVAR had a shorter length of stay (11.1 vs 13.8 days, P < .0001), higher discharges to home (65.1% vs 53.9%, P < .0001), and lower charges (

Vascular surgery training trends from 2001-2007: A substantial increase in total procedure volume is driven by escalating endovascular procedure volume and stable open procedure volume

108,672 vs

Surgeon case volume, not institution case volume, is the primary determinant of in-hospital mortality after elective open abdominal aortic aneurysm repair

114,784, P < .0001). CONCLUSIONS In the United States, for RAAA, EVAR had a lower postoperative mortality than open repair. Higher elective open repair as well as RAAA volume increased this mortality advantage for EVAR. These results support regionalization of RAAA repair to high volume centers whenever possible and a wider adoption of endovascular repair of RAAA nationwide.

Hand-Assisted Laparoscopic Aortobifemoral Bypass Versus Open Bypass for Occlusive Disease

BACKGROUND Endovascular procedure volume has increased rapidly, and endovascular procedures have become the initial treatment option for many vascular diseases. Consequently, training in endovascular procedures has become an essential component of vascular surgery training. We hypothesized that, due to this paradigm shift, open surgical case volume may have declined, thereby jeopardizing training and technical skill acquisition in open procedures. METHODS Vascular surgery trainees are required to log both open and endovascular procedures with the Accreditation Council for Graduate Medical Education (ACGME). We analyzed the ACGME database (2001-2007), which records all cases (by Current Procedural Terminology [CPT] code) performed by graduating vascular trainees. Case volume was evaluated according to the mean number of cases performed per graduating trainee. RESULTS The mean number of total major vascular procedures performed per trainee increased by 174% between 2001 and 2007 (from 298.3 to 519.2). Endovascular diagnostic and therapeutic procedures increased by 422% (from 63.7 to 269.1) and accounted for 93.0% of the increase in total procedures. The number of open aortic procedures (aneurysm, occlusive, mesenteric, renal) decreased by 17.1% (from 49.7 to 41.2), while the number of endovascular aortic aneurysm repair procedures increased by 298.8% (from 16.9 to 50.5). Specifically, open aortic aneurysm procedures decreased by 21.8%, aortobifemoral bypass increased by 3.2%, and open mesenteric or renal procedures decreased by 13%. Infrainguinal bypass procedures remained relatively constant (from 37.6 to 36.5, 2.9% decrease), and the number of carotid endarterectomy procedures performed did not change significantly (from 43.6 to 42.2, 3.2% decrease). CONCLUSION Vascular surgery trainees are performing a vastly increased total number of procedures. This increase in total procedure volume is almost entirely attributable to the recent increase in endovascular procedures. Aside from a small decline in open aortic procedures, the volume of open surgical procedures has largely remained stable. It is essential that vascular surgery training programs continue to focus on both endovascular and open surgical skills in order for vascular surgeons to remain the premier specialists to care for patients with vascular disease.

An analysis of carotid artery stenting procedures performed in New York and Florida (2005-2006): Procedure indication, stroke rate, and mortality rate are equivalent for vascular surgeons and non-vascular surgeons

