Meta-analysis and systematic review of the relationship between volume and outcome in abdominal aortic aneurysm surgery

PRE-oPerative Assessment for Patients with Chronic Limb ThReatening IschEmia (PREPARE): A Multinational Delphi Consensus

BACKGROUND

Chronic limb-threatening ischemia (CLTI) presents significant challenges in both diagnosis and management, with a lack of standardized preoperative assessment and optimization frameworks. This study aimed to establish a contemporary consensus among vascular specialists on the perioperative care of CLTI patients across diverse health-care systems.

METHODS

A modified Delphi methodology was used, involving iterative rounds of consultation with 42 expert vascular surgeons from the United Kingdom, Ireland, Australia, and New Zealand. Four broad domains were explored: availability of services, preoperative assessment, perioperative optimization, and the role of multidisciplinary teams (MDTs). Consensus was defined as ≥70% agreement RESULTS: A total of 59 consensus statements were established, covering key areas such as rapid access clinics, the value of preoperative investigations and anemia. Unanimous agreement was reached regarding the necessity of clear referral pathways, and a strong majority supported the importance of MDTs in complex cases. However, significant uncertainty remained about the utility of existing risk prediction models, with only 53% endorsing tools like the American College of Surgeons Risk Calculator. Notably, 81% agreed that if preoperative investigations could change the type of intervention a patient received, this investigation should be performed prior to surgery even at the expense of delayed intervention.

CONCLUSION

This Delphi consensus study highlights the complexity in managing patients with CLTI and the necessity of a multifaceted, interdisciplinary approach to preoperative care. The findings advocate for improved primary care management, selective use of preoperative investigations and emphasizes the importance of interdisciplinary care. While consensus was reached on several key aspects of care, the study highlights ongoing uncertainties around risk prediction and cardiac stress testing therefore highlighting the need for further research to validate current tools and practices. These results lay the groundwork for future clinical guidelines aimed at reducing practice variability and improving patient outcomes.

Increased market competition is associated with lower mortality after complex aortic surgery

OBJECTIVE

Centralized aortic hubs frequently exist in competitive markets, which have at times demonstrated inferior surgical outcomes. Here we evaluate the impact of local market competition specifically on complex aortic surgical outcomes.

METHODS

A retrospective review included all Vascular Quality Initiative (VQI) patients between 2013 and 2022 undergoing index complex endovascular aortic repair, thoracic endovascular aortic repair, or open aortic repair. Market competition was defined by the Herfindahl-Hirschman index (HHI), using surgeon-level market share within blinded VQI regions or metropolitan statistical areas (MSAs). A higher HHI indicates lower competition. Multivariable logistic 30-day mortality models and Cox survival models were used to examine the association between HHI and outcomes. A sensitivity analysis further adjusted for complexity among all complex and routine aortic surgical patients in the Vascular Implant Surveillance and Interventional Outcomes Network from 2017 to 2019, using generalized estimating equations with MSA-level clustering.

RESULTS

The VQI contained 10,868 complex aortic surgical patients, with 4372 additional patients in MSA-based Vascular Implant Surveillance and Interventional Outcomes Network sensitivity analysis. The median patient age was 75 years. Of these patients, 68.4% were male, with a greater number of patients in high competition regions (51.3%) and MSAs (34.6%) vs medium and low competition locales. Comorbidities and aneurysm diameter were broadly similar across HHI intervals. Lower 30-day mortality was observed in high competition regions (high, 23.7%; medium, 25.9%; low, 25.9%; P = .03). In multivariable logistic models, medium regional competition was associated with greater 30-day mortality odds vs high competition (odds ratio [OR], 1.39; 95% CI, 1.21-1.60; P < .001), with a trend toward increased mortality for low competition (OR, 1.20; 95% CI, 0.98-1.45; P = .07). MSA-based sensitivity analyses demonstrated a similar trend for medium competition MSAs (OR, 1.25; 95% CI, 0.98-1.58; P = .07), without significant relationship for low-competition MSAs. Regional interval was not associated with any long-term mortality difference.

CONCLUSIONS

More competitive regions demonstrate lower 30-day mortality after complex aortic surgery but equivalent long-term survival. Further efforts should focus on drivers of this difference to widen access to high-quality complex aortic care.

The Impact of Simulator Training of Vascular Anastomosis and Video Assessment for Surgical Residents

BACKGROUND

The rapid increase of minimally invasive surgery and the shortened training period for surgical residents has resulted in limited opportunities to acquire proficiency in open surgical techniques, such as vascular anastomosis. However, vascular anastomosis remains an essential skill in every surgery for bleeding control. This study aimed to validate the effectiveness of surgical education model for vascular anastomosis and assess the impact on the comprehension, skill, and confidence of surgical residents in performing vascular anastomosis.

METHODS

A total of 21 surgical residents with first to third years of experience at Seoul National University Hospital participated in a 4-week vascular anastomosis training program. The program included an educational lecture and the performance of an end-to-side anastomosis on a procedural model, with evaluations being conducted using the Objective Structured Assessment of Technical Skills (OSATS) and the End-Product Rating Score (EPRS) in pretraining and posttraining surveys.

RESULTS

Significant improvement was observed in the OSATS score (from 9.22 ± 2.4 in week 1 to 12.87 ± 3.1 in week 4; P < 0.001) and the EPRS score (from 12.47 ± 4.1 in week 1 to 17.57 ± 2.2 in week 4; P < 0.001). Additionally, the surgical performance time significantly decreased from 20.99 ± 4.6 min to 16.33 ± 4.2 min (P = 0.019) CONCLUSIONS: Simulator training of in vitro vascular anastomosis, when accompanied by expert-led instruction, can effectively enhance the surgical proficiency, confidence, and overall surgical outcomes of residents, as inferred from the observed improvements in OSATS and EPRS scores. The results suggest that integration of this training model into surgical curricula could be a promising strategy for enhancing vascular surgical training.

Midterm Outcomes and Predictors of Failure of Lower Extremity Bypass to Para-Malleolar and Pedal Targets

BACKGROUND

The frequency of distal lower extremity bypass (LEB) for infrapopliteal critical limb threatening ischemia (IP-CLTI) has significantly decreased. Our goal was to analyze the contemporary outcomes and factors associated with failure of LEB to para-malleolar and pedal targets.

METHODS

We queried the Vascular Quality Initiative infrainguinal database from 2003 to 2021 to identify LEB to para-malleolar or pedal/plantar targets. Primary outcomes were graft patency, major adverse limb events [vascular reintervention, above ankle amputation] (MALE), and amputation-free survival at 2 years. Standard statistical methods were utilized.

RESULTS

We identified 2331 LEB procedures (1,265 anterior tibial at ankle/dorsalis pedis, 783 posterior tibial at ankle, 283 tarsal/plantar). The prevalence of LEB bypasses to distal targets has significantly decreased from 13.37% of all LEB procedures in 2003-3.51% in 2021 (P < 0.001). The majority of cases presented with tissue loss (81.25. Common postoperative complications included major adverse cardiac events (8.9%) and surgical site infections (3.6%). Major amputations occurred in 16.8% of patients at 1 year. Postoperative mortality at 1 year was 10%. On unadjusted Kaplan-Meier survival analysis at 2 years, primary patency was 50.56% ± 3.6%, MALE was 63.49% ± 3.27%, and amputation-free survival was 71.71% ± 0.98%. In adjusted analyses [adjusted for comorbidities, indication, conduit type, urgency, prior vascular interventions, graft inflow vessel (femoral/popliteal), concomitant inflow procedures, surgeon and center volume] conduits other than great saphenous vein (P < 0.001) were associated with loss of primary patency and increased MALE. High center volume (>5 procedures/year) was associated with improved primary patency (P = 0.015), and lower MALE (P = 0.021) at 2 years.

CONCLUSIONS

Despite decreased utilization, open surgical bypass to distal targets at the ankle remains a viable option for treatment of IP-CLTI with acceptable patency and amputation-free survival rates at 2 years. Bypasses to distal targets should be performed at high volume centers to optimize graft patency and limb salvage and minimize reinterventions.

Burden of aortic aneurysm in Iran from 1990 to 2019: an analysis based on global burden of disease study

Background

Limited studies have been conducted on the epidemiology of aortic aneurysms in Iran. In this study, the authors aimed to comprehensively evaluate the burden and epidemiology of aortic aneurysms across various age groups, sexes, and provinces in Iran from 1990 to 2019.

Materials and methods

The authors used global burden of disease (GBD) study data in the current study. The authors retrieved data on the burden of aortic aneurysms across sexes and age groups at national and subnational levels from 1990 to 2019. The authors extracted mortality, years of life lost (YLL), years lived with disability (YLD), and disability-adjusted life year (DALY), numbers, rates, and age-standardized rates. Additionally, the authors extracted the burden of AA attributable to its risk factors, such as lead exposure, high systolic blood pressure, high dietary intake of sodium, and smoking.

Results

National ASDR (age-standardized DALY rate) was also observed to be reduced from 1990 [22.20 (17.46-26.86)] to 2019 [19.97 (17.98-21.98)]. However, the inclinations were evaluated to be slighter than the world (%change ASDR=-19.5%). In 2019, three leading risk factors yielding death in AA patients were smoking [ASMR attributable=0.73 (0.67-0.80)], high sodium intake [ASMR attributable=0.11 (0.03-0.27)], and lead exposure [ASMR attributable=0.04 (0.02-0.07)].

Conclusion

Mortality and DALYs due to AA both decreased slightly during the last three decades. Considering the role of smoking in the burden of AA in Iran, interventions targeting smoking cessation among high-risk groups, such as males, may be helpful to reduce the burden of AA in Iran in the coming years.

[Recommendations for the specialist further training of nursing personnel on intensive care units in the treatment of abdominal aortic aneurysms: results of a modified Delphi procedure with experts]

INTRODUCTION

The medical development in the previous 15 years and the changes in treatment reality of the comprehensive elective treatment of abdominal aortic aneurysms necessitate a re-evaluation of the quality assurance guidelines of the Federal Joint Committee in Germany (QBAA-RL). In the current version this requires a specialist further training quota for nursing personnel in intensive care wards of 50%. The quota was determined in 2008 based on expert opinions, although a direct empirical evidence base for this does not exist.

METHODS

Representatives from the fields of patient representation, physicians, nursing personnel and other relevant interface areas were invited to participate in a modified Delphi procedure. Following a comprehensive narrative literature search, a survey and focus group discussions with national and international experts, a total of three anonymized online-based voting rounds were carried out for which previously determined key statements were assessed with a 4‑point Likert scale (totally disagree up to totally agree). In addition, the expert panel had also defined a recommendation for a minimum quota for the specialist training of nursing personnel on intensive care wards in the treatment of abdominal aortic aneurysms, whereby an a priori agreement of 80% of the participants was defined as the consensus limit.

