TBD Meeting (3909-18)

NEW YORK – The rates of carotid artery revascularization with either endarterectomy or stenting declined precipitously over a recent 15-year period, at least among Medicare fee-for-service beneficiaries, according to data presented at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

Ted Bosworth/MDedge News

A reduction in carotid endarterectomies (CEA) largely accounted for the decline during 1999-2014 although there was a cumulative decline in all carotid revascularization procedures when rates of CEA and stenting were combined, according to Brajesh K. Lal, MD, professor of surgery, University of Maryland Medical System, Baltimore.

In 1999, when enthusiasm for CEA appears to have peaked, 81,306 patients received this procedure, but a steady decline was observed until 2014, when 36,325 patients were being treated annually in the Medicare database. When calculated as endarterectomies per 100,000 beneficiaries, the rate declined from 298 to 128 (57%; P less than .001) over this 15-year period.

The number of stenting procedures had not reached its peak in 1999, when 10,416 were performed. Rather, the number performed annually nearly doubled to, 22.865 by 2006. However, it then began to decline and reached 10,208 by 2014, which was slightly fewer than in 1999, according to Dr. Lal.

These trends have been observed even though outcomes are getting better, at least for CEA, according to Dr. Lal. From the same pool of data, there was a 31% (1.1% vs. 1.6%) reduction from 1999 to 2014 in mortality at 30 days following CEA. For a composite of ischemic stroke and all-cause mortality, the rate fell 29.5% (3.1% vs. 4.4%). Both reductions were called statistically significant by Dr. Lal.

The improvements in CEA outcomes were observed even though “the treated patients got sicker when looking at comorbidities and risk factors, particularly hypertension, renal insufficiency, and diabetes,” Dr. Lal said.

Outcomes also improved among patients undergoing carotid stenting in general, although the patterns were described as “more complex.” In general, there was steady improvement on outcomes during 1999-2006, but there was no further gain and some lost ground during 2006-2014. For example, ischemic stroke or death fell from 7.0% in 1999 to 4.8% in 2006, but it had climbed back to 7.0% by 2014 with no net change when the first and last year were compared.

However, with risk adjustment, there was a reduction in in-hospital mortality (1.13% vs. 2.78%) over the study period for patients undergoing carotid stenting, according to Dr. Lal, who said this reached statistical significance. Like the CEA group, there was more comorbidity among those treated with stenting at the end, relative to the early part of the study period.

In the stenting group, patients with symptomatic carotid disease rose from 14.4% in 1999 to 25.9% in 2014. This tracks with Medicare policy, which required patients after 2005 to have symptomatic disease for reimbursement, according to Dr. Lal. Prior to 2005, reimbursement was granted for patients participating in clinical trials only.

The rates of carotid revascularization are not evenly distributed geographically in the United States, according to the Medicare data. Endarterectomy in particular has been more common in the south and Midwest than on either coast. This was true in 1999 and remained so in 2014. The distribution was similar for stenting, although it was also relatively common in the southwest in the early part of the study period.

In the beginning of the study, the increased rate of stenting might have contributed to the decline in endarterectomy, but there are several other factors that are implicated in the observed trends, according to Dr. Lal. He suggested that decreasing reimbursement for the performance of these procedures, better clinical management of risk factors, and advances in medical therapy. He cited a physician survey that showed a growing preference for medical management over invasive procedures in patients with high-grade stenosis and indicated that this last factor might be a particularly important driver of the decline in revascularization referrals for asymptomatic carotid disease.

The degree to which these Medicare data are representative of overall trends in the United States is unclear, but Dr. Lal called for further work to understand the forces that these data suggest are driving the changing patterns of carotid revascularization.

NEW YORK – The rates of carotid artery revascularization with either endarterectomy or stenting declined precipitously over a recent 15-year period, at least among Medicare fee-for-service beneficiaries, according to data presented at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

Ted Bosworth/MDedge News

A reduction in carotid endarterectomies (CEA) largely accounted for the decline during 1999-2014 although there was a cumulative decline in all carotid revascularization procedures when rates of CEA and stenting were combined, according to Brajesh K. Lal, MD, professor of surgery, University of Maryland Medical System, Baltimore.