OBJECTIVE Studies analyzing the effects of volume on outcomes after abdominal aortic aneurysm (AAA) repair have primarily centered on institutional volume and not on individual surgeon volume. We sought to determine the relative effects of both surgeon and institution volume on mortality after open and endovascular aneurysm repair (EVAR) for intact AAAs. METHODS The Nationwide Inpatient Sample (2003-2007) was queried to identify all patients undergoing open repair and EVAR for nonruptured AAAs. To calculate surgeon and institution volume, 11 participating states that record a unique physician identifier for each procedure were included. Surgeon and institution volume were defined as low (first quintile), medium (second, third, or fourth quintile), and high (fifth quintile). Stratification by institution volume and then by surgeon volume was performed to analyze the primary endpoint: in-hospital mortality. Multivariable models were used to evaluate the association of institution and surgeon volume with mortality for open repair and EVAR, controlling for potential confounders. RESULTS During the study period, 5972 open repairs and 8121 EVARs were performed. For open AAA repair, a significant mortality reduction was associated with both annual institution volume (low <7, medium 7-30, and high >30) and surgeon volume (low ≤ 2, medium 3-9, and high >9). High surgeon volume conferred a greater mortality reduction than did high institution volume. When low and medium volume institutions were stratified by surgeon volume, mortality after open AAA repair was inversely proportional to surgeon volume (8.7%, 3.6%, and 0%; P < .0001, for low, medium, and high-volume surgeons at low-volume institutions; and 6.7%, 4.8%, and 3.3%; P = .02, for low, medium, and high-volume surgeons at medium-volume institutions). High-volume institutions stratified by surgeon volume demonstrated the same trend (5.1%, 3.4%, and 2.8%), but this finding was not statistically significant (P = .57). Multivariable analysis was confirmatory: low surgeon volume independently predicted mortality (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.3-3.1; P < .001); low institution volume did not (P = .1). For EVAR, neither institution volume nor surgeon volume influenced mortality (univariate or multivariable). CONCLUSION The primary factor driving the mortality reduction associated with case volume after open AAA repair is surgeon volume, not institution volume. Regionalization of AAAs should focus on open repair, as EVAR outcomes are equivalent across volume levels. Payers may need to re-evaluate strategies that encourage open AAA repair at high-volume institutions if specific surgeon volume is not considered.

Endovascular repair of ruptured abdominal aortic aneurysms does not reduce later mortality compared with open repair

BACKGROUND Aortobifemoral bypass grafting is the treatment of choice for patients with symptomatic aortoiliac occlusive disease. Yet, traditional operative exposure through a midline laparotomy incision carries significant morbidity. The authors compare operative and patient outcomes following hand-assisted laparoscopic aortobifemoral (HALABF) bypass and open aortobifemoral (OABF) bypass. METHODS An initial series of patients who underwent HALABF bypass grafting (n = 8) were compared with a simultaneous cohort of patients treated with standard open bypass (n = 10). The two groups were similar with respect to age, weight, and sex. Operative parameters, clinical outcomes, and complications were compared. RESULTS HALABF was successfully performed in all eight cases attempted. Operative times did not differ between the laparoscopic and open groups (234 +/- 42 minutes vs. 206 +/- 43 minutes, P =.99). Mean blood loss values were comparable (562 mL [HALABF] vs. 756 mL [OABF], P =.56). There were no conversions. Time to resumption of oral intake (1.8 vs. 4.7 days, P =.001) and length of stay (3.8 vs. 6.3 days, P =.0004) were significantly shorter in the laparoscopic than in the open group. CONCLUSIONS HALABF is a safe and technically feasible procedure. When compared with the traditional open operation, this technique may result in shorter hospitalization, more rapid return of bowel function, and earlier return to activity.

Endovascular in situ bypass decreases morbidity and hospital stay following infrainguinal arterial reconstruction.