RESULTS

Overall, 37 experts participated in the discussions and three successive voting rounds (participation rate 89%). The panel confirmed the necessity of a re-evaluation of the guideline recommendations and recommended the introduction of a shift-related minimum quota of 30% of the full-time equivalent of nursing personnel on intensive care wards and the introduction of structured promotional programs for long-term elevation of the quota.

CONCLUSION

In this national Delphi procedure with medical and nursing experts as well as representatives of patients, the fundamental benefits and needs of professional specialist qualifications in the field of intensive care medicine were confirmed. The corresponding minimum quota for specialist further training of intensive care nursing personnel should generally apply without limitations to specific groups. The expert panel stipulates a shift-related minimum quota for intensive care nursing personnel with specialist training of 30% of the nursing personnel on intensive care wards and the obligatory introduction of structured and transparent promotion programs for the long-term enhancement.

Conflicting European and North American Society Abdominal Aortic Aneurysm (AAA) Volume Guidelines Differentially Discriminate Peri-operative Mortality After Elective Open AAA Repair

OBJECTIVE

The European Society for Vascular Surgery (ESVS) guidelines endorse a minimum abdominal aortic aneurysm (AAA) repair volume of 20 open (OAR) and or endovascular (EVAR) AAA repair procedures per year as a proxy for high quality care. In contrast, the Society for Vascular Surgery (SVS) espouses 10 exclusively OARs per year. Given the differences in these volume standards and definitions, debate persists regarding surgeon credentialing and healthcare resource allocation. This analysis aimed to determine which society endorsed volume benchmark better discriminates OAR mortality.

METHODS

A retrospective national registry based cohort analysis. Patients undergoing elective OAR were compared between centres meeting either ESVS (≥ 20 AAA procedures/year) or SVS (≥ 10 OARs/year) volume thresholds within the Vascular Quality Initiative (2010 - 2020). The primary outcome was in hospital death. Logistic regression was used for risk adjusted comparisons.

RESULTS

A total of 8 761 OARs were performed at 193 US centres, and the median (IQR) volume was 6.6 (3.3, 9.9) OARs/year. When applying the SVS centre volume definition, the proportion of centres meeting ESVS and SVS minimum case thresholds was 12% (n = 22) and 25% (n = 48), respectively. The absolute mortality difference was 0.3% between centres performing ≥ 20 vs. ≥ 10 OARs/year (2.6% vs. 2.9%; p = .51). There was an incremental association between OAR volume and crude mortality rate; however, this absolute difference between lower and higher thresholds was only 0.2%/procedure (OR 0.98, 95% CI 0.97 - 0.99; p < .001). Moreover, no difference in risk adjusted mortality was detected between volume standards (≥ 10 vs. ≥ 20; p = .78). In sub-analysis, the ESVS ≥ 20 total composite AAA repair volume threshold was not associated with mortality (p = .17); however, increasing the proportion of OAR cases making up the total annual AAA centre volume inversely correlated with mortality (p = .008).

CONCLUSION

It appears that the SVS endorsed AAA centre volume threshold using exclusively OAR had a modest ability to discriminate peri-operative mortality outcomes and was superior to the current composite ESVS volume guideline in differentiating centre performance. These findings raise questions regarding the clinical validity of using EVAR as a volume proxy for OAR.

Greater Patient Travel Distance is Associated with Perioperative and One-Year Cost Increases After Complex Aortic Surgery

BACKGROUND

With increasing regionalization of complex aortic surgery within fewer US centers, patients may face increased travel burden when accessing aortic surgery. Longer travel distances have been associated with inferior outcomes after major surgery; however, the impacts of distance on reinterventions and costs have not been described. This study aims to assess the association between patient travel distance and longer-term outcomes including costs and reinterventions after complex aortic surgery.

METHODS

A retrospective review was conducted of all patients in the Vascular Implant Surveillance and Interventional Outcomes Network database undergoing complex endovascular aortic repair including internal iliac or visceral vessel involvement, complex thoracic endovascular aortic repair including Zone 0-2 proximal extent or branched devices, and complex open abdominal aortic aneurysm repair including suprarenal or higher clamp sites. Travel distance was stratified by Rural-Urban Commuting Area population-density category. Multinomial logistic regression models, negative-binomial models, and zero-inflated Poisson models were used to assess the association between travel distance and index procedural and comprehensive first-year costs, long-term imaging, and long-term reinterventions, respectively.

RESULTS

Between 2011 and 2018, 8,782 patients underwent complex aortic surgery in the Vascular Implant Surveillance and Interventional Outcomes Network database, including 4,822 complex endovascular aortic repairs, 2,672 complex thoracic endovascular aortic repairs, and 1,288 complex open abdominal aortic aneurysm repairs. Median travel distance was 22.8 miles (interquartile range 8.6-54.8 miles, range 0-2,688.9 miles). Median age was 75 years for all distance quintiles. Patients traveling farther were more likely to be female (26.8% in quintile 5 [Q5] vs. 19.9% in Q1, P < 0.001) and to have had a prior aortic surgery (20.8% for Q5 vs. 5.9% for Q1, P < 0.001). Patients traveling farther had higher index procedural costs, with adjusted odds ratio (OR) 2.34 (95% confidence interval [CI] 1.86-2.94, P < 0.0001) of being in the highest cost tertile versus lowest for patients in Q5 vs. Q1. For patients with ≥ 1-year follow-up, those traveling farther had higher imaging costs, with adjusted Q5 OR 1.55 (95% CI 1.22-1.95, P = 0.0002), and comprehensive first-year costs, with adjusted Q5 OR 2.06 (95% CI 1.57-2.70, P < 0.0001). In contrast, patients traveling farther had similar numbers of reinterventions and imaging studies postoperatively.

CONCLUSIONS

Patients traveling farther for complex aortic surgery have higher procedural costs, postoperative imaging costs, and comprehensive first-year costs. These patients should be targeted for increased care coordination for improved outcomes and healthcare system burden.

Longer patient travel distance is associated with increased non-index readmission after complex aortic surgery

OBJECTIVE

Recently evolving practice patterns in complex aortic surgery have led to regionalization of care within fewer centers in the United States, and thus patients may have to travel farther for complex aortic care. Travel distance has been associated with inferior outcomes after non-vascular surgery, particularly non-index readmission. This study aims to assess the impact of patient travel distance on perioperative outcomes and readmissions after complex aortic surgery.

METHODS

A retrospective review was conducted of all patients in the Vascular Quality Initiative and Vascular Implant Surveillance and Interventional Outcomes Network databases undergoing complex endovascular aortic repair (EVAR) including internal iliac or visceral vessel involvement, complex thoracic endovascular aortic repair (TEVAR) including zone 0 to 2 proximal extent or branched devices, and complex open abdominal aortic aneurysm (AAA) repair including suprarenal or higher clamp sites. Travel distance was stratified by rural/urban commuting area (RUCA) population-density category. Wilcoxon and χ2 tests were used to assess relationships between travel distance quintiles and baseline characteristics, mortality, and readmission. Travel distance and other factors were included in multivariable Cox models for survival and Fine-Gray competing risk models for freedom from readmission.

RESULTS

Between 2011 and 2018, 8782 patients underwent complex aortic surgery in the Vascular Quality Initiative and Vascular Implant Surveillance and Interventional Outcomes Network databases, including 4822 complex EVARs, 2672 complex TEVARs, and 1288 complex open AAA repairs. Median travel distance was 22.8 miles (interquartile range [IQR], 8.6-54.8 miles). Median age was 75 years for all distance quintiles, but patients traveling longer distances were more likely female (26.8% in quintile 5 [Q5] vs 19.9% in Q1; P < .001), white (93.8% of Q5 vs 83.8% of Q1; P < .001), to have larger-diameter AAAs (median 59 mm for Q5 vs 55 mm for Q1; P < .001), and to have had prior aortic surgery (20.8% for Q5 vs 5.9% for Q1; P < .001). Overall 30-day readmission was more common at farther distances (18.1% for Q5 vs 14.8% for Q1; P = .003), with higher non-index readmission (11.2% for Q5 vs 2.7% for Q1; P < .001) and conversely lower index readmission (6.9% for Q5 vs 12.0% for Q1; P < .001). Multivariable-adjusted Fine-Gray models confirmed greater hazard of non-index readmission with farther distance, with a Q5 hazard ratio of 3.02 (95% confidence interval, 2.12-4.30; P < .001). Multivariable-adjusted Cox models demonstrated no association between travel distance and long-term survival but found that non-index readmission was associated with increased long-term mortality (hazard ratio, 1.46; 95% confidence interval, 1.20-1.78; P = .0001).

CONCLUSIONS

Patients traveling farther for complex aortic surgery demonstrate higher non-index readmission, which, in turn, is associated with increased long-term mortality risk. Aortic centers of excellence should consider targeting these patients for more comprehensive follow-up and care coordination to improve outcomes.

The impact of race on outcomes following ruptured abdominal aortic aneurysm repair

OBJECTIVES

Racial differences in elective abdominal aortic aneurysm (AAA) repair outcomes have been previously reported; however, data on racial differences in ruptured AAA (rAAA) repair outcomes remain limited. This study assessed in-hospital and long-term mortality after rAAA repair in Black versus White patients.

METHODS

The Vascular Quality Initiative database was queried to identify all Black and White patients who underwent open or endovascular rAAA repair between 2003 and 2019. Baseline demographic and clinical characteristics were recorded, and independent t test and χ2 test were performed to assess differences between groups. In-hospital and 8-year mortality rates were the primary outcomes. Univariate and multivariate logistic regression and Cox proportional hazards analyses were conducted to analyze associations between race and outcomes.

RESULTS

Overall, 310 Black patients and 4679 White patients underwent rAAA repair. A greater proportion of Black patients underwent endovascular repair (73.2% vs 56.1%). Black patients had a lower mean age and were more likely to be female, with a greater proportion being Medicaid insured (9.7% vs 2.1%) or uninsured (4.8% vs 3.3%). Although Black patients were more likely to be current smokers and have hypertension, diabetes, and congestive heart failure, they were not more likely to receive risk reduction medications. The time from symptom onset to incision or access was higher for Black patients (median, 12.0 hours vs 7.0 hours). Similarly, the time from hospital admission to intervention was higher for Black patients (median, 2.8 hours vs 1.3 hours). In-hospital mortality was lower in Black patients (20.0% vs 28.6%; odds ratio [OR], 0.63; 95% confidence interval [CI], 0.47-0.83); however, this did not persist after adjusting for baseline characteristics (adjusted OR, 0.58; 95% CI, 0.30-1.07; P = .09). Furthermore, the 8-year survival was not different between groups (50.4% vs 46.6%; hazard ratio, 0.85; 95% CI, 0.57-1.26; P = .42), even when stratified by repair type.

