Surgeon Volumes of Endovascular Thoracoabdominal Aneurysm Repairs Are Associated with Outcomes

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. Fenestrated devices are available for juxtarenal aneurysms, but are no eTAAA devices on the US market. We therefore studied how the volume of juxtarenal repairs would translate to outcomes of these more complicated aneurysms. 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 (TALE, a composite of perioperative death, stroke, permanent spinal cord ischemia, and dialysis). We used mixed effects logistic regression clustering by center and surgeon. We identified 651 repairs from 135 surgeons, with annual average eTAAA volumes from <1.3 for Q1 to >9 for Q3. Repairs at higher quartiles were for larger aneurysms, commonly used staged repairs, used spinal drains, and more frequently used physician modified endografts. Low-volume surgeons most commonly used parallel grafting. Higher volume surgeons had overall shorter procedural times (Q1: 326 minutes [range, 301-351 minutes] vs Q4: 273 minutes [range, 261-284 minutes]; P < .001), fluoroscopy times (Q1: 94 minutes [range, 84-104 minutes] vs Q4: 54 [minutes range, 49-60 minutes]; P < .001), and less total contrast use (Q1: 170 minutes [range, 148-191 minutes] vs Q4: 105 minutes [range, 88-141 minutes]; P = .007). Length of stay was shorter (Q1: 12.3 ± 32.0 days vs Q4: 6.9 ± 8.4 days; P = .03), and technical success was significantly higher in the higher quartile groups (Q1: 67% vs Q4: 83%; P = .002). In adjusted analyses, rates of perioperative death, TALE, stroke, acute kidney injury and major adverse cardiac events were lower in the highest quartile compared with the lowest (Figure). 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. Surgeon eTAAA experience shows a strong volume-outcome effect on outcomes in the immediate postoperative period and in permanent patient-centered outcomes. 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.