In 1999, when enthusiasm for CEA appears to have peaked, 81,306 patients received this procedure, but a steady decline was observed until 2014, when 36,325 patients were being treated annually in the Medicare database. When calculated as endarterectomies per 100,000 beneficiaries, the rate declined from 298 to 128 (57%; P less than .001) over this 15-year period.

The number of stenting procedures had not reached its peak in 1999, when 10,416 were performed. Rather, the number performed annually nearly doubled to, 22.865 by 2006. However, it then began to decline and reached 10,208 by 2014, which was slightly fewer than in 1999, according to Dr. Lal.

These trends have been observed even though outcomes are getting better, at least for CEA, according to Dr. Lal. From the same pool of data, there was a 31% (1.1% vs. 1.6%) reduction from 1999 to 2014 in mortality at 30 days following CEA. For a composite of ischemic stroke and all-cause mortality, the rate fell 29.5% (3.1% vs. 4.4%). Both reductions were called statistically significant by Dr. Lal.

The improvements in CEA outcomes were observed even though “the treated patients got sicker when looking at comorbidities and risk factors, particularly hypertension, renal insufficiency, and diabetes,” Dr. Lal said.

Outcomes also improved among patients undergoing carotid stenting in general, although the patterns were described as “more complex.” In general, there was steady improvement on outcomes during 1999-2006, but there was no further gain and some lost ground during 2006-2014. For example, ischemic stroke or death fell from 7.0% in 1999 to 4.8% in 2006, but it had climbed back to 7.0% by 2014 with no net change when the first and last year were compared.

However, with risk adjustment, there was a reduction in in-hospital mortality (1.13% vs. 2.78%) over the study period for patients undergoing carotid stenting, according to Dr. Lal, who said this reached statistical significance. Like the CEA group, there was more comorbidity among those treated with stenting at the end, relative to the early part of the study period.

In the stenting group, patients with symptomatic carotid disease rose from 14.4% in 1999 to 25.9% in 2014. This tracks with Medicare policy, which required patients after 2005 to have symptomatic disease for reimbursement, according to Dr. Lal. Prior to 2005, reimbursement was granted for patients participating in clinical trials only.

The rates of carotid revascularization are not evenly distributed geographically in the United States, according to the Medicare data. Endarterectomy in particular has been more common in the south and Midwest than on either coast. This was true in 1999 and remained so in 2014. The distribution was similar for stenting, although it was also relatively common in the southwest in the early part of the study period.

In the beginning of the study, the increased rate of stenting might have contributed to the decline in endarterectomy, but there are several other factors that are implicated in the observed trends, according to Dr. Lal. He suggested that decreasing reimbursement for the performance of these procedures, better clinical management of risk factors, and advances in medical therapy. He cited a physician survey that showed a growing preference for medical management over invasive procedures in patients with high-grade stenosis and indicated that this last factor might be a particularly important driver of the decline in revascularization referrals for asymptomatic carotid disease.

The degree to which these Medicare data are representative of overall trends in the United States is unclear, but Dr. Lal called for further work to understand the forces that these data suggest are driving the changing patterns of carotid revascularization.

NEW YORK – The rates of carotid artery revascularization with either endarterectomy or stenting declined precipitously over a recent 15-year period, at least among Medicare fee-for-service beneficiaries, according to data presented at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

Ted Bosworth/MDedge News

A reduction in carotid endarterectomies (CEA) largely accounted for the decline during 1999-2014 although there was a cumulative decline in all carotid revascularization procedures when rates of CEA and stenting were combined, according to Brajesh K. Lal, MD, professor of surgery, University of Maryland Medical System, Baltimore.

In 1999, when enthusiasm for CEA appears to have peaked, 81,306 patients received this procedure, but a steady decline was observed until 2014, when 36,325 patients were being treated annually in the Medicare database. When calculated as endarterectomies per 100,000 beneficiaries, the rate declined from 298 to 128 (57%; P less than .001) over this 15-year period.

The number of stenting procedures had not reached its peak in 1999, when 10,416 were performed. Rather, the number performed annually nearly doubled to, 22.865 by 2006. However, it then began to decline and reached 10,208 by 2014, which was slightly fewer than in 1999, according to Dr. Lal.