CONCLUSIONS

This study identified racial differences in demographic, clinical, and procedural characteristics for patients undergoing rAAA repair. In particular, the door-to-intervention time for Black patients of 2.8 hours does not meet the Society for Vascular Surgery recommendation of 90 minutes. Despite these differences, the 8-year mortality is similar for Black and White patients. These differences should be investigated further, and there are opportunities to improve rAAA care for Black patients.

Incidence and Outcomes of Abdominal Aortic Aneurysm Repair in New Zealand from 2001 to 2021

Purpose: The burden of abdominal aortic aneurysms (AAA) has changed in the last 20 years but is still considered to be a major cause of cardiovascular mortality. The introduction of endovascular aortic repair (EVAR) and improved peri-operative care has resulted in a steady improvement in both outcomes and long-term survival. The objective of this study was to identify the burden of AAA disease by analysing AAA-related hospitalisations and deaths. Methodology: All AAA-related hospitalisations in NZ from January 2001 to December 2021 were identified from the National Minimum Dataset, and mortality data were obtained from the NZ Mortality Collection dataset from January 2001 to December 2018. Data was analysed for patient characteristics including deprivation index, repair methods and 30-day outcomes. Results: From 2001 to 2021, 14,436 patients with an intact AAA were identified with a mean age of 75.1 years (SD 9.7 years), and 4100 (28%) were females. From 2001 to 2018, there were 5000 ruptured AAA with a mean age of 77.8 (SD 9.4), and 1676 (33%) were females. The rate of hospitalisations related to AAA has decreased from 43.7 per 100,000 in 2001 to 15.4 per 100,000 in 2018. There was a higher proportion of rupture AAA in patients living in more deprived areas. The use of EVAR for intact AAA repair has increased from 18.1% in 2001 to 64.3% in 2021. The proportion of octogenarians undergoing intact AAA repair has increased from 16.2% in 2001 to 28.4% in 2021. The 30-day mortality for intact AAA repair has declined from 5.8% in 2001 to 1.7% in 2021; however, it has remained unchanged for ruptured AAA repair at 31.6% across the same period. Conclusions: This study highlights that the incidence of AAA has declined in the last two decades. The mortality has improved for patients who had a planned repair. Understanding the contemporary burden of AAA is paramount to improve access to health, reduce variation in outcomes and promote surgical quality improvement.

Qualitative Study of Medical Doctors on Their Experiences and Opinions of the Characteristics of Exceptionally Good Doctors

Background

It is generally accepted that there is a therapist effect in psychotherapy, with master therapists being studied using qualitative methods. There are surgeons with exceptionally positive patients' physical health outcomes, and qualitative research on what makes good doctors. However, characteristics of exceptionally good doctors are less studied and understood.

Objective

To qualitatively study the opinions of physicians on exceptionally good doctors.

Methods

Thirteen semi-structured interviews of English-speaking medical doctors of any specialty were conducted. Recruitment was achieved through the authors' network; contacting authors of relevant research papers; and Bond University's General Practitioner recruitment program. Their opinion was sought on what makes an exceptionally good doctor, whether they have met such a person, what was their experience of that person, and whether they consider themselves as exceptionally good doctors.

Analysis

A six-phase thematic analysis in an experiential framework, as per Braun and Clarke, was implemented to identify themes and their details in an inductive approach with a realist epistemological position, ie, assuming truthful knowledge on what makes exceptionally good doctors can be obtained.

Results

Each interviewee had met and been inspired by exceptionally good doctors. Descriptions covered six themes: character traits; other characteristics; patient relationships; peer and health care system relations; education; and treatment examples. Exceptionally good doctors were found to have up-to-date extensive medical knowledge and skills, relate well with patients, and have excellent diagnostic abilities. They tend to be humble, approachable, inspiring, and are long-remembered role models. However, they may not always be appreciated by their peers and their health care system because of their exceptional abilities.

Discussion and Conclusion

Exceptional doctors are beneficial for their peers, their patients, and their health care system. Identifying, acknowledging, and making such doctors more accessible to medical students and junior doctors could have a positive impact on medical practice.

Delays to revascularization for patients with chronic limb-threatening ischaemia

BACKGROUND

Vascular services in England are organized into regional hub-and-spoke models, with hubs performing arterial surgery. This study examined time to revascularization for chronic limb-threatening ischaemia (CLTI) within and across different care pathways, and its association with postrevascularization outcomes.

METHODS

Three inpatient and four outpatient care pathways were identified for patients with CLTI undergoing revascularization between April 2015 and March 2019 using Hospital Episode Statistics data. Differences in times from presentation to revascularization across care pathways were analysed using Cox regression. The relationship between postoperative outcomes and time to revascularization was evaluated by logistic regression.

RESULTS

Among 16 483 patients with CLTI, 9470 had pathways starting with admission to a hub or spoke hospital, whereas 7013 (42.5 per cent) were first seen at outpatient visits. Among the inpatient pathways, patients admitted to arterial hubs had shorter times to revascularization than those admitted to spoke hospitals (median 5 (i.q.r. 2-10) versus 12 (7-19) days; P < 0.001). Shorter times to revascularization were also observed for patients presenting to outpatient clinics at arterial hubs compared with spoke hospitals (13 (6-25) versus 26 (15-35) days; P < 0.001). Within most care pathways, longer delays to revascularizsation were associated with increased risks of postoperative major amputation and in-hospital death, but the effect of delay differed across pathways.

CONCLUSION

For patients with CLTI, time to revascularization was influenced by presentation to an arterial hub or spoke hospital. Generally, longer delays to revascularization were associated with worse outcomes, but the impact of delay differed across pathways.

Intensive Care Unit Volume of Sepsis Patients Does Not Affect Mortality: Results of a Nationwide Retrospective Analysis

BACKGROUND

There is little research evaluating outcomes from sepsis in intensive care units (ICUs) with lower sepsis patient volumes as compared to ICUs with higher sepsis patient volumes. Our objective was to compare the outcomes of septic patients admitted to ICUs with different sepsis patient volumes.

MATERIALS AND METHODS

We included all patients from the eICU-CRD database admitted for the management of sepsis with blood lactate ≥ 2mmol/L within 24 hours of admission. Our primary outcome was ICU mortality. Secondary outcomes included hospital mortality, 30-day ventilator free days, and initiation of renal replacement therapy (RRT). ICUs were grouped in quartiles based on the number of septic patients treated at each unit.

RESULTS

10,716 patients were included in our analysis; 272 (2.5%) in low sepsis volume ICUs, 1,078 (10.1%) in medium-low sepsis volume ICUs, 2,608 (24.3%) in medium-high sepsis volume ICUs, and 6,758 (63.1%) in high sepsis volume ICUs. On multivariable analyses, no significant differences were documented regarding ICU and hospital mortality, and ventilator days in patients treated in lower versus higher sepsis volume ICUs. Patients treated at lower sepsis volume ICUs had lower rates of RRT initiation as compared to high volume units (medium-high vs. high: OR = 0.78, 95%CI = 0.66-0.91, P-value = 0.002 and medium-low vs. high: OR = 0.57, 95%CI = 0.44-0.73, P-value < 0.001).

CONCLUSION

The previously described volume-outcome association in septic patients was not identified in an intensive care setting.

Mortality following elective abdominal aortic aneurysm repair in women

BACKGROUND

Previous studies have focused on patient-related risk factors to explain the higher mortality risk in women undergoing elective abdominal aortic aneurysm (AAA) repair. The aim of this study was to evaluate whether hospital-related factors influence outcomes following AAA repair in women.

METHODS

Patients undergoing elective AAA repair in 61 hospitals in the Netherlands were identified from the Dutch Surgical Aneurysm Audit registry (2013-2018). A mixed-effects logistic regression analysis was conducted to assess the effect of sex on in-hospital and/or 30-day mortality. This analysis accounted for possible correlation of outcomes among patients who were treated in the same hospital, by adding a hospital-specific random effect to the statistical model. The analysis adjusted for patient-related risk factors and hospital volume of open surgical repair (OSR) and endovascular aneurysm repair (EVAR).

RESULTS

Some 12 034 patients were included in the analysis. The mortality rate was higher in women than among men: 53 of 1780 (3.0 per cent) versus 152 of 10 254 (1.5 per cent) respectively. Female sex was significantly associated with mortality after correction for patient- and hospital-related factors (odds ratio 1.68, 95 per cent c.i. 1.20 to 2.37). OSR volume was associated with lower mortality (OR 0.91 (0.85 to 0.95) per 10-procedure increase) whereas no such relationship was identified with EVAR volume (OR 1.03 (1.01 to 1.05) per 10-procedure increase).

CONCLUSION

Women are at higher risk of death after abdominal aortic aneurysm repair irrespective of patient- and hospital-related factors.

In-hospital outcomes of ruptured abdominal aortic aneurysms: A single center experience

Introduction: Ruptured abdominal aortic aneurysm (RAAA) is a catastrophic condition with in-hospital mortalities up to 89%. Patient survival depends on multiple factors; however, prompt surgery is essential to prevent mortality. We report the in-hospital outcomes of RAAA at a high-volume and teaching vascular surgery center in Iran.

Methods: This study is a single-center retrospective analysis of patients with infrarenal RAAA during February 20, 2012 to December 21, 2019 at Shohada-Tajrish Medical Center, Tehran,Iran. We identified 66 patients with RAAA during the study period. The patients were dividedinto two groups based on their transfer status (Transfer group versus non-transfer group). The primary outcome was in-hospital death. The secondary outcomes were in-hospital myocardial infarction (MI), abdominal compartment syndrome (ACS) and postoperative renal dysfunction requiring dialysis.

Results: The mean age of the patients was 74.2 ± 8.3 years. Forty-seven patients (71.2%) were transferred to our center from other institutions. There were 46 in-hospital deaths (69.7%) and three in-hospital MIs (4.5%). Three patients (4.5%) had postoperative ACS and six patients (9.1%)had postoperative renal dysfunction requiring dialysis. Transfer patients had an increased rate of in-hospital death compared to non-transferred patients (76.6.1% versus 52.6%); however, the difference was not statistically significant (P =0.055).

Conclusion: We found no significant different between operative mortality of transferred and non-transferred RAAA patients. Transfer of patients to tertiary centers with experienced vascular surgeons may delay the surgery. However, the transfer may be inevitable in areas where the optimal care of RAAA patients is not possible.

