Capturing the Complexity of Open Abdominal Aortic Surgery in the Endovascular Era

Abstract

Volume and quality benchmarks for open abdominal aortic surgery and, in particular, for open aortic aneurysm repair (OAR) in the endovascular era are actively debated. The Vascular Quality Initiative (VQI) OAR module has failed to capture the full spectrum of complex OAR. We hypothesized that VQI-ineligible complex OAR would be the dominant form of open repair performed at a VQI-participating tertiary center. All OAR cases performed from 2007 to 2019 were reviewed. The VQI OAR criteria were applied, with exclusions (non-VQI) defined as concomitant renal bypass, clamping above the superior mesenteric artery or celiac artery, and repairs performed for trauma, an anastomotic aneurysm, isolated iliac aneurysm, or infected aneurysm. Linear regression was used to assess the temporal trends. Among a total of 456 open abdominal aortic operations, 330 (72%) were OARs. The average annual OAR volume remained stable over 13 years (25 ± 6; R2 = 0.05; P = .45). Non-VQI OAR comprised 54% of all cases and persisted over time (R2 = 0.03; P = .85; Fig). Both suprarenal (28%) and supraceliac (35%) clamping were often necessary. The proportion of endograft explantation cases increased significantly over time from 4% to 20% (mean, 14%; R2 = 0.47; P = .01). An infectious indication was present for 68 cases (21%). Visceral branch grafts were performed in 16% of all cases. OARs for a ruptured aneurysm constituted 10% of all cases. No statistically significant difference was found in 30-day mortality between the non-VQI and VQI-eligible OAR cases (8% vs 4%; P = .11). Complex OAR comprised a majority of OAR cases in a contemporary tertiary referral hospital; however, these cases were not accounted for in the VQI. Creation of a “complex OAR” VQI module would capture these cases in a quality-driven national registry and help to better inform the benchmarks for volume and outcomes in aortic surgery.