Surgeon volumes of endovascular thoracoabdominal aneurysm repairs, but not juxtarenal repairs, are associated with outcomes following endovascular repair of thoracoabdominal aneurysms

Objective

Endovascular thoracoabdominal aortic aneurysm (eTAAA) repair remains one of the more technically challenging aspect of vascular surgery, with significant risk of mortality, spinal cord ischemia, and end organ damage. Although fenestrated devices are available for juxtarenal aneurysms, there are no commercially available eTAAA devices on the United States market currently. We therefore studied how the volume of juxtarenal repairs would translate to outcomes of these more complicated aneurysms.

Methods

We studied all eTAAA repairs (Crawford type 1-3) in the Vascular Quality Initiative from 2014 to 2021 and categorized surgeons into quartiles based on their average annual eTAAA volume and endovascular juxtarenal volume. Our primary outcome was thoracoabdominal life altering events (composite of perioperative death, stroke, permanent spinal cord ischemia, and dialysis). We employed mixed effects logistic regression clustering by center and surgeon.

Results

We identified 5335 repairs from 607 surgeons, with annual average eTAAA volumes of 2629 from 400 surgeons. Quartile 1 involved less than two repairs and quartile 4 involved >12 repairs per year. Repairs at higher quartiles were for larger aneurysms, more commonly employed staged repairs, utilized spinal drains, and more frequently utilized physician-modified endografts, whereas low-volume surgeons most commonly employed parallel grafting. Higher volume surgeons had overall shorter procedural times, fluoroscopy time, and less total contrast. Technical success similarly increased as procedure volume increased. In adjusted analyses, rates of perioperative death, thoracoabdominal life altering events, stroke, acute kidney injury, and major adverse cardiac events were all lower in the highest volume quartile compared with the lowest. However, after accounting for eTAAA volume, surgeon volume of endovascular juxtarenal repairs was not associated with any postoperative outcome, and there was no significant interaction between juxtarenal and eTAAA volume. Medium-term mortality was lowest in patients treated in the top two quartiles of volume (hazard ratio, 0.77; 95% confidence interval, 0.61-0.97; P = .024).

Conclusions

Surgeon eTAAA experience shows a strong volume-outcome effect on outcomes in the immediate post operative period and in permanent patient-centered outcomes. However, experience in less extensive aneurysms did not directly translate to thoracoabdominal aneurysms. Further study is needed to evaluate the role that commercial graft availability and repair type contributes to these findings.