OBJECTIVE Carotid artery stenting (CAS) has emerged as an alternative to carotid endarterectomy (CEA) for the treatment of carotid artery stenosis. Unlike CEA, CAS is performed by a wide variety of specialists including vascular surgeons (VS), interventional cardiologists (IC), and interventional radiologists (IR). This study compares the indications, in-patient mortality rate, and in-patient stroke rate for patients undergoing CAS, according to operator specialty. METHODS The State In-patient Databases from New York and Florida, made available by the Healthcare Cost and Utilization Project, were reviewed by International Classification of Disease (ICD)-9-CM codes to identify all patients treated with CAS for the years 2005 and 2006. This cohort was then stratified according to operator specialty defined by procedures performed by each operator over the years surveyed. Primary endpoints were in-patient death and stroke. Propensity score matching adjusting for indication, demographics, and comorbidities was employed to evaluate the influence of operator type on outcomes. RESULTS During the study period, 4001 CAS procedures were performed. All primary analyses compared VS (n = 1350) to non-VS (n = 2651). Patient characteristics were similar, except VS treated fewer patients with CAD (44.2% vs 50.9%, P < .001) and valvular disease (6.3% vs 8.6%, P = .01) and more patients with chronic lung disease (19.4% vs 15.9%, P = .01). Each group performed an equal proportion of CAS for symptomatic disease (8.1% vs 9.0%, P = .32). Univariate analysis revealed no difference in mortality (0.9% vs 0.5%, P = .13) or stroke (1.3% vs 1.5%, P = .73). Propensity score matched analysis also demonstrated no difference in mortality (0.7% vs 0.4%, P = .48) or stroke (1.1% vs 1.7%, P = .27). Subgroup analysis comparing VS, IC, and IR showed no significant difference in mortality or stroke, but demonstrated that of the three specialties, IC treated the smallest proportion of symptomatic patients. The proportion of CAS performed by VS differed significantly by state (New York 46%, Florida 19%, P < .01). CONCLUSION Despite a paucity of level 1 evidence for CAS in asymptomatic patients and current Centers for Medicare and Medicaid Services (CMS) policy limiting reimbursement for CAS to only high-risk symptomatic patients, VS and non-VS are treating primarily asymptomatic patients. Perioperative rates of stroke and death are equivalent between VS, IC, and IR. Regional variation of operator type is substantial, and despite similar outcomes, <50% of CAS is performed by VS.

An intensive vascular surgical skills and simulation course for vascular trainees improves procedural knowledge and self-rated procedural competence

OBJECTIVE Endovascular aneurysm repair (EVAR) of ruptured abdominal aortic aneurysms (RAAAs) reduces in-hospital mortality compared with open repair (OR), but it is unknown whether EVAR reduces long-term mortality. We hypothesized that EVAR of RAAA would independently reduce long-term mortality compared with OR. METHODS The Vascular Quality Initiative database (2003-2013) was used to determine Kaplan-Meier 1-year and 5-year mortality after EVAR and OR of RAAA. Multivariate analysis was performed to identify patient and operative characteristics associated with mortality at 1 year and 5 years after RAAA repair. RESULTS Among 590 patients who underwent EVAR and 692 patients who underwent OR of RAAA, the lower mortality seen in the hospital after EVAR (EVAR 23% vs OR 35%; P < .001) persisted at 1 year (EVAR 34% vs OR 42%; P = .001) and 5 years (EVAR 50% vs OR 58%; P = .003) after repair. After adjusting for patient and operative characteristics, EVAR did not independently reduce mortality at 1 year (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.7-1.1) or 5 years (HR, 0.95; 95% CI, 0.77-1.2) compared with OR. Dialysis dependence (HR, 3.9; 95% CI, 1.8-8.6), home oxygen use (HR, 1.9; 95% CI, 1.3-2.7), cardiac ejection fraction <50% (HR, 1.5; 95% CI, 1.03-2.1), female gender (HR, 1.3; 95% CI, 1.04-1.6), and age (HR, 1.06; 95% CI, 1.05-1.08 per 5 years) as well as cardiac arrest (HR, 3.4; 95% CI, 2.5-4.5), loss of consciousness (HR, 1.7; 95% CI, 1.3-2.2), and preoperative systolic blood pressure <90 mm Hg (HR, 1.4; 95% CI, 1.1-1.8) on admission predicted mortality at 1 year and 5 years after RAAA repair. Type I endoleak (HR, 2.2; 95% CI, 1.2-3.8) also predicted mortality at 1 year. CONCLUSIONS EVAR does not independently reduce long-term mortality compared with OR. Patient comorbidities and indices of shock on admission are the primary independent determinants of long-term mortality. However, the lower early mortality observed in the Vascular Quality Initiative for patients selected to undergo EVAR of RAAA compared with patients selected for OR is sustained over time, suggesting that EVAR for RAAA is beneficial in appropriate candidates. Better elucidation of the key selection factors, including aneurysm anatomy, is needed to best select patients for EVAR and OR to reduce long-term mortality.

