Introduction Of Endovascular Aneurysm Repair Research Articles

The association of ruptured abdominal aortic aneurysm diameter with mortality in the International Consortium of Vascular Registries

BackgroundThe mortality after ruptured abdominal aortic aneurysm (rAAA) repair is high, despite improvements in perioperative care, centralization of emergency vascular surgical services, and the introduction of endovascular aneurysm repair (EVAR). The diameter of intact AAA has been shown to be a predictor of short- and long-term survival. The aim of this study was to analyze the impact of AAA diameter on mortality for rAAA repair using contemporary data collected from the International Consortium of Vascular Registries and compare outcomes by sex and the type of repair patients received. MethodsProspective registry data on repair of rAAA from seven countries were collected from 2010 to 2016. The primary outcome was perioperative mortality after EVAR and open surgical repair (OSR). Data were stratified by type of repair and sex. Logistic regression models were used to estimate odds ratio (OR) for the association between AAA diameter and perioperative mortality and the association between type of repair and mortality. Multivariable logistic regression models were used to adjust for differences in patient characteristics. ResultsThe study population consisted of 6428 patients with a mean age ranging from 70.2 to 75.4 years; the mean AAA diameter was 7.7 ± 1.8 cm. Females had a significantly smaller AAA diameter at presentation compared with males (6.9 ± 1.6 cm vs 7.9 ± 1.8 cm; P < .001). who underwent OSR had larger AAA diameters compared with those who underwent EVAR (P < .001). Females who underwent repair were significantly older (P < .001). Males were more likely to have cardiac disease, diabetes mellitus, and renal impairment. Overall, AAA diameter was a predictor of mortality in univariate and multivariate analysis. When analyzing EVAR and OSR separately, the impact of AAA diameter per cm increase on mortality was apparent in both males and females undergoing EVAR, but not OSR (EVAR: male OR, 1.09 [95% confidence interval, 1.03-1.16] and EVAR: female OR, 1.17 [95% confidence interval, 1.02-1.35]). The early mortality rate for males and females who underwent EVAR was 18.9% and 25.9% (P < .001), respectively. The corresponding mortality for males and females who underwent OSR was 30.2% and 38.6% (P < .001), respectively. ConclusionsIn these real-world international data, there is a significant association between rAAA diameters and early mortality in males and females. This association was more evident in patients undergoing EVAR, but not shown in OSR. Despite improvements in overall AAA repair outcomes, the risk of mortality after rAAA repair is consistently higher for females.

Endovascular infrarenal aortic aneurysm repair: Perhaps we've gone about it all wrong

Endovascular infrarenal aortic aneurysm repair: Perhaps we've gone about it all wrong

Predictors of Outcome in Urgent Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysm in Octogenarian Patients: Abdominal Aortic Aneurysms

Introduction: The introduction of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysms (rAAAs) has led to a significant overall amelioration of both peri-operative and 30 day mortality; however, octogenarians with rAAAs remain an extremely high risk group, even if treated with EVAR. The aim of this study was to evaluate the efficacy of urgent EVAR (uEVAR) in patients aged > 80 years with rAAAs.

Did Percutaneous Compared with Cutdown Access for Endovascular Aneurysm Repair Really Make a Difference?

Did Percutaneous Compared with Cutdown Access for Endovascular Aneurysm Repair Really Make a Difference?