Myocardial ischaemia secondary to ruptured abdominal aortic aneurysm

A 63-year-old man presented to an outside hospital with presyncope, back pain, hypotension and inferior ST segment elevations. He received aspirin, ticagrelor and heparin and was transferred to our institution as a Code STEMI (ST-segment elevation myocardial infarction). A coronary angiogram demonstrated multivessel disease but no occlusive lesion for acute intervention. The following day, he developed worsening abdominal/back pain. A CT angiogram (CTA) showed a ruptured infrarenal abdominal aortic aneurysm. He underwent urgent percutaneous endovascular aneurysm repair. CTA on postoperative day (POD) 10 demonstrated a patent stent graft with no endoleak. The patient was discharged on POD 12 in stable condition.

Reliability of hospital-level mortality in abdominal aortic aneurysm repair

OBJECTIVE

The relationship between volume and surgical outcomes has been shown for a variety of surgical procedures. The effects in abdominal aortic aneurysm repair have continued to be debated. Reliability adjustment has been used as a method to remove statistical noise from hospital-level outcomes. However, its impact on aortic aneurysm repair is not well understood.

METHODS

We used prospectively collected data from the Vascular Quality Initiative to identify all patients who had undergone abdominal aortic aneurysm repair from 2003 to 2019. We first calculated the hospital-level risk-adjusted 30-day mortality rates. We subsequently used hierarchical logistic regression modeling to adjust for measurement reliability using empirical Bayes techniques. The effect of volume on risk- and reliability-adjusted mortality rates was then assessed using linear regression.

RESULTS

Between 2003 and 2019, 67,073 abdominal aortic aneurysms were repaired, of which 11,601 (17.3%) were repaired with an open approach. The median annual volume was 7.4 (interquartile range, 3.0-13.3) for open repairs and 35.4 (interquartile range, 18.8-59.8) for endovascular repairs. Of the 223 hospitals that had performed open repairs during the study period, only 11 (4.9%) had performed ≥15 open repairs annually, and the risk-adjusted mortality rates varied from 0% to 75% across all centers. After reliability adjustment, the variability of the risk-adjusted mortality rates had decreased significantly to 1.3% to 8.2%. The endovascular repair risk-adjusted mortality rate variability had decreased from 0% to 14.3% to 0.3% to 2.8% after reliability adjustment. A decreasing trend in mortality was found with increasing an annual case volume for open repair with each additional annual case associated with a 0.012% decrease in mortality (P = .05); however, the relationship was not significant for endovascular repair (P = .793).

CONCLUSIONS

We found that most hospitals do not perform a sufficient number of annual cases to generate a reliable center-specific mortality rate for open aneurysm repair. Center-specific mortality rates for low-volume centers should be viewed with caution, because a substantial proportion of the variation for these outcomes will be statistical noise rather than true center-level differences in the quality of care.

Association of Hospital Volume with Perioperative Mortality of Endovascular Repair of Complex Aortic Aneurysms: A Nationwide Cohort Study

OBJECTIVE

We evaluate nationwide perioperative outcomes of complex EVAR and assess the volume-outcome association of complex EVAR.

SUMMARY OF BACKGROUND DATA

Endovascular treatment with fenestrated (FEVAR) or branched (BEVAR) endografts is progressively used for excluding complex aortic aneurysms (complex AAs). It is unclear if a volume-outcome association exists in endovascular treatment of complex AAs (complex EVAR).

METHODS

All patients prospectively registered in the Dutch Surgical Aneurysm Audit who underwent complex EVAR (FEVAR or BEVAR) between January 2016 and January 2020 were included. The effect of annual hospital volume on perioperative mortality was examined using multivariable logistic regression analyses. Patients were stratified into quartiles based on annual hospital volume to determine hospital volume categories.

RESULTS

We included 694 patients (539 FEVAR patients, 155 BEVAR patients). Perioperative mortality following FEVAR was 4.5% and 5.2% following BEVAR. Postoperative complication rates were 30.1% and 48.7%, respectively. The first quartile hospitals performed <9 procedures/yr; second, third, and fourth quartile hospitals performed 9-12, 13-22, and ≥23 procedures/yr. The highest volume hospitals treated the significantly more complex patients. Perioperative mortality of complex EVAR was 9.1% in hospitals with a volume of < 9, and 2.5% in hospitals with a volume of ≥13 (P = 0.008). After adjustment for confounders, an annual volume of ≥13 was associated with less perioperative mortality compared to hospitals with a volume of < 9.

CONCLUSIONS

Data from this nationwide mandatory quality registry shows a significant effect of hospital volume on perioperative mortality following complex EVAR, with high volume complex EVAR centers demonstrating lower mortality rates.

Low Volume Hospitals Are Not Associated with Inferior Outcomes After Thoracic Endovascular Aortic Repair

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) has been used increasingly to treat complex thoracic aortic pathology. This study aimed to assess hospital volume's impact on outcomes in patients undergoing TEVAR.

STUDY DESIGN

Patients undergoing TEVAR between January 2015 and December 2019 were identified in the Vascular Quality Initiative (VQI) database. The participating centers were grouped into either low-volume hospitals (LVH) or high-volume hospitals (HVH). We assessed the impact of hospital volume on 30-day mortality and major postoperative complications using a multivariable logistic regression analysis.

RESULTS

A total of 3,584 TEVAR patients (asymptomatic = 1,720; symptomatic/ruptured =1,864) were identified at 147 centers. The median average annual number of TEVAR cases at LVH and HVH was 6 and 17 cases, respectively. There was no significant difference in 30-day mortality between LVH and HVH (asymptomatic: 3.7% vs. 3.7%, p = 0.98; symptomatic/rupture: 9.3% vs. 7.3%, p = 0.13). After adjusting for multiple clinical and anatomical factors, being treated in LVH was not associated with increased 30-day mortality (asymptomatic: OR = 0.98, 95% CI: 0.52, 1.87, p = 0.96; symptomatic/rupture: OR = 1.15, 95%CI: 0.75, 1.77, p = 0.53) nor an increased risk of major complications, including renal, neurological, cardiac, pulmonary, and femoral artery access complication (all p > 0.05).

CONCLUSION

Using a large national database, we demonstrate that LVH is not associated with inferior TEVAR outcomes than HVH. The technical aspect of the procedure might play a role in the similarity of outcomes across the different institutional experiences.

In-hospital survival after pancreatoduodenectomy is greater in high-volume hospitals versus lower-volume hospitals: a meta-analysis

BACKGROUND

Variation in cut-off values for what is considered a high volume (HV) hospital has made assessments of volume-outcome relationships for pancreaticoduodenectomy (PD) challenging. Accordingly, we performed a systematic review and meta-analysis comparing in-hospital mortality after PD in hospitals above and below HV thresholds of various cut-off values.

METHOD

PubMed/MEDLINE, Embase and Cochrane Library were searched to 4 January 2021 for studies comparing in-hospital mortality after PD in hospitals above and below defined HV thresholds. After data extraction, risk of bias was assessed using the Downs and Black checklist. A random-effects model was used for meta-analysis, including meta-regressions. Registration: PROSPERO, CRD42021224432.

RESULTS

From 1855 records, 17 observational studies of moderate quality were included. Median HV cut-off was 25 PDs/year (IQR: 20-32). Overall relative risk of in-hospital mortality was 0.37 (95% CI: 0.30, 0.45), that is, 63% less in HV hospitals. All subgroup analyses found an in-hospital survival benefit in performing PDs at HV hospitals. Meta-regressions from included studies found no statistically significant associations between relative risk of in-hospital mortality and region (USA vs. non-USA; p = 0.396); or 25th percentile (p = 0.231), median (p = 0.822) or 75th percentile (p = 0.469) HV cut-off values. Significant inverse relationships were found between PD hospital volume and other outcomes.

CONCLUSION

In-hospital survival was significantly greater for patients undergoing PDs at HV hospitals, regardless of HV cut-off value or region. Future research is required to investigate regions where low-volume centres have specialized PD infrastructure and the potential impact on mortality.

Editor's Choice - Systematic Review and Meta-Analysis of the Impact of Institutional and Surgeon Procedure Volume on Outcomes After Ruptured Abdominal Aortic Aneurysm Repair

OBJECTIVE

To investigate whether there is a correlation between institutional or surgeon case volume and outcomes in patients with ruptured abdominal aortic aneurysm (rAAA).

DATA SOURCES

The Healthcare Database Advanced Search interface developed by the National Institute of Health and Care Excellence was used to search MEDLINE, Embase, CINAHL, and CENTRAL.

REVIEW METHODS

The systematic review complied with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines with the protocol registered in PROSPERO (CRD42020213121). Prognostic studies were considered comparing outcomes of patients with rAAA undergoing repair in high and low volume institutions or by high and low volume surgeons. Pooled estimates for peri-operative mortality were calculated using the odds ratio (OR) and 95% confidence intervals (CI), applying the Mantel-Haenszel method. Analysis of adjusted outcome estimates was performed with the generic inverse variance method.

RESULTS

Thirteen studies reporting a total of 120 116 patients were included. Patients treated in low volume centres had a statistically significantly higher peri-operative mortality than those treated in high volume centres (OR 1.39; 95% CI 1.22 - 1.59). Subgroup analysis showed a mortality difference in favour of high volume centres for both endovascular aneurysm repair (EVAR; OR 1.61, 95% CI 1.11 - 2.35) and open repair (OR 1.50, 95% CI 1.25 - 1.81). Adjusted analysis showed a benefit of treatment in high volume centres for open repair (OR 1.68, 95% CI 1.21 - 2.33) but not for EVAR (OR 1.42, 95% CI 0.84 - 2.41). Differences in peri-operative mortality between low and high volume surgeons were not statistically significant for either EVAR (OR 1.06, 95% CI 0.59 - 1.89) or open surgical repair (OR 1.18, 95% CI 0.87 - 1.63).

CONCLUSION

A high institutional volume may result in a reduction of peri-operative mortality following surgery for rAAA. This peri-operative survival advantage is more pronounced for open surgery than EVAR. Individual surgeon caseload was not found to have a significant impact on outcomes.

Association between Hospital Volume and Failure to Rescue after Open or Endovascular Repair of Intact Abdominal Aortic Aneurysms in the VASCUNET and International Consortium of Vascular Registries

OBJECTIVE

To investigate the association between hospital volume and failure to rescue (FtR), after open (OAR) and endovascular (EVAR) repair of intact abdominal aortic aneurysms (AAA) among centers participating in the VASCUNET and International Consortium of Vascular Registries (ICVR).

SUMMARY BACKGROUND DATA

FtR (i.e., in-hospital death following major complications) is a composite end-point representing the inability to treat complications effectively and prevent death.

METHODS

Using data from eight vascular registries, complication and mortality rates after intact AAA repair were examined (n = 60,273; EVAR-43,668; OAR-16,605). A restricted analysis using pooled data from four countries (Australia, Hungary, New Zealand, USA) reporting data on all postoperative complications (bleeding, stroke, cardiac, respiratory, renal, colonic ischemia) was performed to identify risk-adjusted association between hospital volume and FtR.

