Carotid endarterectomy surgeon volumes in contemporary practice: A comparison to randomized trial inclusion criteria

Guideline Compliant Minimum Asymptomatic Carotid Endarterectomy Surgeon and Hospital Volume Cutoffs

BACKGROUND

There is a known association between volume and outcomes after carotid endarterectomy (CEA). A recent analysis suggested rates of stroke and death do not significantly reduce after a surgeon volume cutoff of 20 CEAs per year. However, these results would severely limit access. The objective here is to identify a lower optimal cutpoint for surgeon and hospital volume for asymptomatic CEA.

METHODS

We evaluated asymptomatic CEA patients using The New York Statewide Planning and Research Cooperative System database from 2000-2014. The relationship of 3-year averaged volumes for surgeons and hospitals to 30-day stroke was assessed using multiple logistic regression and included both hospital and surgeon volume in all analyses. Optimized cut points were the lowest significant volume cutoff that minimized the adjusted odds ratio of stroke.

RESULTS

We studied 32,549 CEAs performed by 271 surgeons in 136 centers by vascular surgeons. The median surgeon volume was 26.3 (interquartile range: 12.3-51.7) and the median hospital volume was 67 (interquartile range: 36.3-119.3). The surgeon volume cut point was 3 and the hospital volume cut point was 6 cases per year. There were 756 (2.3%) procedures performed by surgeons with a volume < 3 and 560 (1.7%) procedures performed by hospitals with a volume < 6. Perioperative stroke and death rates were 2.0% (95% confidence interval [CI]: 1.8-2.1) and 3.8% (95% CI: 2.6-5.5) for an average yearly surgeon volume ≥ 3 and < 3 (P = 0.070), respectively. The combined stroke and death rate was 2.0% (95% CI: 1.8-2.1) and 4.8% (95% CI: 3.2-7.0) for an average yearly center volume ≥ 6 and < 6 (P = 0.007), respectively. A combined surgeon and hospital volume variable also predicted outcomes and low-volume procedures did not meet previously proposed American Heart Association and Society for Vascular Surgery quality measures.

CONCLUSIONS

These data demonstrate an improvement in outcomes at a lower volume threshold than previously reported. These modest cutoff values should be used for asymptomatic CEA volume guideline formation and for future studies, after accounting for the impact of other important factors that may be driving volume-outcome relationships in asymptomatic CEA.

Higher Surgeon Volume is Associated with Lower Odds of Complication Following TEVAR for Aortic Dissections

OBJECTIVE

This study aimed to understand the impact of surgeon volume on outcomes of thoracic endovascular aortic repair (TEVAR) in patients being treated for aortic dissection.

METHODS

Patients undergoing TEVAR from January 2014 - March 2021 in the Vascular Quality Initiative (VQI) database were analyzed. Patients with aortic dissection who underwent TEVAR were divided into quartiles based on the annual TEVAR volume of their vascular surgeon. The highest quartile, middle two quartiles, and lowest quartile were deemed high volume (HV), moderate volume (MV), and low volume (LV), respectively. Multivariable logistic regressions were performed to compare cohort outcomes in terms any postoperative complication, stroke, spinal cord ischemia, reintervention, and 30-day mortality. A Cox proportional hazard model was used to assess the hazard of overall postoperative mortality.

RESULTS

Amongst 1,217 patients undergoing TEVAR, 321, 621, and 275 were performed by HV, MV, and LV surgeons, respectively. HV performed >19 annual TEVARs, MV surgeons between 5 and 18, and LV surgeons ≤4. Adjusted odds of any postoperative complication revealed that HV and MV surgeons had lower odds of overall postoperative complications [(OR 0.58, (95% CI 0.30 - 0.85), p = 0.011) and (OR 0.60, (95% CI 0.38 - 0.87), p = 0.008)], respectively when compared to LV patients. HV had lower odds of respiratory complications than LV surgeons complications [(OR 0.42, (95% CI 0.17 - 0.93), p = 0.039)]. Adjusted analysis of outcomes including spinal cord ischemia, stroke, myocardial infarction, 30-day mortality, and overall mortality did not reveal statistically significant differences between cohorts.

CONCLUSION

Surgeon volume does not to impact 30-day mortality or long-term mortality after TEVAR for aortic dissection, but the odds of overall postoperative complications were lower for HV and MV surgeons when compared to LV surgeons.