These trends have been observed even though outcomes are getting better, at least for CEA, according to Dr. Lal. From the same pool of data, there was a 31% (1.1% vs. 1.6%) reduction from 1999 to 2014 in mortality at 30 days following CEA. For a composite of ischemic stroke and all-cause mortality, the rate fell 29.5% (3.1% vs. 4.4%). Both reductions were called statistically significant by Dr. Lal.

The improvements in CEA outcomes were observed even though “the treated patients got sicker when looking at comorbidities and risk factors, particularly hypertension, renal insufficiency, and diabetes,” Dr. Lal said.

Outcomes also improved among patients undergoing carotid stenting in general, although the patterns were described as “more complex.” In general, there was steady improvement on outcomes during 1999-2006, but there was no further gain and some lost ground during 2006-2014. For example, ischemic stroke or death fell from 7.0% in 1999 to 4.8% in 2006, but it had climbed back to 7.0% by 2014 with no net change when the first and last year were compared.

However, with risk adjustment, there was a reduction in in-hospital mortality (1.13% vs. 2.78%) over the study period for patients undergoing carotid stenting, according to Dr. Lal, who said this reached statistical significance. Like the CEA group, there was more comorbidity among those treated with stenting at the end, relative to the early part of the study period.

In the stenting group, patients with symptomatic carotid disease rose from 14.4% in 1999 to 25.9% in 2014. This tracks with Medicare policy, which required patients after 2005 to have symptomatic disease for reimbursement, according to Dr. Lal. Prior to 2005, reimbursement was granted for patients participating in clinical trials only.

The rates of carotid revascularization are not evenly distributed geographically in the United States, according to the Medicare data. Endarterectomy in particular has been more common in the south and Midwest than on either coast. This was true in 1999 and remained so in 2014. The distribution was similar for stenting, although it was also relatively common in the southwest in the early part of the study period.

In the beginning of the study, the increased rate of stenting might have contributed to the decline in endarterectomy, but there are several other factors that are implicated in the observed trends, according to Dr. Lal. He suggested that decreasing reimbursement for the performance of these procedures, better clinical management of risk factors, and advances in medical therapy. He cited a physician survey that showed a growing preference for medical management over invasive procedures in patients with high-grade stenosis and indicated that this last factor might be a particularly important driver of the decline in revascularization referrals for asymptomatic carotid disease.

The degree to which these Medicare data are representative of overall trends in the United States is unclear, but Dr. Lal called for further work to understand the forces that these data suggest are driving the changing patterns of carotid revascularization.

NEW YORK – It is well known that reoperative carotid endarterectomy can be technically challenging because of the scarring left from the initial procedure, but an analysis of a large database presented at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation also revealed that the risk of complications, particularly stroke, is greater.

When “redo” carotid endarterectomies were compared with the index primary procedure collected in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, the odds ratio for stroke was several times greater (odds ratio, 3.71; P = .002) on univariate analysis, reported Jeffrey J. Siracuse, MD, associate professor of surgery and radiology at Boston University.

Previous single-center reports of redo endarterectomies “showed terrific results, really no perioperative stroke or morbidity, but this is older data from a different era,” said Dr. Siracuse, who undertook this study to determine whether “real-world” data would tell a different story.

In this study, 75,943 primary carotid endarterectomies and 140 redo procedures were identified in the ACS NSQIP database and compared. The redo population had a significantly higher incidence of end-stage renal disease (3.6% vs. 1.1%; P = .004), but history of stroke, whether with deficit (20.8% vs. 15.4%) or without (11.5% vs. 9.1%), was numerically higher among those undergoing a primary procedure even though these differences did not reach statistical significance. Baseline demographics and comorbidities were otherwise similar.

Presumably because of the difficulty of recanalizing scarred tissue, the mean procedure time for redos was longer than that for the primary procedures (137 vs. 49 minutes; P less than .001), but there were no significant differences in the rate of surgical site infections (0.7% vs. 0.3%; P = .482), return to the operating room (3.6% vs. 4%; P = .853), or 30-day readmissions (2.1% vs. 6.9%; P = .810) for the redo and index procedures, respectively.