RESULTS

The most frequently reported complications were cardiac (EVAR-3.0%, OAR-8.9%) and respiratory (EVAR-1.0%, OAR-5.7%). In adjusted analysis, 4.3% of EVARs and 18.5% of OARs had at least one complication. The overall FtR rate was 10.3% after EVAR and 15.7% after OAR. Subjects treated in the highest volume centers(Q4) had 46% and 80% lower odds of FtR after EVAR (OR = 0.54; 95%CI = 0.34-0.87;p = 0.04) and OAR (OR = 0.22; 95%CI = 0.11-0.44;p < 0.001) when compared to lowest volume centers(Q1), respectively. Colonic ischemia had the highest risk of FtR for both procedures (adjusted predicted risks, EVAR: 27%, 95%CI 14%-45%; OAR: 30%, 95%CI 17%-46%).

CONCLUSIONS

In this multi-national dataset, FtR rate after intact AAA repair with EVAR and OAR is significantly associated with hospital volume. Hospitals in the top volume quartiles achieve the lowest mortality after a complication has occurred.

Surgeon experience versus volume differentially affects lower extremity bypass outcomes in contemporary practice

BACKGROUND

Calls for minimum case thresholds to guide surgeon credentialing paradigms are increasing in contemporary practice. To date, the volume-outcome relationship and the role of surgeon experience as a proxy for quality have remained primarily focused on nonvascular extirpative surgery and aneurysm repair. However, it is unclear whether these data can be rightly extrapolated to predict lower extremity bypass (LEB) outcomes. Thus, the purpose of the present study was to examine whether the annualized case volume vs surgeon experience is more consequential in predicting for successful LEB reconstruction.

METHODS

A total of 25,852 procedures with sufficient 1-year follow-up data from the Society for Vascular Surgery Vascular Quality Initiative infrainguinal bypass registry (2003-2019) were reviewed for chronic limb threatening ischemia among patients undergoing infrageniculate reconstruction. The procedures were categorized according to surgeon years of practice experience at surgery (ie, 0-5, 6-10, 11-15, >15 years) and the number of LEB procedures performed by the surgeon during the year of surgery (volume quartiles: 1-8, 9-14, 15-21, and >21). Mixed effects logistic and Cox regression models were used to assess the effects of experience, volume, and their interaction on outcomes.

RESULTS

Increasing practice experience was more significantly associated with a reduction of in-hospital complications (odds ratio, 0.97; 95% confidence interval [CI], 0.96-0.99; P = .002) and the risk of major adverse limb events (odds ratio, 0.94; 95% CI, 0.92-0.97; P < .0001) compared with the volume. Increasing experience and volume were both associated with increased freedom from thrombosis (hazard ratio, 0.95; 95% CI, 0.93-0.98; P = .001). In contrast, neither experience nor volume had any significant association with early mortality. However, a higher volume was associated with diminished long-term survival (hazard ratio, 1.04; 95% CI, 1.0-1.1; P = .01). The most experienced surgeons (>15 years' experience) were significantly more likely to perform LEB for rest pain (P < .0001). No significant differences were found in the bypass rates among patients with tissue loss. The most experienced and highest volume surgeons were more likely to use an autogenous and/or composite conduit, in situ reconstruction, and/or pedal targets (P < .05). Similarly, more experienced and higher volume surgeons had less blood loss and shorter procedure times (P < .0001). Overall, the most experienced surgeons (>15 years' experience) were significantly more likely to have a higher volume with a diminished risk for all LEB outcomes.

CONCLUSIONS

Surgeon experience appears to have the most important role in predicting for overall LEB performance with improved in-hospital outcomes and major adverse limb events. The more experienced surgeons performed more complex reconstructions with fewer complications. These findings have significant clinical and educational implications as our most experienced surgeons approach retirement. Mentorship strategies to facilitate ongoing technical development among less experienced surgeons are imperative to sustain optimal limb salvage outcomes and have significant ramifications regarding expectations for regulatory and credentialing paradigms.

Association and interplay of surgeon and hospital volume with mortality after open abdominal aortic aneurysm repair in the modern era

OBJECTIVE

Operative volume has been used as a marker of quality. Research from previous decades has suggested minimum open abdominal aortic aneurysm (AAA) repair volume requirements for surgeons of 9 to 13 open AAA repairs annually and for hospitals of 18 open AAA repairs annually to purportedly achieve acceptable results. Given concerns regarding the decreased frequency of open repairs in the endovascular era, we examined the association of surgeon and hospital volume with the 30- and 90-day mortality in the Vascular Quality Initiative (VQI) registry.

METHODS

Patients who had undergone elective open AAA repair from 2013 to 2018 were identified in the VQI registry. We performed a cross-sectional evaluation of the association between the average hospital and surgeon volume and 30-day postoperative mortality using a hierarchical Bayesian model. Cross-level interactions were permitted, and random surgeon- and hospital-level intercepts were used to account for clustering. The mortality results were adjusted by standardizing to the observed distribution of relevant covariates in the overall cohort. The outcomes were compared to the Society for Vascular Surgery guidelines recommended criteria of <5% perioperative mortality.

RESULTS

A total of 3078 patients had undergone elective open AAA repair by 520 surgeons at 128 hospitals. The 30- and 90-day risks of postoperative mortality were 4.1% (n = 126) and 5.4% (n = 166), respectively. The mean surgeon volume and hospital volume both correlated inversely with the 30-day mortality. Averaged across all patients and hospitals, we found a 96% probability that surgeons who performed an average of four or more repairs per year achieved <5% 30-day mortality. Substantial interplay was present between surgeon volume and hospital volume. For example, at lower volume hospitals performing an average of five repairs annually, <5% 30-day mortality would be expected 69% of the time for surgeons performing an average of three operations annually. In contrast, at higher volume hospitals performing an average of 40 repairs annually, a <5% 30-day mortality would be expected 96% of the time for surgeons performing an average of three operations annually. As hospital volume increased, a diminishing difference occurred in 30-day mortality between lower and higher volume surgeons. Likewise, as surgeon volume increased, a diminishing difference was found in 30-day mortality between the lower and higher volume hospitals.

CONCLUSIONS

Surgeons and hospitals in the VQI registry achieved mortality outcomes of <5% (Society for Vascular Surgery guidelines), with an average surgeon volume that was substantially lower compared with previous reports. Furthermore, when considering the development of minimal surgeon volume guidelines, it is important to contextualize the outcomes within the hospital volumes.

Configuration of vascular services: a multiple methods research programme

Background

Vascular services is changing rapidly, having emerged as a new specialty with its own training and specialised techniques. This has resulted in the need for reconfiguration of services to provide adequate specialist provision and accessible and equitable services.

Objectives

To identify the effects of service configuration on practice, resource use and outcomes. To model potential changes in configuration. To identify and/or develop electronic data collection tools for collecting patient-reported outcome measures and other clinical information. To evaluate patient preferences for aspects of services other than health-related quality of life.

Design

This was a multiple methods study comprising multiple systematic literature reviews; the development of a new outcome measure for users of vascular services (the electronic Personal Assessment Questionnaire – Vascular) based on the reviews, qualitative studies and psychometric evaluation; a trade-off exercise to measure process utilities; Hospital Episode Statistics analysis; and the development of individual disease models and a metamodel of service configuration.

Setting

Specialist vascular inpatient services in England.

Data sources

Modelling and Hospital Episode Statistics analysis for all vascular inpatients in England from 2006 to 2018. Qualitative studies and electronic Personal Assessment Questionnaire – Vascular evaluation with vascular patients from the Sheffield area. The trade-off studies were based on a societal sample from across England.

Interventions

The data analysis, preference studies and modelling explored the effect of different potential arrangements for service provision on the resource use, workload and outcomes for all interventions in the three main areas of inpatient vascular treatment: peripheral arterial disease, abdominal aortic aneurysm and carotid artery disease. The electronic Personal Assessment Questionnaire – Vascular was evaluated as a potential tool for clinical data collection and outcome monitoring.

Main outcome measures

Systematic reviews assessed quality and psychometric properties of published outcome measures for vascular disease and the relationship between volume and outcome in vascular services. The electronic Personal Assessment Questionnaire – Vascular development considered face and construct validity, test–retest reliability and responsiveness. Models were validated using case studies from previous reconfigurations and comparisons with Hospital Episode Statistics data. Preference studies resulted in estimates of process utilities for aneurysm treatment and for travelling distances to access services.

Results

Systematic reviews provided evidence of an association between increasing volume of activity and improved outcomes for peripheral arterial disease, abdominal aortic aneurysm and carotid artery disease. Reviews of existing patient-reported outcome measures did not identify suitable condition-specific tools for incorporation in the electronic Personal Assessment Questionnaire – Vascular. Reviews of qualitative evidence, primary qualitative studies and a Delphi exercise identified the issues to be incorporated into the electronic Personal Assessment Questionnaire – Vascular, resulting in a questionnaire with one generic and three disease-specific domains. After initial item reduction, the final version has 55 items in eight scales and has acceptable psychometric properties. The preference studies showed strong preference for endovascular abdominal aortic aneurysm treatment (willingness to trade up to 0.135 quality-adjusted life-years) and for local services (up to 0.631 quality-adjusted life-years). A simulation model with a web-based interface was developed, incorporating disease-specific models for abdominal aortic aneurysm, peripheral arterial disease and carotid artery disease. This predicts the effects of specified reconfigurations on workload, resource use, outcomes and cost-effectiveness. Initial exploration suggested that further reconfiguration of services in England to accomplish high-volume centres would result in improved outcomes, within the bounds of cost-effectiveness usually considered acceptable in the NHS.

Limitations

The major source of evidence to populate the models was Hospital Episode Statistics data, which have limitations owing to the complexity of the data, deficiencies in the coding systems and variations in coding practice. The studies were not able to address all of the potential barriers to change where vascular services are not compliant with current NHS recommendations.

Conclusions

There is evidence of potential for improvement in the clinical effectiveness and cost-effectiveness of vascular services through further centralisation of sites where major vascular procedures are undertaken. Preferences for local services are strong, and this may be addressed through more integrated services, with a range of services being provided more locally. The use of a web-based tool for the collection of clinical data and patient-reported outcome measures is feasible and can provide outcome data for clinical use and service evaluation.

Future work

Further evaluation of the economic models in real-world situations where local vascular service reconfiguration is under consideration and of the barriers to change where vascular services do not meet NHS recommendations for service configuration is needed. Further work on the electronic Personal Assessment Questionnaire – Vascular is required to assess its acceptability and usefulness in clinical practice and to develop appropriate report formats for clinical use and service evaluation. Further studies to assess the implications of including non-health-related preferences for care processes, and location of services, in calculations of cost-effectiveness are required.

