Adoption and clinical outcomes of fenestrated endovascular aneurysm repair in a regional, multistate community hospital system

OBJECTIVE

Complex endovascular abdominal aortic aneurysm (AAA) repair techniques have evolved over the last decade, yet patterns of physician and hospital system adoption of fenestrated endovascular aneurysm repair (FEVAR) remain poorly defined. We investigated clinical outcomes, use trends, and surgeon and hospital experience for FEVAR in a large community hospital system.

METHODS

We conducted a retrospective cohort study of all FEVAR procedures within our 5-state hospital system between April 2012 and June 2021. AAA repair volumes (open, EVAR, and FEVAR) were captured at the hospital and surgeon levels using Current Procedural Terminology and International Classification of Diseases codes. Clinical and outcomes data were collected for FEVAR patients. To consider if surgeon or hospital experience influenced outcomes, sequential case number was used to divide patients into surgeon experience and hospital experience groups. Inverse probability weighted and generalized linear mixed models, adjusted for demographics and comorbidities, were built to examine risk-adjusted outcomes for surgeon and hospital experience groups.

RESULTS

Of 3850 patients treated with AAA procedures of any kind between 2012 and 2021, 160 (4.2%) underwent FEVAR. FEVAR procedures were performed by 34 different surgeons at 12 hospitals, with intraoperative complications and unplanned adjunctive procedures occurring in 18.8% (n = 30) and 19.4% (n = 31) of patients, respectively. Among FEVAR patients, in-hospital mortality was 1.3% (n = 2) and postoperative morbidity was 16.9% (n = 27). Renal function decline occurred postoperatively in 5.1% of patients. Early (<30 day) postoperative endoleaks occurred in 15.3% of patients (n = 21). Target vessel patency was 95.6% on initial postoperative imaging. Surgeon and hospital experience had a small positive impact on outcomes after the first one to three cases. Significant decreases in operative time, fluoroscopy time, and estimated blood loss were observed with increased surgeon experience, relative to a surgeon's first case (P < .05). There were lower odds of intraoperative complications after a surgeon's first case (odds ratio [OR], 0.16; 95% confidence interval [CI], 0.03-0.77, for cases 2-3) or after a hospital's first one to three cases (OR, 0.19; 95% CI, 0.04-0.89, for cases 4-8; OR, 0.12; 95% CI, 0.03-0.55 for cases 9-49).

CONCLUSIONS

Clinical outcomes of FEVAR across our hospital system compare favorably with previously published reports. Although system-wide FEVAR adoption increased 3-fold over the last decade, FEVAR continued to be performed by a minority of hospitals in our system. The results from this cohort demonstrate low rates of adverse events, high rates of technical efficiency, and a small impact of surgeon and hospital experience, thereby supporting this advanced endovascular technology as a safe, efficacious, and generalizable treatment alternative to open repair for patients with complex aortic anatomy.

A systematic review of the effect of surgeon and hospital volume on survival in aortic, thoracic and fenestrated endovascular aneurysm repair

BACKGROUND

Endovascular aneurysm repair (EVAR) is becoming a mainstay in vascular surgery, both in metropolitan and regional hospitals. This review aims to assess the impact of hospital and surgeon volume on perioperative mortality specific to this surgery type to support the use of this treatment modality extensively.

METHODS

A literature search was performed on multiple dedicated medical databases using a detailed search strategy with terms focusing on hospital volume and EVARs. Inclusion and exclusion criteria were used to screen and evaluate suitable sources, focusing on operators and hospitals performing EVARs and the morbidity/mortality as outcomes. The results were then appraised using a PRISMA framework.

RESULTS

We reviewed 45 articles. Twelve articles met inclusion criteria for complete review. There was no level 1 evidence, and only a single systematic review and meta-analysis. EVAR and thoracic EVAR perioperative mortality had no correlation with hospital volume. Limited evidence was presented for fenestrated EVAR, where a mortality risk based on hospital volume remains unanswered. Open procedures for aneurysm repair had perioperative mortality outcomes that grossly correlated with hospital volume, supporting their use in high-volume centers.

CONCLUSIONS

With open aneurysm repairs having an increased mortality risk in low-volume centers, and endovascular treatment options gaining momentum, there is considerable support for the use of EVAR and thoracic EVAR in smaller regional centers safely and effectively. There is very limited evidence in the use of fenestrated EVAR, which remains unanswered, but presents a significant opportunity for research.