Although perioperative MI rates were higher in the redo group (2.1%) than in the primary endarterectomy group (0.9%), this difference did not reach statistical significance (P = .125). However, a multivariate analysis associated redo carotid endarterectomy procedures with a nearly threefold increase in risk of a composite of major adverse cardiovascular events when compared on a multivariate analysis (OR, 2.76; P = .007), Dr. Siracuse reported.

For the surgeons considering a redo carotid endarterectomy, these data “inform a risk-benefit analysis,” according to Dr. Siracuse, but he also said that redo procedures still should be considered a viable strategy when considered in the context of other options.

Presenting a case he performed just prior to the VEITHsymposium, Dr. Siracuse displayed CT images that showed internal and common carotids with more than 75% stenosis in an 80-year-old women 7 years after a primary carotid endarterectomy. The tight stenoses and the evidence of substantial intra-arterial debris were concerns, but a decision to perform a redo endarterectomy was reached after other options, including stenting, were considered.

“She did great. She went home and has had no more symptoms,” Dr. Siracuse reported. “The point is you still have to take these [potential redo endarterectomies] on a case-by case basis.”

Dr. Siracuse reported he had no financial relationships relevant to this study.

NEW YORK – It is well known that reoperative carotid endarterectomy can be technically challenging because of the scarring left from the initial procedure, but an analysis of a large database presented at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation also revealed that the risk of complications, particularly stroke, is greater.

When “redo” carotid endarterectomies were compared with the index primary procedure collected in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, the odds ratio for stroke was several times greater (odds ratio, 3.71; P = .002) on univariate analysis, reported Jeffrey J. Siracuse, MD, associate professor of surgery and radiology at Boston University.

Previous single-center reports of redo endarterectomies “showed terrific results, really no perioperative stroke or morbidity, but this is older data from a different era,” said Dr. Siracuse, who undertook this study to determine whether “real-world” data would tell a different story.

In this study, 75,943 primary carotid endarterectomies and 140 redo procedures were identified in the ACS NSQIP database and compared. The redo population had a significantly higher incidence of end-stage renal disease (3.6% vs. 1.1%; P = .004), but history of stroke, whether with deficit (20.8% vs. 15.4%) or without (11.5% vs. 9.1%), was numerically higher among those undergoing a primary procedure even though these differences did not reach statistical significance. Baseline demographics and comorbidities were otherwise similar.

Presumably because of the difficulty of recanalizing scarred tissue, the mean procedure time for redos was longer than that for the primary procedures (137 vs. 49 minutes; P less than .001), but there were no significant differences in the rate of surgical site infections (0.7% vs. 0.3%; P = .482), return to the operating room (3.6% vs. 4%; P = .853), or 30-day readmissions (2.1% vs. 6.9%; P = .810) for the redo and index procedures, respectively.

Although perioperative MI rates were higher in the redo group (2.1%) than in the primary endarterectomy group (0.9%), this difference did not reach statistical significance (P = .125). However, a multivariate analysis associated redo carotid endarterectomy procedures with a nearly threefold increase in risk of a composite of major adverse cardiovascular events when compared on a multivariate analysis (OR, 2.76; P = .007), Dr. Siracuse reported.

For the surgeons considering a redo carotid endarterectomy, these data “inform a risk-benefit analysis,” according to Dr. Siracuse, but he also said that redo procedures still should be considered a viable strategy when considered in the context of other options.

Presenting a case he performed just prior to the VEITHsymposium, Dr. Siracuse displayed CT images that showed internal and common carotids with more than 75% stenosis in an 80-year-old women 7 years after a primary carotid endarterectomy. The tight stenoses and the evidence of substantial intra-arterial debris were concerns, but a decision to perform a redo endarterectomy was reached after other options, including stenting, were considered.

“She did great. She went home and has had no more symptoms,” Dr. Siracuse reported. “The point is you still have to take these [potential redo endarterectomies] on a case-by case basis.”

Dr. Siracuse reported he had no financial relationships relevant to this study.

NEW YORK – It is well known that reoperative carotid endarterectomy can be technically challenging because of the scarring left from the initial procedure, but an analysis of a large database presented at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation also revealed that the risk of complications, particularly stroke, is greater.