Study registration

This study is registered as PROSPERO CRD42016042570, CRD42016042573, CRD42016042574, CRD42016042576, CRD42016042575, CRD42014014850, CRD42015023877 and CRD42015024820.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 5. See the NIHR Journals Library website for further project information.

Editor's Choice - Optimal Threshold for the Volume-Outcome Relationship After Open AAA Repair in the Endovascular Era: Analysis of the International Consortium of Vascular Registries

OBJECTIVE

As open abdominal aortic aneurysm (AAA) repair (OAR) rates decline in the endovascular era, the endorsement of minimum volume thresholds for OAR is increasingly controversial, as this may affect credentialing and training. The purpose of this analysis was to identify an optimal centre volume threshold that is associated with the most significant mortality reduction after OAR, and to determine how this reflects contemporary practice.

METHODS

This was an observational study of OARs performed in 11 countries (2010 - 2016) within the International Consortium of Vascular Registry database (n = 178 302). The primary endpoint was post-operative in hospital mortality. Two different methodologies (area under the receiving operating curve optimisation and Markov chain Monte Carlo procedure) were used to determine the optimal centre volume threshold associated with the most significant mortality improvement.

RESULTS

In total, 154 912 (86.9%) intact and 23 390 (13.1%) ruptured AAAs were analysed. The majority (63.1%; n = 112 557) underwent endovascular repair (EVAR) (OAR 36.9%; n = 65 745). A significant inverse relationship between increasing centre volume and lower peri-operative mortality after intact and ruptured OAR was evident (p < .001) but not with EVAR. An annual centre volume of between 13 and 16 procedures per year was associated with the most significant mortality reduction after intact OAR (adjusted predicted mortality < 13 procedures/year 4.6% [95% confidence interval 4.0% - 5.2%] vs. ≥ 13 procedures/year 3.1% [95% CI 2.8% - 3.5%]). With the increasing adoption of EVAR, the mean number of OARs per centre (intact + ruptured) decreased significantly (2010 - 2013 = 35.7; 2014 - 2016 = 29.8; p < .001). Only 23% of centres (n = 240/1 065) met the ≥ 13 procedures/year volume threshold, with significant variation between nations (Germany 11%; Denmark 100%).

CONCLUSION

An annual centre volume of 13 - 16 OARs per year is the optimal threshold associated with the greatest mortality risk reduction after treatment of intact AAA. However, in the current endovascular era, achieving this threshold requires significant re-organisation of OAR practice delivery in many countries, and would affect provision of non-elective aortic services. Low volume centres continuing to offer OAR should aim to achieve mortality results equivalent to the high volume institution benchmark, using validated data from quality registries to track outcomes.

Endovascular repair for abdominal aortic aneurysms

Management of abdominal aortic aneurysms has been the subject of rigorous scientific scrutiny. Prevalence studies have directed the formation of screening programmes, and observational studies and randomised controlled trials have defined aneurysm growth and treatment thresholds. Pre-emptive intervention with traditional open surgical repair has been the bedrock of improving long-term outcome and survival in patients with abdominal aortic aneurysms but it is associated with a significant procedural morbidity and mortality. Endovascular aneurysm repair (EVAR) has substantially reduced these early complications and has been associated with promising results in both elective and emergency aneurysm repair. However, the technique has brought its own unique complications, endoleaks. An endoleak is the presence of blood flow within the aneurysm sac but outside the EVAR graft. Although in randomised control trials EVAR was associated with a reduced early mortality compared with open repair, its longer-term morbidity and mortality was higher because endoleak development is associated with a higher risk of rupture. These endoleak complications have necessitated the development of postoperative imaging surveillance and re-intervention. These contrasting benefits and risks inform the selection of the mode of repair and are heavily influenced by individual patient factors. An improved strategy to predict endoleak development could further help direct treatment choice for patients and improve both early and late outcomes. This article reviews current EVAR practice, recent updates in clinical practice guidelines and the potential future developments to facilitate the selection of mode of aneurysm repair.Trial registration number: ClinicalTrials.gov NCT04577716.

Referral patterns for catheter-directed thrombolysis for iliofemoral deep venous thrombosis

OBJECTIVES

Post thrombotic syndrome (PTS) is a serious complication of deep venous thromboses (DVTs). PTS occurs more frequently and severely following iliofemoral DVT compared to distal DVTs. Catheter directed thrombolysis (CDT) of iliofemoral DVTs may reduce PTS incidence and severity.We aimed to determine the rate of iliofemoral DVT within our institution, their subsequent management, and compliance with NICE guidelines.

METHODS

Retrospective review of all DVTs diagnosed over a 3-year period was conducted. Cases of iliofemoral DVT were identified using ICD-10 codes from patient notes, and radiology reports of Duplex scans. Further details were retrieved, such as patient demographics and referrals to vascular services. NICE guidance was applied to determine if patients would have been suitable for CDT. A survey was sent to clinicians within medicine to identify awareness of CDT and local guidelines for iliofemoral DVT management.

RESULTS

225 patients with lower limb DVTs were identified. Of these, 96 were radiographically confirmed as iliofemoral DVTs. The median age was 77. 67.7% of iliofemoral DVTs affected the left leg. Right leg DVTs made up 30.2% and 2.1% were bilateral DVTs. Of the 96 iliofemoral DVTs, 21 were deemed eligible for CDT. Only 3 patients (14.3%) were referred to vascular services, and 3 received thrombolysis.From our survey, 95.5% of respondents suggested anticoagulation alone as management for iliofemoral DVT. Only one respondent recommended referral to vascular services. There was a knowledge deficiency regarding venous anatomy, including superficial versus deep veins.

CONCLUSIONS

CDT and other mechanochemical procedures have been shown to improve outcomes of patients post-iliofemoral DVT, however a lack of awareness regarding CDT as a management option results in under-referral to vascular services. We suggest closer relations between vascular services and their "tributary" DVT clinics, development of guidelines and robust care pathways in the management of iliofemoral DVT.

Simulation Based Training and Assessment in Open Vascular Surgery: A Systematic Review

OBJECTIVE

The aim of this study was to systematically review the literature and give evidence based recommendations for future initiatives for simulation based training (SBT) and assessment in open vascular surgery.

DATA SOURCES

PubMed, Embase, and the Cochrane Library.

REVIEW METHODS

A systematic review of PubMed, Embase, and the Cochrane Library was performed, with the last search on 31 March 2020, to identify studies describing SBT and assessment in open vascular surgery. Kirkpatrick's levels for efficacy of training were evaluated. Validity evidence for assessment tools was evaluated according to the recommended contemporary framework by Messick.

RESULTS

Of 2 844 studies, 51 were included for data extraction. A high degree of heterogeneity in reporting standards and varying types of simulation was found. Vascular anastomosis was the most frequently simulated technical skill (43%). Assessment was mostly carried out using the Objective Structured Assessment of Technical Skills (55%). Validity evidence for assessment tools was found using outdated frameworks, and only one study used Messick's framework. Self directed training is valuable, the low trainer to trainee ratio is important to maximise efficiency, and experienced vascular surgeons are the most effective trainers.

CONCLUSION

Carefully designed and structured SBT is effective and can improve technical skills, especially in less experienced trainees. However, the supporting evidence lacks homogeneity in the reporting standards and types of simulations. Pass/fail standards that support proficiency based learning and studies investigating skills transfer should be the focus in future studies. Validity evidence of assessment tools needs to be addressed using contemporary frameworks.

Survival following abdominal aortic aneurysm repair in North Queensland is not associated with remoteness of place of residence

Objective

To assess whether survival and clinical events following elective abdominal aortic aneurysm (AAA) repair were associated with remoteness of residence in North Queensland, Australia.

Methods

This retrospective cohort study included participants undergoing elective AAA repair between February 2002 and April 2020 at two hospitals in Townsville, North Queensland, Australia. Outcomes were all-cause survival and AAA-related events, defined as requirement for repeat AAA repair or AAA-related mortality. Remoteness of participant’s place of residence was assessed by the Modified Monash Model classifications and estimated distance from the participants’ home to the tertiary vascular centre. Cox proportional hazard analysis examined the association of remoteness with outcome.

Results

The study included 526 participants undergoing elective repair by open (n = 204) or endovascular (n = 322) surgery. Fifty-four (10.2%) participants had a place of residence at a remote or very remote location. Participants' were followed for a median of 5.2 (inter-quartile range 2.5–8.3) years, during which time there were 252 (47.9%) deaths. Survival was not associated with either measure of remoteness. Fifty (9.5%) participants had at least one AAA-related event, including 30 (5.7%) that underwent at least one repeat AAA surgery and 23 (4.4%) that had AAA-related mortality. AAA-related events were more common in participants resident in the most remote areas (adjusted hazard ratio 2.83, 95% confidence intervals 1.40, 5.70) but not associated with distance from the participants’ residence to the tertiary vascular centre

Conclusions

The current study found that participants living in more remote locations were more likely to have AAA-related events but had no increased mortality following AAA surgery. The findings emphasize the need for careful follow-up after AAA surgery. Further studies are needed to examine the generalisability of the findings.

The Effects of Minimum Caseload Requirements on Management and Outcome in Abdominal Aortic Aneurysm Repair

BACKGROUND

The German quality assurance guideline on abdominal aortic aneurysm (AAA) was implemented by the Joint Federal Committee (Gemeinsamer Bundesausschuss, G-BA) in 2008. The aims of this study were to verify the association between hospital case volume and outcome and to assess the hypothetical effect of minimum caseload requirements.

METHODS

The German diagnosis-related groups statistics for the years 2012 to 2016 were scrutinized for AAA (ICD-10 GM I71.3/4) with procedure codes for endo - vascular or open surgical treatment. The primary endpoint was in-hospital mortality. Logistic regression models were used for risk adjustment, and odds ratios (OR) were calculated as a function of the annual hospital-level case volume of AAA. In a hypo - thetical approach, the linear distances for various minimum caseloads (MC) were evaluated to assess accessibility.

RESULTS

The mortality of intact AAA (iAAA) was 2.7% (men [M] 2.4%, women [W] 4.2%); ruptured AAA (rAAA), 36.9% (M 36.9%, F 37.5%). An inverse relationship between annual hospital case volume of AAA and mortality was confirmed (iAAA/rAAA: from 3.9%/51% [<10 cases/year] through 3.3%/37% [30-39 cases/year] to 1.9%/28% [≥ 75 cases/year]). For a reference category of 30 AAA procedures/year, the following significant OR were found: 10 AAA cases/year, OR 1.21 (95% confidence interval [1.20; 1.21]); 20 cases, OR 1.09 [1.09; 1.09]; 50 cases, OR 0.89 [0.89; 0.89]; 75 cases, OR 0.82 [0.82; 0.82]. In a hypothetical centralization scenario with assumed MC of 30/year, 86% of the population would have to travel less than 100 km to the nearest hospital; with an MC of 40, this would apply to only 50% (without redistribution effects).