Different Preoperative Factors Affect Early Versus Late Mortality After Repair of Ruptured Abdominal Aortic Aneurysm

Outcomes after endovascular aneurysm repair (EVAR) or open repair of ruptured abdominal aortic aneurysms (RAAA) are dependent on both intraoperative and postoperative care of this patient population. We sought to characterize perioperative RAAA care and determine the effect of patient characteristics and interventions, including the role of perioperative blood product administration, on survival. We reviewed demographic, comorbidity, perioperative, and transfusion data for patients who underwent treatment of RAAA at a single institution between 2003 and 2018. The primary outcomes were 30-day and early (48-hour) mortality. Use of EVAR and perioperative blood product administration over time were measured as secondary outcomes. We identified 466 patients (age 74.5 ± 0.44, 74.3% male). EVAR was utilized in 29.6% of patients overall, increasing to 50% over the last 5 years as we shifted to an EVAR-first approach over time (Fig 1). Median time from arrival to the operating room was 63 minutes (interquartile range [IQR], 41-124 minutes). The proportion of crystalloid to total fluid (65.1 ± 28.4%) and blood to total fluid (23.7 ± 21%) did not change over time. The proportion of plasma to blood was 51% (IQR, 0%-91%) and increased over time. Mortality at 30 days was 34.1% (39.3% open, 21.7% EVAR) and did not change over time despite low EVAR mortality, due to increasing open surgical mortality after the introduction of EVAR (Fig 2). Blood product resuscitation ratios did not affect 30-day, early, or late mortality on adjusted analysis. Multivariable logistic regression showed that age >76 years (odds ratio [OR], 2.69; 95% confidence interval [CI], 1.70-4.26; P < .001), creatinine >2 mg/dL (OR, 3.09; 95% CI, 1.77-5.39; P < .001), systolic blood pressure 2 mg/dL (OR, 4.82; 95% CI, 2.53-9.20 P < .001) with nonsignificant impact from systolic blood pressure and cardiopulmonary resuscitation. Mortality rates for RAAA have not improved despite increasing use and low perioperative mortality of EVAR over time as mortality for open surgery has increased. Increasing perioperative plasma to blood ratios have not demonstrated any mortality benefit in our study. Early mortality is strongly associated with the shock-based factors of hypotension and need for cardiopulmonary resuscitation, while late mortality is more strongly associated with elevated creatinine suggesting multiple organ failure despite hemodynamic stability.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Updates on Ultrasonography Imaging in Abdominal Aortic Aneurysm.

Abdominal aortic aneurysms (AAAs) are life-threatening and are associated with >80% mortality when they rupture. Therefore, detecting these aneurysms before they rupture is critical. Ultrasonography is a non-invasive tool that is used for screening AAAs by measuring abdominal aorta diameter. A recent meta-analysis demonstrated the positive effects of ultrasonography. To date, aneurysm diameter is the most reliable predictor for aneurysm rupture and is used as a criterion for surgical intervention. However, some AAAs rupture at small diameters. Therefore, a better predictor for AAA rupture that is independent of aneurysm diameter is needed. Recently, an aortic wall strain examined using ultrasonography has been reported to have a potential in predicting AAA rupture. Since the introduction of endovascular aneurysm repair (EVAR), a paradigm shift has occurred in the management of AAAs. EVAR is broadly spread with the advantage of early favorable results but with concerning endoleak complications. At present, computed tomography angiography (CTA) is considered to be a gold standard for surveillance following EVAR, but it encounters some problems, such as contrast usage or radiation exposure. Ultrasonography offers an examination free from these problems and can this be an alternative to CTA. In this review article, current trends and new technologies regarding AAA assessment using ultrasonography are introduced.

Open and Endovascular Management of Aortic Aneurysms.

Aneurysmal disease can affect any segment of the aorta, from the aortic root to the aortic bifurcation. The treatment of aortic aneurysms has evolved dramatically in the past 3 decades, with the introduction of endovascular aneurysm repair using stent grafts causing a major paradigm shift in the field of aortic aneurysm surgery. While the technical details of the management of aortic aneurysms vary greatly depending on the location of an aneurysm, the principles remain the same. Successful aortic aneurysm treatment depends on either open replacement or endovascular exclusion of the aneurysmal segment with healthy artery proximal and distal to the repair. Major aortic branches of the arch and visceral segment add additional technical complexity to aneurysms involving these regions. Even as endovascular repair becomes the primary treatment modality for most aortic aneurysms, open repair remains an essential treatment modality in many circumstances. Additionally, long-term results of endovascular repair suggest that younger patients with long life expectancy and low-perioperative risk may benefit more from open repair. Therefore, technical expertise in both endovascular and open treatment is necessary for a comprehensive aortic aneurysm surgery practice.

