The impact of endovascular repair on specialties performing abdominal aortic aneurysm repair

Abstract

Background: Abdominal aortic aneurysm (AAA) repair has been performed by various surgical specialties for many years. Endovascular aneurysm repair (EVAR) may be a disruptive technology, having an impact on which specialties care for patients with AAA. Therefore, we examined the proportion of AAA repairs performed by various specialties over time in the United States and evaluated the impact of the introduction of EVAR.

Methods: The Nationwide Inpatient Sample (2001-2009) was queried for intact and ruptured AAA and for open repair and EVAR. Specific procedures were used to identify vascular surgeons (VSs), cardiac surgeons (CSs), and general surgeons (GSs) as well as interventional cardiologists and interventional radiologists for states that reported unique treating physician identifiers. Annual procedure volumes were subsequently calculated for each specialty.

Results: We identified 108,587 EVARs and 85,080 open AAA repairs (3011 EVARs and 12,811 open repairs for ruptured AAA). VSs performed an increasing proportion of AAA repairs during the study period (52% in 2001 to 66% in 2009; P < .001). GSs and CSs performed fewer repairs during the same period (25% to 17% [P < .001] and 19% to 13% [P < .001], respectively). EVAR was increasingly used for intact (33% to 78% of annual cases; P < .001) as well as ruptured AAA repair (5% to 28%; P < .001). The proportion of intact open repairs performed by VSs increased from 52% to 65% (P < .001), whereas for EVAR, the proportion went from 60% to 67% (P < .001). The proportion performed by VSs increased for ruptured open repairs from 37% to 53% (P < .001) and for ruptured EVARs from 28% to 73% (P < .001). Compared with treatment by VSs, treatment by a CS (0.55 [0.53-0.56]) and GS (0.66 [0.64-0.68]) was associated with a decreased likelihood of undergoing endovascular rather than open AAA repair.

Conclusions: VSs are performing an increasing majority of AAA repairs, in large part driven by the increased utilization of EVAR for both intact and ruptured AAA repair. However, GSs and CSs still perform AAA repair. Further studies should examine the implications of these national trends on the outcome of AAA repair.

Figure 1

Proportion of all abdominal aortic aneurysm repairs (both open and endovascular) performed by each physician specialty from 2001-2009 in the Nationwide Inpatient Sample (totals sum to 100%)

Figure 2A

Proportion of all open repairs for intact abdominal aortic aneurysms performed by physician specialty from 2001-2009 in the Nationwide Inpatient Sample (totals sum to 100%)

Figure 2B

Proportion of all endovascular repairs for intact abdominal aortic aneurysms performed by physician specialty from 2001-2009 in the Nationwide Inpatient Sample (totals sum to 100%)

Figure 3

Proportion of intact abdominal aortic aneurysms treated by endovascular repair within each specialty from 2001-2009 in the Nationwide Inpatient Sample

Figure 4A

Proportion of all open ruptured AAA repairs performed by physician specialty from 2001-2009 in the Nationwide Inpatient Sample (totals sum to 100%)

Figure 4B

Proportion of all EVARs for ruptured AAA repairs performed by physician specialty from 2001-2009 in the Nationwide Inpatient Sample (totals sum to 100%)

Figure 5

Proportion of ruptured abdominal aortic aneurysms treated by endovascular repair within each specialty from 2001-2009 in the Nationwide Inpatient Sample