Capturing the complexity of open abdominal aortic surgery in the endovascular era

Curtis Woodford; Rym El Khoury; Joel L Ramirez; Iris H Liu; Elizabeth M Lancaster; Joyce Nacario; Jade S Hiramoto; Charles M Eichler; Linda M Reilly; James C Iannuzzi; Michael S Conte

doi:10.1016/j.jvs.2022.06.007

Capturing the complexity of open abdominal aortic surgery in the endovascular era

J Vasc Surg. 2022 Dec;76(6):1520-1526. doi: 10.1016/j.jvs.2022.06.007. Epub 2022 Jun 15.

Affiliations

¹ Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA.
² Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA. Electronic address: michael.conte2@ucsf.edu.

PMID: 35714893
DOI: 10.1016/j.jvs.2022.06.007

Abstract

Objective: Volume and quality benchmarks for open abdominal aortic surgery and particularly open aortic aneurysm repair (OAR) in the endovascular era are guided by the Society for Vascular Surgery guidelines, but the Vascular Quality Initiative (VQI) OAR module fails to capture the full spectrum of complex OAR. We hypothesized that VQI-ineligible complex OAR would be the dominant form of open repairs performed at a VQI-participating tertiary center.

Methods: All OAR cases performed at a single tertiary care center from 2007 to 2020 were reviewed. The VQI OAR criteria were applied with exclusions (non-VQI) defined as concomitant renal bypass, clamping above the superior mesenteric artery or celiac artery, repairs performed for trauma, anastomotic aneurysm, isolated iliac aneurysm, or infected aneurysms. Linear regression was used to assess temporal trends.

Results: Among a total of 481 open abdominal aortic operations, 355 (74%) were OAR. The average annual OAR volume remained stable over 14 years (25 ± 6; P = .46). Non-VQI OAR comprised 54% of all cases and persisted over time (R² = 0.047, P = .46). Supraceliac clamping (35%) was often necessary. The proportion of endograft explantation cases significantly increased over time from 4% in 2007 to 20% in 2019 (P = .01). Infectious indications represented 20% (n = 70) of cases. Visceral branch grafts were performed in 16% of all cases. OAR for ruptured aneurysm constituted 10% of cases. Thirty-day mortality was significantly higher in non-VQI vs VQI-eligible OAR cases (10% vs 4%; P = .04).

Conclusions: Complex OAR comprises a majority of OAR cases in a contemporary tertiary referral hospital, yet these cases are not accounted for in the VQI. Creation of a "complex OAR" VQI module would capture these cases in a quality-driven national registry and help to better inform benchmarks for volume and outcomes in aortic surgery.

Keywords: Abdominal aortic aneurysm; Open repair; VQI; Volume.

MeSH terms

Aortic Aneurysm, Abdominal* / diagnostic imaging
Aortic Aneurysm, Abdominal* / surgery
Blood Vessel Prosthesis Implantation* / adverse effects
Endovascular Procedures*
Humans
Postoperative Complications / surgery
Retrospective Studies
Risk Factors
Time Factors
Treatment Outcome