Systematic review of mortality risk prediction models in the era of endovascular abdominal aortic aneurysm surgery.

The introduction of endovascular aneurysm repair (EVAR) has reduced perioperative mortality after abdominal aortic aneurysm (AAA) surgery. The objective of this systematic review was to assess existing mortality risk prediction models, and identify which are most useful for patients undergoing AAA repair by either EVAR or open surgical repair. A systematic search of the literature was conducted for perioperative mortality risk prediction models for patients with AAA published since 2006. PRISMA guidelines were used; quality was appraised, and data were extracted and interpreted following the CHARMS guidelines. Some 3903 studies were identified, of which 27 were selected. A total of 13 risk prediction models have been developed and directly validated. Most models were based on a UK or US population. The best performing models regarding both applicability and discrimination were the perioperative British Aneurysm Repair score (C-statistic 0·83) and the preoperative Vascular Biochemistry and Haematology Outcome Model (C-statistic 0·85), but both lacked substantial external validation. Mortality risk prediction in AAA surgery has been modelled extensively, but many of these models are weak methodologically and have highly variable performance across different populations. New models are unlikely to be helpful; instead case-mix correction should be modelled and adapted to the population of interest using the relevant mortality predictors.

Open versus endovascular abdominal aortic aneurysm repair in Medicare beneficiaries

Abdominal aortic aneurysms are relatively common and often life-threatening, with especially high mortality after aneurysm rupture. The introduction of endovascular aneurysm repair, a minimally invasive alternative to traditional open repair, led to decreased mortality and morbidity in randomized controlled trials, but these trials were conducted in highly selected patients and providers and were underpowered to detect differences in rare adverse events throughout follow-up. With observational studies of Medicare beneficiaries, we demonstrate that the randomized trial results are generalizable to the majority of patients undergoing abdominal aortic aneurysm repair in the United States. Additionally, with a larger cohort, comparative analyses evaluating rare, previously unstudied late outcomes such as laparotomy-related complications, late reinterventions, mortality with reinterventions, and late rupture could be conducted. Furthermore, trends in management over time and relationships between surgeon and hospital volume and outcomes can be studied. The goal of this review was to summarize the existing literature regarding abdominal aortic aneurysms among Medicare beneficiaries and to evaluate the benefits and limitations of administrative claims data in comparative effectiveness research.

National trends for open and endovascular repair of aneurysms in Korea: 2004-2013.

The introduction of endovascular aneurysm repair has led to a dramatic decline in open aneurysm repair. The aim of this report was to evaluate Korean national trends for the treatment of aneurysms. A serial, cross-sectional study of time trends of patients who underwent aneurysm repair between 2004 and 2013 was conducted. Data from the Health Insurance Review and Assessment Service were used to evaluate the trends of aneurysm repair in the Korean population and to analyze the trends of open and endovascular aneurysm repair among Medicare beneficiaries. A linear-by-linear association was performed to determine alterations in the rates at which these aneurysm repair techniques were performed. A total of 32,130 patients underwent aneurysm repair between 2004 and 2013. The proportion of patients who underwent open repair decreased from 94.0% in 2004 to 54.9% in 2013; whereas the proportion of patients who underwent endovascular repair increased from 6.0% in 2004 to 45.1% in 2013. During the study period, the number of patients undergoing endovascular repair of aortic aneurysms significantly increased from 82 to 1,396 (relative risk, 16.17; 95% confidence interval: 12.94-20.21). Endovascular repair of abdominal aortic aneurysms (AAAs)overtook open repair between 2010 and 2011. The frequency of open aneurysm repair increased 1.2-fold, with an overall downward trend. The prevalence of endovascular repair markedly increased 15.3-fold. These findings indicated that, in Korea, the endovascular repair of AAAs overtook open repair as the most common technique between 2010 and 2011.

