SAN FRANCISCO – Patients undergoing carotid endarterectomy and open abdominal aortic aneurysm repair are less likely to have complications and die if their surgeon is a vascular specialist, according to a study reported at the annual clinical congress of the American College of Surgeons.
“We feel that carotid endarterectomy and open triple-A repair performed by a vascular surgeon is an independent predictor of improved morbidity and mortality. Hospitals should consider utilizing this specialty-specific information to identify potential quality improvement initiatives,” recommended lead investigator Dr. Carla C. Moreira, a surgeon in the division of vascular and endovascular surgery, Boston Medical Center.
She and her colleagues analyzed data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP), assessing outcomes for 94,029 patients who underwent open vascular procedures between 2006 and 2012. Some 8% had abdominal aneurysm repairs, 57% had carotid endarterectomies, and 35% had lower-extremity bypasses.
Overall, 94% of the procedures were performed by vascular surgeons, while the rest were performed by other types of surgeons (including cardiac surgeons because their numbers were too small to tease out, according to Dr. Moreira).
Results showed that for patients undergoing abdominal aneurysm repair, the unadjusted rate of 30-day mortality did not differ significantly by surgeon specialty. However, in multivariate, propensity-matched analysis, the odds of complications were reduced by half when the repair was done by a vascular surgeon as compared with some other type of surgeon (odds ratio, 0.50).
Patients undergoing carotid endarterectomy had a lower unadjusted mortality if the operation was performed by a vascular surgeon (0.7% vs. 1.0%), although the difference was no longer significant after multivariate adjustment. However, they had significantly lower adjusted odds of complications (odds ratio, 0.62).
For patients undergoing lower-extremity bypass, neither the rate of mortality nor the odds of complications differed significantly by surgeon specialty.
An analysis of temporal trends showed that the proportions of all eligible patients undergoing open abdominal aneurysm repair and lower-extremity bypass during the study period fell, regardless of surgeon type, whereas the proportion of eligible patients undergoing carotid endarterectomies remained stable. “I think this is reflective likely of the penetration of endovascular procedures when it comes to the treatment of abdominal aneurysm and lower-extremity peripheral arterial disease, as compared to carotid disease,” speculated Dr. Moreira, who disclosed that she had no relevant conflicts of interest.
Session moderator Dr. Peter K. Henke, associate chair of research, department of surgery, and Leland Ira Doan Professor of Vascular Surgery at the University of Michigan in Ann Arbor, asked whether the findings have implications for surgeon training.
“Our results were different from what has been previously published for open aneurysm repair. I think that open aneurysm repair is probably becoming more and more specialized in terms that more and more, you are going to see just vascular surgeons performing it as compared to other specialties, especially as I have shown that there is a decreasing number of general surgeons being exposed to open vascular procedures,” Dr. Moreira replied. “So I think this [speaks] to individual surgeons and their individual experience with triple-A repair. Our data does show that general surgeons who are performing these procedures are doing a good job because there is not a difference in outcome at least in terms of mortality. But as the easy triple-A repairs go away, I think it’s going to push the procedure to be done more by specialized surgeons.”
In an interview, Dr. Henke commented, “I think it has been alluded to in other studies and other reports in the literature, but this study brings to the forefront the fact that overall numbers of open vascular procedures are less and less, so the surgeons performing those procedures need to be specialists. And I’d say within the U.S. anyway, most practitioners who do vascular procedures are vascular surgeons or cardiovascularly trained, as compared with general surgeons. I suspect that some of the general surgeons who are still doing these procedures may be at a place where they are the only ones who can do it or there are no vascular specialists there.
“The other issue that this study may impact, as more of these reports come out, is hospital credentialing, because hospital credentialing of surgeons really determines what they can and cannot do at that hospital,” he added. “So as more hospital credentialing boards see this type of data, I think they will limit open vascular procedures to vascular specialists who have had training in vascular disease.”