Utilization Of An Increased Variety Of Aortic Endograft Types Does Not Impact Outcomes After Aortic Endovascular Repair Among High Volume Surgeons
Rebecca E. Scully, MD, MPH, Edward Marcaccio, MD, Matthew Menard, MD, Louis L. Nguyen, MD, MBA, MPH, Michael Belkin, MD, Marcus Semel, MD, MPH.
Brigham and Women's Hospital, Boston, MA, USA.
Objectives: Previous work has demonstrated a learning curve associated with the use of aortic stent grafts and that facility with devices at both the surgeon and institution level is associated with improved patient outcomes. The impact of an individual surgeon’s use of multiple different graft types in their practice has not yet been evaluated.Methods: Individuals undergoing EVAR in the Vascular Quality Initiative database (VQI) between 2015 and 2019 performed by surgeons with 50 or more procedures during that period were captured. The Herfindahl-Hirschman Index (HHI), a measure of market concentration, was calculated for each surgeon based on their graft use with a value of 1 representing complete homogeneity in graft manufacturer choice and 0 indicating increasing heterogeneity. Adjusted odds of intraoperative and post-operative complications were modeled using logistic regression. Results: 10,881 procedures were performed by 151 surgeons using endografts from 7 different manufacturers. HHI, representing graft-choice homogeneity, ranged from 0.23 to 1 (median 0.53 [IQR 0.40-0.79]) with 10 surgeons using only 1 graft manufacturer throughout the study period. The intraoperative complication rate (including endoleak, arterial injury, embolization, and conversion to open) was 25.7%, postoperative complication rate was 7.1%, and rate of return to the OR was 2.4%. When adjusting for gender, age, and aortic neck length and diameter, HHI was not associated with odds of intraoperative (OR 1.11 [95%CI 0.86-1.43] P=0.41) or postoperative (OR 0.85 [95%CI 0.54-1.34] P=0.49) complications or odds of reintervention during the initial hospitalization (OR 0.63 [95%CI 0.28-1.39] P=0.25). With a median 1.5 years of follow-up, the overall reintervention-free survival was 89.4% with no association with HHI (HR 0.97 [95%CI 0.76-1.26] P=0.87). Conclusions: Neither increasing homogeneity in graft choice, which may reflect either increased facility with a specific endograft, nor increased heterogeneity, which may imply a more tailored approach to a specific patient’s anatomy, appear to be associated with patient outcomes following EVAR among high volume surgeons.
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