Current treatment strategies for ruptured abdominal aortic aneurysm.

Ruptured abdominal aortic aneurysm (rAAA) represents one of the most challenging emergencies in surgery. Open repair (OR) is associated with relevant morbidity and mortality and has not been reduced significantly over the last decade. The introduction of endovascular aneurysm repair (EVAR) and its meanwhile common use in the treatment of rAAA has raised the demand for randomised controlled trials (RCTs) in order to resolve a potential superiority of either OR or EVAR. This review discusses the current treatment strategies in rAAA repair including diagnostics, peri-operative management and results of OR and EVAR, focussing on RCTs comparing both modalities. Thirty-day mortality after OR and EVAR shows no significant difference in published RCTs. In particular with respect to OR, 30-day mortality was much lower than anticipated throughout all RCTs ranging from 18 to 37%. EVAR for rAAA resulted in reduced in-hospital stay. Limitations of all except one RCT are low patient recruitment and exclusion of haemodynamically unstable patients. OR and EVAR need to be provided for rAAA. Despite lacking evidence, EVAR is the first choice treatment in experienced high-volume vascular centres. Low mortality rates in all RCTs raise the question if aortic surgery should be centralised.

Predicted shortfall in open aneurysm experience for vascular surgery trainees

Since the introduction of endovascular aneurysm repair (EVAR), the volume of open aneurysm repair (OAR) has steadily declined since 2000. The introduction of next-generation devices and branched and fenestrated endograft technology continues to increase the anatomic applicability of EVAR, further decreasing the need for OAR. This study models the decline in OAR and uses historical trends to forecast future decline in volume and its potential effect on vascular surgery training. An S-curve modified logistic function was used to model the effect of introducing a new technology (EVAR) on the standard management of abdominal aortic aneurysm (AAA) with OAR starting in the year 2000, when an International Classification of Diseases, Ninth Revision, code was first introduced for EVAR. Patients who underwent EVAR and OAR for AAA were determined using the Nationwide Inpatient Sample from 1998 to 2011. Weighted samples and data from the United States Census Bureau were used to extrapolate these numbers to estimate population statistics. The number of cases completed at teaching hospitals was calculated using the Nationwide Inpatient Sample, and Accreditation Council for Graduate Medical Education case logs were used to forecast the number of cases completed by vascular surgery trainees. The highest number of OAR cases in this study was 42,872 in 2000 compared with just 10,039 in 2011. This was mirrored by a rise in EVAR from 2358 cases in 2000 (5.2%) to 35,028 in 2011 (76.5% by volume). Of the OAR volume in 2011, 6055 cases (60.3%) were completed at teaching institutions. An S-curve model with a correlation coefficient of R2 = 0.982 predicted 3809 open AAA cases at teaching hospitals by 2015, 2162 by 2020, and 1231 by 2025. When compared with the 2011 Accreditation Council for Graduate Medical Education National Resident Report, vascular surgery residents had 44.4% utilization with regard to OAR (2690 cases covered of 6055 total). When combined with the increase in vascular surgery trainees and lower number of open repairs, vascular fellows will complete about 10 OAR cases in 2015 and five OAR cases in 2020. The decreasing number of OAR cases will limit exposure for vascular trainees, who may be ill equipped to treat patients who require open repair beyond 2015. Additional methods for providing OAR training should be explored.