When “redo” carotid endarterectomies were compared with the index primary procedure collected in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, the odds ratio for stroke was several times greater (odds ratio, 3.71; P = .002) on univariate analysis, reported Jeffrey J. Siracuse, MD, associate professor of surgery and radiology at Boston University.

Previous single-center reports of redo endarterectomies “showed terrific results, really no perioperative stroke or morbidity, but this is older data from a different era,” said Dr. Siracuse, who undertook this study to determine whether “real-world” data would tell a different story.

In this study, 75,943 primary carotid endarterectomies and 140 redo procedures were identified in the ACS NSQIP database and compared. The redo population had a significantly higher incidence of end-stage renal disease (3.6% vs. 1.1%; P = .004), but history of stroke, whether with deficit (20.8% vs. 15.4%) or without (11.5% vs. 9.1%), was numerically higher among those undergoing a primary procedure even though these differences did not reach statistical significance. Baseline demographics and comorbidities were otherwise similar.

Presumably because of the difficulty of recanalizing scarred tissue, the mean procedure time for redos was longer than that for the primary procedures (137 vs. 49 minutes; P less than .001), but there were no significant differences in the rate of surgical site infections (0.7% vs. 0.3%; P = .482), return to the operating room (3.6% vs. 4%; P = .853), or 30-day readmissions (2.1% vs. 6.9%; P = .810) for the redo and index procedures, respectively.

Although perioperative MI rates were higher in the redo group (2.1%) than in the primary endarterectomy group (0.9%), this difference did not reach statistical significance (P = .125). However, a multivariate analysis associated redo carotid endarterectomy procedures with a nearly threefold increase in risk of a composite of major adverse cardiovascular events when compared on a multivariate analysis (OR, 2.76; P = .007), Dr. Siracuse reported.

For the surgeons considering a redo carotid endarterectomy, these data “inform a risk-benefit analysis,” according to Dr. Siracuse, but he also said that redo procedures still should be considered a viable strategy when considered in the context of other options.

Presenting a case he performed just prior to the VEITHsymposium, Dr. Siracuse displayed CT images that showed internal and common carotids with more than 75% stenosis in an 80-year-old women 7 years after a primary carotid endarterectomy. The tight stenoses and the evidence of substantial intra-arterial debris were concerns, but a decision to perform a redo endarterectomy was reached after other options, including stenting, were considered.

“She did great. She went home and has had no more symptoms,” Dr. Siracuse reported. “The point is you still have to take these [potential redo endarterectomies] on a case-by case basis.”

Dr. Siracuse reported he had no financial relationships relevant to this study.

NEW YORK – If New York State is representative, the risk of bad outcomes in patients undergoing open abdominal aortic aneurysm repair (OAR) or carotid endarterectomy (CEA), including death in the case of OAR, is about double when performed by very low- versus higher-volume surgeons, according to data presented at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

“What should we do to fix the problem? We could require surgeons to track their outcomes in quality improvement registry,” suggested Jack L. Cronenwett, MD, professor of surgery, Geisel School of Medicine at Dartmouth, Hanover, N.H.

The outcomes were evaluated from inpatient data gathered from patients undergoing OAR or CEA in an all-payer database involving every hospital discharge in New York State. Surgeons were defined as very-low-volume for a given procedure if they averaged one or less per year, though the results held true if very-low-volume was defined as less than three cases per year, according to Dr. Cronenwett.

The database had outcomes on 8,781 OAR procedures and 68,896 CEA procedures performed from 2000 to 2014.

Of the 614 surgeons who performed one or more OARs over this period, 318 (51.8%) were defined as low-volume surgeons. Despite their substantial representation, they performed just 7.6% of the procedures.

When outcomes from procedures performed by very-low-volume surgeons were compared to those done by higher-volume surgeons, the mortality rates without adjustments were nearly double (6.7% vs. 3.5%; P less than .001). Procedures performed by low-volume surgeons were associated with far higher rates of sepsis or shock (5.7% vs. 3.7%; P = .008), and patients treated by low-volume surgeons were more likely to spend 9 or more days in the hospital (39.3% vs. 30.1%; P less than .001).