A giant common carotid artery pseudoaneurysm after penetrating injury

Purpose: To report the early results of endovascular in situ saphenous vein bypass (EISVB) using side branch coil occlusion. Methods: Between September 1997 and November 1998, 25 patients (15 men; mean age 70.9 years, range 53–85) with lower limb ischemia were treated with endovascular femorodistal bypass. The saphenous vein was prepared using retrograde valvulotomy and endoscopic cannulation with coil occlusion of the side branches. Duplex graft surveillance was performed at 1, 3, 6, and 12 months. Results: The 25 EISVB procedures consisted of 15 femorodistal popliteal, 7 femorotibial, 2 femoroperoneal, and 1 femorodorsalis pedis in situ saphenous vein reconstructions. Mean operative time was 202 ± 40 minutes, mean number of side branch coils per case was 5.1 ± 1.3, and mean number of incisions per case was 2.9 ± 0.6. Mean hospital length of stay (LOS) was 35 ± 13 hours (1.4 ± 0.6 days); 19 (76%) patients were discharged on the first postoperative day. Short-term follow-up (mean 6.2 months, range 2–15) was notable for 2 graft thromboses and 1 graft stenosis; primary and secondary patency rates were 88% and 92%, respectively. Three asymptomatic, persistent arteriovenous fistulas discovered on routine duplex were ligated in the outpatient setting. Only 1 (4%) minor wound complication was encountered. Conclusions: EISVB provides early patency comparable to conventional in situ infrainguinal bypass. Its distinct advantages, however, are the ability to minimize incision length with resultant reductions in wound-related complications, hospital LOS, and recovery time. EISVB promises to be a useful adjunct in the approach to peripheral vascular insufficiency.

C10: Poster CompetitionPC094 Increasing the Number of Integrated Vascular Surgery Residency Positions Is Necessary to Address the Impending Shortage of Vascular Surgeons in the United States

Background: Surgical skills and simulation courses are emerging to meet the demand for vascular simulation training for vascular surgical skills, but their educational effect has not yet been described. We sought to determine the effect of an intensive vascular surgical skills and simulation course on the procedural knowledge and self‐rated procedural competence of vascular trainees and to assess participant feedback regarding the course. Methods: Participants underwent a 1.5‐day course covering open and endovascular procedures on high‐fidelity simulators and cadavers. Before and after the course, participants completed a written test that assessed procedural knowledge concerning index open vascular and endovascular procedures. Participants also assessed their own procedural competence in open and endovascular procedures on a 5‐point Likert scale (1: no ability to perform, 5: performs independently). Scores before and after the course were compared among postgraduate year (PGY) 1–2 and PGY 3–7 trainees. Participants completed a survey to rate the relevance and realism of open and endovascular simulations. Results: Fifty‐eight vascular integrated residents and vascular fellows (PGY 1–7) completed the course and all assessments. After course participation, procedural knowledge scores were significantly improved among PGY 1–2 residents (50% correct before vs 59% after; P < .0001) and PGY 3–7 residents (52% correct before vs 63% after; P = .003). Self‐rated procedural competence was significantly improved among PGY 1–2 (2.2 ± 0.1 before vs 3.1 ± 0.1 after; P < .0001) and PGY 3–7 (3.0 ± 0.1 before vs 3.7 ± 0.1 after; P ≤ .0001). Self‐rated procedural competence significantly improved for both endovascular (2.4 ± 0.1 before vs 3.3 ± 0.1 after; P < .0001) and open procedures (2.7 ± 0.1 before vs 3.5 ± 0.1 after; P < .0001). More than 93% of participants reported they were “satisfied” or “very satisfied” with the relevance and realism of the open and endovascular simulations. All participants reported they would recommend the course to other trainees. Conclusions: This intensive vascular surgical skills and simulation course improved procedural knowledge concerning index open vascular and endovascular procedures among PGY 1–2 and PGY 3–7 trainees. The course also improved self‐rated procedural competence across all levels of training for open and endovascular procedures. Trainees rated the value of a surgical skills and simulation course highly. These results support strong consideration for the implementation of similar intensive simulation and surgical skills courses with ongoing objective assessment of their educational effect.