Endovascular Aneurysm Repair of Abdominal Aortic Aneurysms: Standards, Technical Options and Advanced Indications

Since the introduction of endovascular aneurysm repair (EVAR) in 1991, the endovascular therapy with newest stent grafts has assumed a prominent role in the clinical management of abdominal aortic aneurysms (AAA) with a superior perioperative mortality of EVAR and an equivalent mid-term outcome, compared to open surgery. Newest techniques using chimney or periscope grafts and customized fenestrated and branched stent grafts allow the endovascular treatment of complex pararenal AAA. This article reviews EVAR in the treatment of AAA, evidence based results and advanced indication by newest interventional techniques and technical developments. • EVAR has become standard treatment of abdominal aortic aneurysm with equivalent results to open surgery.• Technical advancements and the introduction of newest stent grafts continually expand the indication of EVAR.• Chimney- and periscope grafts as well as custom-made prothesis systems allow endovascular treatment of complex para- and suprarenal aneurysms.

Impact of Introducing Endovascular Aneurysm Repair on Treatment Strategy for Repair of Abdominal Aortic Aneurysm

The objective of the present study was to assess the hypothesis that the introduction of endovascular aneurysm repair (EVAR) into Japan has expanded the indication of abdominal aortic aneurysm (AAA) repair without increasing surgical mortality. From 10 national hospitals, we registered a total of 2,154 consecutive patients (Open surgery [OS]: n=1,577, EVAR: n=577) over 8 years, divided into 4 time periods: Group I (2005-2006: n=522), Group II (2007-2008: n=475), Group III (2009-2010: n=551), Group IV, (2011-2012: n=606). Mean age increased over the 4 time periods (P<0.0001). The incidences of COPD, smoking history, history of abdominal surgery and concomitant malignancy significantly increased as well, while the numbers of patients with preoperative shock or high ASA status reduced over time. The proportion of EVAR in AAA repair increased from: 0% in Group I, 11.6% in Group II, 41.0% in Group III, to 48.8% in Group IV (P<0.0001). Early mortality was 0.8% in the EVAR and 3.4% in the OS (P<0.001) groups. Survival rates among the 4 groups free of all-cause death and aneurysm-related death at 1 year were 92.1-96.3% (P=0.1555) and 95.5-96.8% (P=0.9891), respectively. Multiple logistic regression analysis for surgical death failed to demonstrate survival advantage of EVAR over OS. Introduction of EVAR expanded the indication of AAA repair without increasing mortality, while high risk for anesthesia and emergency cases reduced over time. UMIN-CTR (UMIN000008345).

Hospitalization Rates and Post-Operative Mortality for Abdominal Aortic Aneurysm in Italy over the Period 2000–2011

BackgroundRecent studies have reported declines in incidence, prevalence and mortality for abdominal aortic aneurysms (AAAs) in various countries, but evidence from Mediterranean countries is lacking. The aim of this study is to examine the trend of hospitalization and post-operative mortality rates for AAAs in Italy during the period 2000–2011, taking into account the introduction of endovascular aneurysm repair (EVAR) in 1990s.MethodsThis retrospective cohort study was carried out in Emilia-Romagna, an Italian region with 4.5 million inhabitants. A total of 19,673 patients hospitalized for AAAs between 2000 and 2011, were identified from the hospital discharge records (HDR) database. Hospitalization rates, percentage of OSR and EVAR and 30-day mortality rates were calculated for unruptured (uAAAs) and ruptured AAAs (rAAAs).ResultsAdjusted hospitalization rates decreased on average by 2.9% per year for uAAAs and 3.2% for rAAAs (p<0.001). The temporal trend of 30-day mortality rates remained stable for both groups. The percentage of EVAR for uAAAs increased significantly from 2006 to 2011 (42.7 versus 60.9% respectively, mean change of 3.9% per year, p<0.001). No significant difference in mortality was found between OSR and EVAR for uAAAs and rAAAs.ConclusionsThe incidence and trend of hospitalization rates for rAAAs and uAAAs decreased significantly in the last decade, while 30-day mortality rates in operated patients remained stable. OSR continued to be the most common surgery in rAAAs, although the gap between OSR and EVAR recently declined. The EVAR technique became the preferred surgery for uAAAs since 2008.