When fully adjusted for other variables, “low-volume surgeons had twofold higher odds [OR 2.09] of postoperative death,” Dr. Cronenwett reported.

Of the 1,071 surgeons who performed CEA over this period, 512 (47.8%) were low-volume. They performed 1.3% of the procedures.

Mortality and sepsis or shock following CEA were less than 1% in procedures performed by either low- or higher-volume surgeons without significant differences. However, procedures performed by low-volume surgeons were associated with a three-times higher rate of myocardial infarction (1.5% vs. 0.5%; P less than .001) and a 65% higher rate of stroke (3.5% vs. 2.1%; P = .003).

In addition, patients who underwent CEA performed by a low-volume surgeon had a significantly higher rate of 30-day readmission (11.5% vs. 8.5%; P = .002) and a significantly longer median length of stay (2 days vs. 1 day; P less than .001) than did those treated by a higher-volume surgeon.

Whether OAR or CEA, patients treated by a low-volume surgeon were more likely to have Medicaid coverage. The fact that procedures by low-volume surgeons were more likely to be performed in New York City than other areas of the state suggest that access to care was not a variable, according to Dr. Cronenwett.

Surgeon volume was calculated in this study by dividing the total number of OAR or CEA procedures performed by the number of years that the surgeon was in practice in New York State. Surgeons were classified as vascular surgeons if 75% or more of their surgical practice involved vascular procedures, cardiac surgeons if more than 20% of their surgical practice involved cardiac procedures, and general surgeons if they did not meet either of these criteria.

Of OAR procedures were done by a higher-volume surgeon, approximately 65% were by vascular specialists, 5% were by cardiac specialists, and the remaining were by general surgeons.

Of OAR procedures were done by a low-volume surgeon, approximately 25% were by vascular surgeons, 20% were by cardiac surgeons, and the remaining were by general surgeons. For CEA, there was a somewhat greater representation of general surgeons in both categories, but the patterns were similar.

Dr. Cronenwett argued that more rigorous steps should be taken to ensure that those with proven skills perform OAR and CEA and that open abdominal aortic aneurysm repair should be performed only by high-volume surgeons and hospitals. He suggested there are a variety of incentives or disincentives that could help, but he stressed the importance of tracking results and making them available to referring physicians and to patients.

“Some of the low-volume surgeons are probably not tracking their results so are not even aware of these bad outcomes,” he added.

Dr. Cronenwett reported that he had no relevant disclosures.

SOURCE: Cronenwett JL et al. 2018; VEITHsymposium.

NEW YORK – If New York State is representative, the risk of bad outcomes in patients undergoing open abdominal aortic aneurysm repair (OAR) or carotid endarterectomy (CEA), including death in the case of OAR, is about double when performed by very low- versus higher-volume surgeons, according to data presented at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

“What should we do to fix the problem? We could require surgeons to track their outcomes in quality improvement registry,” suggested Jack L. Cronenwett, MD, professor of surgery, Geisel School of Medicine at Dartmouth, Hanover, N.H.

The outcomes were evaluated from inpatient data gathered from patients undergoing OAR or CEA in an all-payer database involving every hospital discharge in New York State. Surgeons were defined as very-low-volume for a given procedure if they averaged one or less per year, though the results held true if very-low-volume was defined as less than three cases per year, according to Dr. Cronenwett.

The database had outcomes on 8,781 OAR procedures and 68,896 CEA procedures performed from 2000 to 2014.

Of the 614 surgeons who performed one or more OARs over this period, 318 (51.8%) were defined as low-volume surgeons. Despite their substantial representation, they performed just 7.6% of the procedures.

When outcomes from procedures performed by very-low-volume surgeons were compared to those done by higher-volume surgeons, the mortality rates without adjustments were nearly double (6.7% vs. 3.5%; P less than .001). Procedures performed by low-volume surgeons were associated with far higher rates of sepsis or shock (5.7% vs. 3.7%; P = .008), and patients treated by low-volume surgeons were more likely to spend 9 or more days in the hospital (39.3% vs. 30.1%; P less than .001).

When fully adjusted for other variables, “low-volume surgeons had twofold higher odds [OR 2.09] of postoperative death,” Dr. Cronenwett reported.

