Vascular Surgery in Australia and New Zealand (Australasia)

Vascular Surgery Education and Training in the American Continent: Current Status and Future Directions

OBJECTIVE

Despite the increasing burden of cardiovascular diseases, there is a shortage of vascular surgeons worldwide, with a higher scarcity in low and middle-income countries. The objective of the present study was to report the current status of vascular surgery education and training on the American continent.

MATERIALS AND METHODS

Official government, postgraduate medical schools, and medical associations' websites were searched for data regarding vascular surgery training positions, programs, and pathways available in the 35 countries of the American continent.

RESULTS

There are 707 annual positions for training in vascular surgery offered by 367 training programs. Of the 35 countries in America, only 17 (48.5%) offer vascular surgery training as an independent specialty. In one (2.8%) country, Peru, vascular surgery is mixed with cardiothoracic surgery. There is no vascular surgery training in the remaining 17 (48.5%) countries. Brazil has the highest number of training positions, offering 292 (41.3%) positions per year, followed by the United States, with 214 (30.2%) positions per year, and Mexico, with 69 (9.7%) positions per year. The country with more positions per 1,000,000 inhabitants is Cuba (3.93), followed by Brazil (1.34) and Uruguay (0.87). Brazil, Canada, Mexico, and the United States are the only four countries that have vascular surgery board exams.

CONCLUSION

This is the first report presenting a large-scale picture of vascular surgery education and training in the American continent. Brazil is the country that offers more vascular surgery training opportunities, followed by the United States and Mexico. Disseminating vascular surgery training in America is of utmost importance to help fight the cardiovascular diseases pandemic the world faces.

Propensity score analysis demonstrates no long term survival benefit from contemporary endovascular aneurysm repair compared to open in Aotearoa New Zealand

BACKGROUND

Current guidelines for AAA management are based on landmark trials comparing EVAR and open aneurysm repair (OAR) conducted more than 20 years ago. Important advancements have been made in peri-operative care but the impact of EVAR and OAR on long-term patient survival has not been well reported using contemporary data. The objective of this study was to compare the short and long-term outcomes of OAR and EVAR in the recent era.

METHODS

This retrospective observational study included all patients undergoing intact AAA repair in NZ from 1st of January 2011 until 31st of December 2019. Data was collected from national administrative and clinical vascular databases and matched using unique identifiers. Time-to-event survival analyses was conducted using cox proportional hazard models to adjust for confounders and propensity score matching were used.

RESULTS

Two thousand two hundred and ninety-seven patients had an intact AAA repair with a median (IQR) age of 75 (69-80) years; 494 (21.2%) patients were females and 1206 (53%) underwent EVAR. The 30-day mortality for OAR and EVAR was 4.8% and 1.2%. The median (IQR) follow up was 5.2 (2.3-9.2) years. After propensity matching for co-variates, the study cohort consisted of 835 patients in each matched group. Patients undergoing EVAR had a higher overall mortality (HR 1.48 (95% CI: 1.26-1.74) after adjusting for confounders compared to OAR.

CONCLUSION

Analysis of survival following EVAR and OAR in the current era demonstrates that patients that underwent EVAR had a lower 30-day mortality. However, in the long-term after adjusting for confounders OAR had a better overall survival.

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.