The Rest of the Story: The Decline of Aortic Surgical Experience in the EVAR Era

OBJECTIVES:
Eligibility criteria for endovascular abdominal aortic aneurysm (AAA) repair (EVAR) have broadened significantly in recent years. Despite prior predictions to the contrary, open AAA repair (OR) volume continues to decline. We examined trends in training and hospital discharge data to define the current status and future prospects for open aortic surgery.
METHODS:
Operative logs from our center as well as 91 ACGME-accredited vascular training programs and the National Inpatient Sample (NIS, teaching vs. non-teaching hospitals) were queried for type of AAA repair (OR or EVAR). Changes in procedural frequency over time were calculated from joinpoint regression analysis; differences between data sources were determined using t-tests.
RESULTS:
Our center performed 1,409 AAA repairs since 1997. Although national AAA repair rates (OR+EVAR) remain stable, OR volume has decreased significantly (-12.44%/yr, p<0.03) since 2001 with a reciprocal increase in EVAR procedures (+12.18%/yr). No differences were noted between local, ACGME and NIS-reported trends. Our local ratio of OR/EVAR declined by >50% since 2003 (Figure).
CONCLUSIONS:
EVAR adoption is accelerating due to continuing improvements in device design, procedural planning tools, and endovascular skills. Rapid declines in OR volume nationally are limiting surgical training opportunities and open aortic skills maintenance in even high volume academic centers. Near term reductions in the availability and quality of open aortic expertise may adversely impact vascular-related disciplines including trauma, oncologic, and transplantation surgery.