Of the 1,071 surgeons who performed CEA over this period, 512 (47.8%) were low-volume. They performed 1.3% of the procedures.

Mortality and sepsis or shock following CEA were less than 1% in procedures performed by either low- or higher-volume surgeons without significant differences. However, procedures performed by low-volume surgeons were associated with a three-times higher rate of myocardial infarction (1.5% vs. 0.5%; P less than .001) and a 65% higher rate of stroke (3.5% vs. 2.1%; P = .003).

In addition, patients who underwent CEA performed by a low-volume surgeon had a significantly higher rate of 30-day readmission (11.5% vs. 8.5%; P = .002) and a significantly longer median length of stay (2 days vs. 1 day; P less than .001) than did those treated by a higher-volume surgeon.

Whether OAR or CEA, patients treated by a low-volume surgeon were more likely to have Medicaid coverage. The fact that procedures by low-volume surgeons were more likely to be performed in New York City than other areas of the state suggest that access to care was not a variable, according to Dr. Cronenwett.

Surgeon volume was calculated in this study by dividing the total number of OAR or CEA procedures performed by the number of years that the surgeon was in practice in New York State. Surgeons were classified as vascular surgeons if 75% or more of their surgical practice involved vascular procedures, cardiac surgeons if more than 20% of their surgical practice involved cardiac procedures, and general surgeons if they did not meet either of these criteria.

Of OAR procedures were done by a higher-volume surgeon, approximately 65% were by vascular specialists, 5% were by cardiac specialists, and the remaining were by general surgeons.

Of OAR procedures were done by a low-volume surgeon, approximately 25% were by vascular surgeons, 20% were by cardiac surgeons, and the remaining were by general surgeons. For CEA, there was a somewhat greater representation of general surgeons in both categories, but the patterns were similar.

Dr. Cronenwett argued that more rigorous steps should be taken to ensure that those with proven skills perform OAR and CEA and that open abdominal aortic aneurysm repair should be performed only by high-volume surgeons and hospitals. He suggested there are a variety of incentives or disincentives that could help, but he stressed the importance of tracking results and making them available to referring physicians and to patients.

“Some of the low-volume surgeons are probably not tracking their results so are not even aware of these bad outcomes,” he added.

Dr. Cronenwett reported that he had no relevant disclosures.

SOURCE: Cronenwett JL et al. 2018; VEITHsymposium.

NEW YORK – If New York State is representative, the risk of bad outcomes in patients undergoing open abdominal aortic aneurysm repair (OAR) or carotid endarterectomy (CEA), including death in the case of OAR, is about double when performed by very low- versus higher-volume surgeons, according to data presented at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

“What should we do to fix the problem? We could require surgeons to track their outcomes in quality improvement registry,” suggested Jack L. Cronenwett, MD, professor of surgery, Geisel School of Medicine at Dartmouth, Hanover, N.H.

The outcomes were evaluated from inpatient data gathered from patients undergoing OAR or CEA in an all-payer database involving every hospital discharge in New York State. Surgeons were defined as very-low-volume for a given procedure if they averaged one or less per year, though the results held true if very-low-volume was defined as less than three cases per year, according to Dr. Cronenwett.

The database had outcomes on 8,781 OAR procedures and 68,896 CEA procedures performed from 2000 to 2014.

Of the 614 surgeons who performed one or more OARs over this period, 318 (51.8%) were defined as low-volume surgeons. Despite their substantial representation, they performed just 7.6% of the procedures.

When outcomes from procedures performed by very-low-volume surgeons were compared to those done by higher-volume surgeons, the mortality rates without adjustments were nearly double (6.7% vs. 3.5%; P less than .001). Procedures performed by low-volume surgeons were associated with far higher rates of sepsis or shock (5.7% vs. 3.7%; P = .008), and patients treated by low-volume surgeons were more likely to spend 9 or more days in the hospital (39.3% vs. 30.1%; P less than .001).

When fully adjusted for other variables, “low-volume surgeons had twofold higher odds [OR 2.09] of postoperative death,” Dr. Cronenwett reported.

Of the 1,071 surgeons who performed CEA over this period, 512 (47.8%) were low-volume. They performed 1.3% of the procedures.