CONCLUSION

In the observed period, a significant correlation was confirmed between high annual case volume and low in-hospital mortality. A minimum caseload requirement of 30 AAA operations/year seems reasonable in view of the accessibility of hospitals. Cite this.

Outcome analysis and risk factors for postoperative colonic ischaemia after aortic surgery

Purpose

Colonic ischaemia (CI) represents a serious complication after aortic surgery. This study aimed to analyse risk factors and outcome of patients suffering from postoperative CI.

Methods

Data of 1404 patients who underwent aortic surgery were retrospectively analysed regarding CI occurrence. Co-morbidities, procedural parameters, colon blood supply, procedure-related morbidity and mortality as well as survival during follow-up (FU) were compared with patients without CI using matched-pair analysis (1:3).

Results

Thirty-five patients (2.4%) with CI were identified. Cardiovascular, pulmonary and renal comorbidity were more common in CI patients. Operation time was longer (283 ± 22 vs. 188 ± 7 min, p < 0.0001) and blood loss was higher (2174 ± 396 vs. 1319 ± 108 ml, p = 0.0049) in the CI group. Patients with ruptured abdominal aortic aneurysm (AAA) showed a higher rate of CI compared to patients with intact AAA (5.4 vs. 1.9%, p = 0.0177). CI was predominantly diagnosed by endoscopy (26/35), generally within the first 4 postoperative days (20/35). Twenty-eight patients underwent surgery, all finalised with stoma creation. Postoperative bilateral occlusion and/or relevant stenosis of hypogastric arteries were more frequent in CI patients (57.8 vs. 20.8%, p = 0.0273). In-hospital mortality was increased in the CI group (26.7 vs. 2.9%, p < 0.0001). Survival was significantly reduced in CI patients (median: 28.2 months vs. 104.1 months, p < 0.0001).

Conclusion

CI after aortic surgery is associated with considerable perioperative sequelae and reduced survival. Especially in patients at risk, such as those with rAAA, complicated intraoperative course, severe cardiovascular morbidity and/or perioperative deterioration of the hypogastric perfusion, vigilant postoperative multimodal monitoring is required in order to initiate diagnosis and treatment.

Electronic supplementary material

The online version of this article (10.1007/s00423-020-01964-2) contains supplementary material, which is available to authorized users.

Editor's Choice - Volume-Outcome Relationships in Elective Abdominal Aortic Aneurysm Surgery: Analysis of the UK Hospital Episodes Statistics Database for the Getting It Right First Time (GIRFT) Programme

OBJECTIVE

To investigate whether a volume-outcome relationship exists for elective abdominal aortic aneurysm (AAA) surgery conducted within the National Health Service (NHS) in England.

METHODS

This was an analysis of administrative data. Data were extracted from the Hospital Episodes Statistics database for England from April 2011 to March 2019 for all adult admissions for elective infrarenal AAA surgery. Data were extracted for the NHS trust and surgeon undertaking the procedure, the surgical technique used (open or endovascular), the financial year of admission, length of hospital and critical care stay during the procedure and subsequent emergency re-admissions (primary outcome) and deaths within 30 days. Multilevel modelling was used to adjust for hierarchy and confounding.

RESULTS

A dataset of 31 829 procedures (8867 open, 22 962 endovascular) was extracted. For open surgery, lower trust annual volume was associated with higher 30 day emergency re-admission rates and higher 30 day mortality. For open surgery, lower surgeon annual volume was associated with higher 30 day mortality and length of hospital stay greater than the median. For endovascular surgery, lower surgeon annual volume was associated with not having an overnight stay in critical care. None of the other volume-outcome relationships investigated was significant.

CONCLUSION

For elective infrarenal AAA surgery in the UK NHS, there was strong evidence of a volume-outcome relationship for open surgery. However, evidence for a volume-outcome relationship is dependent on the specific procedure undertaken and the outcome of interest.

National temporal trends and determinants of cost of abdominal aortic aneurysm repair

INTRODUCTION

In recent decades, there has been a shift in the management of aortic abdominal aneurysm from open intervention (open aortic aneurysm repair) to an endovascular approach (endovascular aortic aneurysm repair). This shift has yielded clinical as well as socioeconomic reverberations. In our current study, we aim to analyze these effects brought about by the switch to endovascular treatment and to scrutinize the determinants of cost variations between the two treatment modalities.

METHODS

The National (Nationwide) Inpatient Sample database was queried for clinical data ranging from 2001 to 2013 using International Classification of Disease, 9th Revision (ICD-9) codes for open and endovascular aortic repair. Clinical parameters and financial data related to the two treatment modalities were analyzed. Temporal trends of index hospitalization costs were determined. Multivariate linear regression was used to characterize determinants of cost for endovascular aneurysm repair and open abdominal aortic aneurysm repair.

RESULTS

A total of 128,154 aortic repairs were captured in our analysis, including 62,871 open repairs and 65,283 endovascular repairs. Over the assessed time period, there has been a decrease in the cost of elective endovascular aortic aneurysm repair from $34,975.62 to $31,384.90, a $3,590.72 difference (p < 0.01), while the cost of open aortic repair has increased from $37,427.77 to $43,640.79 by 2013, a $6,212.79 increase (p < 0.01). The cost of open aortic aneurysm repair disproportionately increased at urban teaching hospitals, where by 2013, it costs $50,205.59, compared to $34,676.46 at urban nonteaching hospitals, and $34,696.97 at rural institutions. Urban teaching hospitals were found to perform an increasing proportion of complex open aneurysm repairs, involving concomitant renal and visceral bypass procedures. On multivariate analysis, strong determinants of cost increase for both endovascular aortic aneurysm repair and open aortic aneurysm repair are rupture status, prolonged length of stay, occurrence of complications, and the need for disposition to a nursing facility or another acute care institution.

CONCLUSION

As the vascular community has shifted from an open repair of abdominal aortic aneurysm to an endovascular approach, a number of unforeseen clinical and economic effects were noted. We have characterized these ramifications to help guide further clinical decision and resource allocation.

A dual-team approach benefits standard-volume surgeons, but has minimal impact on outcomes for a high-volume surgeon in AIS patients

STUDY DESIGN

Retrospective chart review of prospectively collected data.

OBJECTIVE

This study seeks to evaluate the effect of number of surgeons, surgeon experience, and surgeon volume on AIS surgery. Recent literature suggests that utilizing two surgeons for spine deformity correction surgery can improve perioperative outcomes. However, the surgeon's experience and surgical volume are likely as important.

METHODS

AIS patients undergoing PSF from 2009 to 2019 were included. Patient demographics, X-ray and perioperative outcomes were collected and collated based on primary surgeon. Analysis was performed for single versus dual surgeons, surgeon experience (≤ 10 years in practice), and surgical volume (less/greater than 50 cases/year). Median (IQR) values, Wilcoxon Rank Sums test, Kruskal-Wallis test, and Fisher's exact test were utilized.

RESULTS

519 AIS cases, performed by 4 surgeons were included. Two surgeons were highly experienced, 1 of whom was also high volume. Five cohorts were studied: a single senior high volume (S1) (n = 302), dual-junior surgeons (DJ) (n = 73), dual senior-junior (SJ) (n = 36), dual-senior (DS) (n = 21) and a single senior, standard-volume surgeon alone (S2) (n = 87). Radiographic parameters were similar between the groups (p > 0.05). Preoperative Cobb was significantly higher for DS compared to S1 (p = 0.034) Pre- and post-op kyphosis were similar (p > 0.05). Cobb correction was similar (p > 0.05). Levels fused, fixation points, anesthesia and surgical times were similar (p > 0.05). When the standard-volume surgeon operated with a second surgeon, radiographic parameters were similar (p > 0.05), but anesthesia time, surgical time, and hospital length of stay were significantly shorter (p < 0.05). Additionally, DJ had significantly shorter anesthesia and operative times (p < 0.001) and length of stay (p < 0.001) compared to S2.

CONCLUSION

Standard-volume surgeons have better outcomes with a dual surgeon approach. Junior surgeons benefit operating with an experienced surgeon. A high-volume surgeon, however, does not benefit from a dual surgeon approach.

LEVEL OF EVIDENCE

Level II.

A Nationwide Study Assessing Preventable Hospitalization Rate on Mortality After Major Cardiovascular Surgery

Despite the use of various factors to measure hospital quality, most measures have not resulted in long-term improvements in patient outcomes. This study's purpose is to determine the effect of a previously unassessed measure of quality of care-a hospital's preventable hospitalization rate-on 30-day mortality at both the hospital and individual levels after three major cardiovascular surgery procedures. This is a population-based study using Taiwan's National Health Insurance database. We retrieved data from 2001 to 2014 for patients who had undergone abdominal aortic aneurysm (AAA) repair, coronary artery bypass graft, or aortic valve replacement (AVR). Preventable hospitalizations are hospitalizations for 11 chronic conditions that are considered preventable with effective primary care. The outcome was 30-day surgical mortality. Our dataset contained 65,863 patients who had undergone surgery for one of the three cardiovascular procedures. Preventable hospitalization rate was significantly associated with higher hospital mortality rates for all procedures. At the patient level, the adjusted odds of mortality after AAA repair were increased 55% (P < 0.01) for every 2% increase in the preventable hospitalization rate. For coronary artery bypass graft, preventable hospitalization was not a significant predictor of mortality, but rather patient factors and surgeon factors were significant. For AVR, the adjusted odds of mortality were increased 7% (P < 0.01) for every 1% increase in preventable hospitalization rate. High preventable hospitalization rate may serve as a hospital quality measure that could signal increased odds of mortality for selected cardiovascular procedures, especially for higher risk-lower volume procedures such as AAA repair and AVR.

One-year patient survival correlates with surgeon volume after elective open abdominal aortic surgery

OBJECTIVE

Volume-outcome relationships in surgery have been well established. Studies have shown that high-volume surgeons provide improved outcomes in performing open abdominal aneurysm repairs. The hypothesis of this study was that high-volume surgeons provide superior short-term and midterm outcomes of elective open aortic operations compared with low-volume surgeons.

