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Declining open AAA repair rates raise questions for vascular surgeons
Rates of open abdominal aortic aneurysm repair decreased by nearly 80% among Medicare beneficiaries during the past decade, thanks mainly to increased use of endovascular repair, prompting researchers to suggest that the procedure cannot be used as a surgeon or hospital quality metric.
“Vascular surgeons, quality assessment experts and surgical educators all need to consider the effect of these changes on the best measure performance of vascular surgery as well as in training of the next generation of invasive vascular specialists,” Bjoern D. Suckow, MD, MS, from the section of vascular surgery at Dartmouth-Hitchcock Medical Center, said in a press release.
Declines in open AAA repair
According to the study, published in the Journal of Vascular Surgery, from 2003 to 2013, the total annual number of overall AAA repair procedures declined by 26% from 31,582 to 23,421 (P < .001). The researchers also noted a 28% decline from 2005, when procedures peaked at 32,540, to 2013.
During the study period, the total number of open AAA repair procedures declined by 76% from 20,533 in 2003 to 4,916 in 2013. In contrast, the number of endovascular aneurysm repair procedures increased by 74%, from 11,049 in 2003 to a peak of 19,247 in 2011 (P < .001). However, a 15% decline was observed from 2011 to 2013 (P < .001).
Notably, the decline in traditional EVAR procedures occurred alongside an increase in the number of branched-fenestrated EVAR procedures from 335 in 2011 to 2,143 in 2013 (P < .001).
In an analysis of regional data, the researchers found declines in rates of overall AAA repair, although they were more pronounced for open AAA repair. Whereas 36 regions in the United States performed more than one open AAA repair procedure per 1,000 Medicare patients in 2003, by 2013, no regions performed more than 0.5 per 1,000 Medicare patients. Moreover, 163 of 307 hospital referral regions did not perform enough procedures to allow calculation of an open AAA repair rate.
During the study period, the in-hospital mortality rate for open AAA repair was greater than 10%, which included patients with infrarenal, juxtarenal and paravisceral repairs of non-ruptured but elective or urgent aneurysms. The mortality rate for EVAR ranged from 2% to 3% (P < .001), as did the mortality rate for branched-fenestrated EVAR. All mortality rates remained similar over time despite an increase in the Charles Comorbidity Index.
The researchers used Medicare Part B claims data and regional information from the Dartmouth Atlas of Healthcare for their analyses.
Vascular surgery in the 21st century
Because open AAA repair serves as a quality metric for both hospitals and individual surgeons, the significant decline in the number of procedures being performed is concerning, according to the researchers. For instance, the outcomes, such as mortality, are easy to measure, whereas mortality is uncommon after EVAR, and measuring surveillance, re-intervention and efficacy is difficult.
“Surgical training will also face difficult challenges as open AAA repair fades from its role as a primary major case for vascular surgery trainees. Who will perform open aortic surgery in the years to come will remain an increasingly important question, as fewer surgeons with extensive expertise are available. Who will train other surgeons is a similarly important question, especially in the endovascular era, when many programs focus heavily on endovascular treatments for aortic aneurysm,” the researchers wrote. “The question arises whether open aortic surgery may be required to be performed at centers of excellence or inherently will become centralized.”
In an invited commentary, M. Ashraf Mansour, MD, from Spectrum Health Medical Group in Michigan, wrote that the rise in popularity of endovascular procedures is not unique to AAA and is also being seen in the management of peripheral artery disease. He noted that it is likely the number of open AAA repair procedures will continue to decrease, leaving physicians at a crossroads.
“The paucity of open aneurysm cases will put pressure on residency programs to find alternatives for training, such as simulation or cadaver laboratories,” he wrote. “A rising number of reports published in this Journal are documenting a significant shift in vascular surgery practice patterns. The practice of vascular surgery, and consequently the essence of residency training, is looking very different in the 21st century, and open aneurysm repair, in a few years, may be relegated to being a historical curiosity.” – by Melissa Foster
Disclosure: The authors and Mansour report no relevant financial disclosures.