Changes in Abdominal Aortic Aneurysm Rupture and Short-Term Mortality, 1995–2008

To examine the modern epidemiology of abdominal aortic aneurysm (AAA) rupture and short-term AAA-related mortality after the introduction of endovascular aneurysm repair (EVAR). Previous epidemiologic studies have demonstrated stable rates of AAA repair, repair mortality, and AAA rupture. Recently, EVAR has been introduced as a less invasive treatment method, and its use has expanded to more than 75% of elective AAA repairs. We identified Medicare beneficiaries undergoing AAA repair and those hospitalized with a ruptured AAA during the period 1995 to 2008 and calculated standardized annual rates of AAA-related deaths due to either elective repair or rupture. A total of 338,278 patients underwent intact AAA repair during the study period. There were 69,653 patients with AAA rupture, of whom 47,524 underwent repair. Intact repair rates increased substantially in those older than 80 years (57.7-92.3 per 100,000, P < 0.001) but decreased in those 65 to 74 years old (81.8-68.9, P < 0.001). A decline in ruptures with and without repair was seen in all age groups. By 2008, 77% of all intact repairs and 31% of all rupture repairs were performed with EVAR (P < 0.001). Operative mortality declined during the study period for both intact (4.9%-2.4%, P < 0.001) and ruptured (44.1%-36.3%, P < 0.001) AAA repair. Short-term AAA-related deaths decreased by more than half (26.1-12.1 per 100,000, P < 0.001), with the greatest decline occurring in those older than 80 years (53.7-27.3, P < 0.001). A recent decline in AAA rupture and short-term AAA-related mortality is demonstrated and likely related in part to the introduction and expansion of EVAR. This is due to decreased deaths from ruptures (with and without repair) and decreased mortality with intact repairs, particularly in patients older than 80 years.

Older Patients Benefited Most From EVAR

Older Patients Benefited Most From EVAR

The impact of endovascular procedures on fellowship training in lower extremity revascularization

The introduction of endovascular aneurysm repair has resulted in a decline in open abdominal aortic aneurysm repairs performed by vascular residents. The purpose of this study was to evaluate if a similar trend has occurred with open lower extremity revascularization procedures, with increased endovascular procedures producing a decrease in the number of open lower extremity revascularizations. Furthermore, this study evaluates the effect of endovascular procedure volume on the frequency of subtypes of open lower extremity procedures performed. The total number of vascular procedures, lower extremity bypasses, and endovascular interventions from 2000 to 2010 were analyzed from case logs of vascular residents as reported by the Accreditation Council for Graduate Medical Education. The average number of cases performed by vascular residents has increased by 150% from 463.9 in 2000 to 1168 in 2009, due to the increased number of endovascular procedures. The average number of endovascular revascularizations has increased by 317% from 40.5 performed in 2000 to 168.9 in 2009. Femoral-popliteal bypasses have increased in frequency by 27% whereas the number of infrapopliteal bypass has remained unchanged. The largest difference is seen in femoral endarterectomies with a 234% increase from 3.2 per resident in 2001 to 10.7 per resident in 2010. Comparison of the proportion of femoral-popliteal and tibioperoneal interventions performed by angioplasty or bypass after 2007 revealed that endovascular interventions comprise 50% of procedures in the femoral-popliteal distribution, whereas 65% of infrapopliteal interventions are still performed using open techniques. The number of procedures performed during vascular residency has dramatically increased over the last decade secondary to the increased number of endovascular procedures. The average vascular surgery resident's open operative experience has been stable over the last 10 years, despite the increasing endovascular case volume. Residents perform femoral endarterectomy with increasing frequency, perhaps representing an increasing volume of hybrid procedures. Gaps in information available for evaluating resident training remain a significant obstacle. Moving forward, revision of the current reporting system to a format that more accurately reflects resident experience would be beneficial.