METHODS

We evaluated patients undergoing elective open abdominal aortic aneurysm repair, aortofemoral bypass, and aortomesenteric bypass by board-certified vascular surgeons using the New York Statewide Planning and Research Cooperative System database from 2002 to 2014. The Contal and O'Quigley technique was used to estimate a cut point objectively and provided an estimate of significance. A division using average yearly volumes (averaged during 3 years) of seven or more cases and fewer than seven cases per year returned the highest Q statistic, and this grouping was used to classify high-volume and low-volume provider groups. Rates of complications during index hospitalization, length of stay, 30-day survival, 90-day survival, 1-year survival, and cause of death were analyzed using mixed effect models.

RESULTS

In 118 hospitals during the 13-year period, 266 board-certified vascular surgeons performed 244 aortomesenteric bypasses, 4202 aortofemoral bypasses, and 6126 abdominal aortic aneurysm repairs. High-volume surgeons' rates of complications during index hospitalization, 30-day survival, 90-day survival, and 1-year survival were superior to those of low-volume surgeons. The Contal and O'Quigley technique returned an estimate of seven operations per year for optimal survival during 1 year. This cutoff is associated with an adjusted 1-year hazard ratio of 0.687 (P = .003), a 2.69% difference in 1-year all-cause survival (P = .003), and a 1.76-day reduction in the mean length of stay at index hospitalization (P < .001). Higher volume surgeons showed a 25.0%, 43.4%, 42.4%, 40.6%, and 45.0% reduction in postoperative rates of acute renal failure (P < .001), hemorrhage (P < .001), pulmonary failure (P < .001), sepsis (P < .001), and venous thromboembolism (P < .001), respectively. Abdominal abscess, acute renal failure, hemorrhage, myocardial infarction, and sepsis were associated with increased cardiovascular cause-specific mortality after open aortic operations (P < .001).

CONCLUSIONS

These data demonstrate that high-volume surgeons performing elective open aortic operations provide reduced complications and improved short-term and midterm survival compared with low-volume surgeons. Clinical and postoperative variables that are associated with increased cardiovascular cause-specific mortality are also identified. These data provide further evidence that elective open abdominal vascular surgery should be centralized to high-volume surgeons.

Impact of Centralisation on Abdominal Aortic Aneurysm Repair Outcomes: Early Experience in Catalonia

OBJECTIVE

Several studies have revealed high volume centres have better outcomes in the treatment of abdominal aortic aneurysms (AAAs), thus supporting centralisation of this procedure into selected centres based on volume. To date however, the real benefit of centralisation of this pathology has not been well demonstrated. The aim of this study was to analyse the impact of centralisation in to high volume centres (defined as those performing more than 30 cases per year) on AAA treatment outcomes carried out in Catalonia (Spain).

METHODS

Data were collected from official national registries (HDMBD) for AAA treated by endovascular aneurysm repair (EVAR) or open repair (OR) over a nine year period. Two time periods were selected for comparison: before centralisation (2009-2014) and after complete centralisation (2015-2017). The primary objective was to determine short term mortality (in hospital and 30 day mortality) and length of stay (LOS) after intact AAA (iAAA) and ruptured AAA (rAAA) repair, before and after centralisation. Uni- and multivariable analyses were performed in order to identify independent outcomes predictors.

RESULTS

A total of 3 501 iAAAs, including 1 124 (32.1%) OR and 2377 (67.9%) EVAR, and 409 rAAAs, including 218 (53.3%) OR and 191 (46.7%) EVAR, were identified. After centralisation, there was a significant decrease in overall mortality in iAAA repair (4.7% vs. 2.0%, p < .001) and rAAA repair (53.1% vs. 41.9%, p = .028). Mortality reduction in iAAAs was significant for OR (8.7% vs. 3.6%, p = .005), but not for EVAR (2.2% vs. 1.5%, p = .25). Overall LOS decreased as well, mainly in iAAAs (9.49 ± 10.84 vs. 7.44 ± 12.23 days, p < .001), and in particular in elective EVAR (7.32 ± 7.73 vs. 6.00 ± 8.97 days, p < .001). Multivariable analysis was identified before the centralisation period as an independent predictor for both mortality (odds ratio 1.484, 95% CI 1.098-2.005, p = .010) and LOS (B coefficient 1.146, 95% CI 0.218-2.073, p = .016).

CONCLUSION

The implementation of a country based centralisation programme for AAA treatment led to a significant reduction in short term mortality, for both iAAA and rAAA, and mainly for elective OR. LOS also significantly decreased, mainly for elective EVAR. These results support the benefit of centralisation of AAA repair procedures.

Nationwide study of the treatment of mycotic abdominal aortic aneurysms comparing open and endovascular repair in The Netherlands

OBJECTIVE

Mycotic aneurysms of the abdominal aorta (MAAA) can be treated by open repair (OR) or endovascular aneurysm repair (EVAR). This nationwide study provides an overview of the situation of MAAA treatment in The Netherlands in 2016.

METHODS

A retrospective cohort study was conducted with all centers that registered aortic abdominal aneurysms in the Dutch Surgical Aneurysm Audit in 2016. Questionnaires on 1-year outcomes were sent to all centers that treated patients with MAAA. The primary aim was to determine 30-day and 1-year mortality and morbidity of OR- and EVAR-treated patients. Morbidity was determined by the need for reoperations and the number of readmissions to the hospital.

RESULTS

Twenty-six MAAA were detected in the Dutch Surgical Aneurysm Audit database of 2016, resulting in an incidence of 0.7% of all registered abdominal aortic aneurysms. The 30-day mortality for OR and EVAR treated patients was 1 in 13 and 0 in 13, respectively. Major and minor reinterventions within 30 days were needed for two (one OR and one EVAR) and two (one OR and one EVAR) patients, respectively. Two patients (15.4%) in the OR group and one patient (7.7%) in the EVAR group were readmitted to hospital within 30 days. In total, 1-year outcomes of 23 patients were available. In the OR group, one patient (9.1%) died in the first postoperative year. There was one major reintervention (removal of endoprosthesis and spiralvein reconstruction) in the EVAR group. Two patients (18.2%) treated with OR and two (16.7%) treated with EVAR required a minor reintervention. In both groups, four patients (OR, 36.4%; EVAR, 33.3%) were readmitted to hospital within 1 year postoperatively.

CONCLUSIONS

Both OR- and EVAR-treated patients show acceptable clinical outcomes after 30 days and at the 1-year follow-up. Depending on the clinical course of the patient, EVAR may be considered in the management of this disease.

[Colonic ischemia after open and endovascular aortic surgery : Epidemiology, Risk Factors, Diagnosis And Therapy]

Despite the successful establishment of endovascular techniques, colonic ischemia continues to be a serious complication of aortic surgery.The risk factors for colonic ischemia include aortic aneurysm rupture, prolonged aortic clamping, perioperative hypotension, the need for catecholamine therapy, occlusion of the hypogastric arteries and renal insufficiency.The clinical presentation of postoperative colonic ischemia is often unspecific. Classic symptoms include abdominal pain, diarrhea, peranal bleeding and rise of inflammatory parameters. A specific laboratory parameter for colonic ischemia does not exist. The diagnostic gold standard is endoscopy. Imaging methods such as sonography or computer tomography play only a supportive role. Transmural ischemia resulting in bowel wall necrosis is an indication for emergency surgery, predominantly colonic resection with creation of artificial anus.

NHS hospital readiness to embrace the proposed NICE guidelines on abdominal aortic aneurysm: a public perspective

INTRODUCTION

The National Institute for Health and Care Excellence published a draft consultation update on abdominal aortic aneurysm, which was expected to be published on 7 November 2018. This article analyses the readiness of NHS hospitals and their workforce to embrace the proposed guidelines.

METHODS

The trust and individual surgeon-level anonymised data in the public domain for elective, rupture and complex abdominal aortic aneurysm cases were collected and analysed for all the acute care trusts providing these services from the Vascular Society of Great Briton and Ireland's prospective National Vascular Registry database.

RESULTS

Of the 95 acute care trusts providing the service for the year 2017, the annual volume of infrarenal abdominal aortic aneurysm (both endovascular and open repairs) ranged between 0 and 137. Of these, 64 (67.36%) trusts had an annual volume of fewer than 60 cases. A total of 366 (approximately 75% of 490) vascular surgeons have performed 10 or fewer open abdominal aortic aneurysm repairs in three years (2014-2016) with a mean operating volume of 1.452 procedures per surgeon per three years (n = 254, median 0, interquartile range, IQR, 0-3, 0.484 procedures per surgeon per year) and about 51% of the vascular surgeons have only performed five or fewer procedures in those three years with a mean operating volume of 3.455 per surgeon per three years (n = 367, median 3, IQR 0-3, 1.151 per surgeon per year).

CONCLUSION

The observations show that most UK acute hospitals lack the optimum case volume necessary to embrace the proposed change in the guideline.

Association of hospital and surgeon volume with mortality following major surgical procedures: Meta-analysis of meta-analyses of observational studies

Accumulation of the literature has suggested an inverse association between healthcare provider volume and mortality for a wide variety of surgical procedures. This study aimed to perform meta-analysis of meta-analyses (umbrella review) of observational studies and to summarize existing evidence for associations of healthcare provider volume with mortality in major operations.We searched MEDLINE, SCOPUS, and Cochrane Library, and screening of references.Meta-analyses of observational studies examining the association of hospital and surgeon volume with mortality following major operations. The primary outcome is all-cause short-term morality after surgery. Meta-analyses of observational studies of hospital/surgeon volume and mortality were included. Overall level of evidence was classified as convincing (class I), highly suggestive (class II), suggestive (class III), weak (class IV), and non-significant (class V) based on the significance of the random-effects summary odds ratio (OR), number of cases, small-study effects, excess significance bias, prediction intervals, and heterogeneity.Twenty meta-analyses including 4,520,720 patients were included, with 19 types of surgical procedures for hospital volume and 11 types of surgical procedures for surgeon volume. Nominally significant reductions were found in odds ratio in 82% to 84% of surgical procedures in both hospital and surgeon volume-mortality associations. To summarize the overall level of evidence, however, only one surgical procedure (pancreaticoduodenectomy) fulfilled the criteria of class I and II for both hospital and surgeon volume and mortality relationships, with a decrease in OR for hospital (0.42, 95% confidence interval[CI] [0.35-0.51]) and for surgeon (0.38, 95% CI [0.30-0.49]), respectively. In contrast, most of the procedures appeared to be weak or "non-significant."Only a very few surgical procedures such as pancreaticoduodenectomy appeared to have convincing evidence on the inverse surgeon volume-mortality associations, and yet most surgical procedures resulted in having weak or "non-significant" evidence. Therefore, healthcare professionals and policy makers might be required to steer their centralization policy more carefully unless more robust, higher-quality evidence emerges, particularly for procedures considered as having a weak or non-significant evidence level including total knee replacement, thyroidectomy, bariatric surgery, radical cystectomy, and rectal and colorectal cancer resections.