Aneurysm Diameter Measurement: A Challenging and Frustrating Task

Diameter is the stronger predictor of abdominal aortic aneurysm (AAA) rupture and related death. In the past decades, the expansion of screening and of surveillance programmes for AAA detection and management as well as the remarkable evolution in imaging technology, especially after the introduction of endovascular aneurysm repair (EVAR), has notably increased our training in measuring an AAA. Nevertheless, it is challenging and frustrating to see that we still do not know how to calculate reliably an aneurysm diameter and the related risk of rupture. This is a worrying awareness for the effectiveness and safety of surveillance and screening management of AAA. There are a number of reasons making diameter measurements inaccurate especially with ultrasound that is today the exclusive technique to screen and survey most AAA. Recent metaanalyses of the literature have shown that inter-observer reproducibility for measurement of AAA with ultrasound is often poor, varying from 1.6 to 7.5 mm.1 However, many of these results are related to studies performed in the nineties. Hopefully, technology has developed since. Nevertheless, a corresponding improvement in reproducibility of measurements has not yet occurred, as shown by recent data from the Viborg Vascular (VIVA) screening trial published in this issue of EJVES. This study suggested that an additional important but usually ignored source of difference in measurements of AAA diameter on ultrasound is cardiac cycle.2 By reviewing ultrasound video recorded in a group of 603 AAAs enrolled in the VIVA trial, Grondal et al. showed an average mean AAA diameter of 41.6 mm when measured in systole and 39.63 mm when measured in diastole. The mean difference of about 2 mm seems clinically irrelevant but this implied a 5% difference of the overall AAA diameter that should be added to intraand inter-operator variability in measurements.2 Furthermore, difference in diameter measurements may double when two different operators perform calculations, one during the

Resident and fellow experiences after the introduction of endovascular aneurysm repair for abdominal aortic aneurysm

This study assessed trends in open and endovascular repair (EVAR) of intact and ruptured abdominal aortic aneurysm (AAA) in the Medicare population and evaluated recent trends in AAA repair at vascular fellowship training programs. We identified all Medicare beneficiaries with a diagnosis of AAA who underwent repair or had a primary diagnosis of rupture (1995-2008). Cohorts were compared by type of repair (open vs EVAR) and presentation (intact vs ruptured AAA). Demographics of age, sex, and race were evaluated. We used unique hospital identifier codes to compare trends and 30-day mortality between hospitals that participate in vascular surgery fellowship training and those that do not. American Council on Graduate Medical Education data, only available for the years 1999 to 2008, were further used to better understand the changes in number of EVAR and open repairs of AAA performed each year for vascular fellows and general surgery residents, over time. We identified 449,122 patients (76% men), with 376,355 intact AAAs (84%) and 72,767 ruptured AAAs (16%). Mean age was 75.1 years. Use of EVAR for intact AAA rose to from 35% in 2001 to 63% in 2005 and comprised 78% of repairs by 2008. During the same period, the number of ruptured AAAs decreased by 40% overall, with nonoperative ruptured AAAs decreasing by 29% and EVAR increasing to 31% of rupture repairs. Hospitals training vascular fellows were quicker to adopt EVAR (2-year lag time) for intact AAA and had higher rates of EVAR for ruptured AAA (41.1% vs 29.2%; P = .001) than did hospitals without fellows. Mortality rates for open repairs of intact (4.0% vs 5.0%; P = .01) and ruptured AAA (34.1% vs 41.0%; P = .031) were lower at fellowship hospitals. The average number of open AAA repairs performed by vascular fellows dropped 50% (44.1 to 21.6/year) from 1999 to 2008. Contrary to the expectation of a plateau, use of EVAR for intact AAA continues to rise at fellowship and nonfellowship hospitals. Use of EVAR for rupture is being used more often at fellowship programs. The decline in open repairs performed by vascular fellows, and at fellowship and non-fellowship hospitals, may have important implications for future attending experience.