Mortality and sepsis or shock following CEA were less than 1% in procedures performed by either low- or higher-volume surgeons without significant differences. However, procedures performed by low-volume surgeons were associated with a three-times higher rate of myocardial infarction (1.5% vs. 0.5%; P less than .001) and a 65% higher rate of stroke (3.5% vs. 2.1%; P = .003).

In addition, patients who underwent CEA performed by a low-volume surgeon had a significantly higher rate of 30-day readmission (11.5% vs. 8.5%; P = .002) and a significantly longer median length of stay (2 days vs. 1 day; P less than .001) than did those treated by a higher-volume surgeon.

Whether OAR or CEA, patients treated by a low-volume surgeon were more likely to have Medicaid coverage. The fact that procedures by low-volume surgeons were more likely to be performed in New York City than other areas of the state suggest that access to care was not a variable, according to Dr. Cronenwett.

Surgeon volume was calculated in this study by dividing the total number of OAR or CEA procedures performed by the number of years that the surgeon was in practice in New York State. Surgeons were classified as vascular surgeons if 75% or more of their surgical practice involved vascular procedures, cardiac surgeons if more than 20% of their surgical practice involved cardiac procedures, and general surgeons if they did not meet either of these criteria.

Of OAR procedures were done by a higher-volume surgeon, approximately 65% were by vascular specialists, 5% were by cardiac specialists, and the remaining were by general surgeons.

Of OAR procedures were done by a low-volume surgeon, approximately 25% were by vascular surgeons, 20% were by cardiac surgeons, and the remaining were by general surgeons. For CEA, there was a somewhat greater representation of general surgeons in both categories, but the patterns were similar.

Dr. Cronenwett argued that more rigorous steps should be taken to ensure that those with proven skills perform OAR and CEA and that open abdominal aortic aneurysm repair should be performed only by high-volume surgeons and hospitals. He suggested there are a variety of incentives or disincentives that could help, but he stressed the importance of tracking results and making them available to referring physicians and to patients.

“Some of the low-volume surgeons are probably not tracking their results so are not even aware of these bad outcomes,” he added.

Dr. Cronenwett reported that he had no relevant disclosures.

SOURCE: Cronenwett JL et al. 2018; VEITHsymposium.

NEW YORK – Guidelines for the management of leg ulcerations will be changed to accommodate the results of the Early Venous Reflux Ablation trial, according to this video interview with the senior author, Alun H Davies, DSc, professor of vascular surgery, Imperial College, London.

In this video interview, conducted at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation, Dr. Davies recaps the major results of the study, which associated immediate endovascular ablation (early intervention) with significantly faster healing than did compression therapy with ablation, considered only after 6 months (delayed intervention).

These data have been published (N Engl J Med 2018 May 31;378:2105-14), but Dr. Davies focused in this interview on the cost efficacy of early intervention with endovascular ablation. In the United Kingdom, where the study was conducted, the data support the cost efficacy, but Dr. Davies predicted even greater savings in the United States because of the expense of frequent wound care visits.

Based on data from a randomized trial, he expects guidelines, including those in the United States, to be revised to list early endovascular ablation as a 1b or 1A recommendation, thereby establishing this intervention as a standard.

If follow-up after 3 years confirms a lower rate of recurrence, an advantage previously shown for open surgery relative to compression healing, the case for early endovascular intervention will be even stronger, according to Dr. Davies.

NEW YORK – Guidelines for the management of leg ulcerations will be changed to accommodate the results of the Early Venous Reflux Ablation trial, according to this video interview with the senior author, Alun H Davies, DSc, professor of vascular surgery, Imperial College, London.

In this video interview, conducted at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation, Dr. Davies recaps the major results of the study, which associated immediate endovascular ablation (early intervention) with significantly faster healing than did compression therapy with ablation, considered only after 6 months (delayed intervention).

These data have been published (N Engl J Med 2018 May 31;378:2105-14), but Dr. Davies focused in this interview on the cost efficacy of early intervention with endovascular ablation. In the United Kingdom, where the study was conducted, the data support the cost efficacy, but Dr. Davies predicted even greater savings in the United States because of the expense of frequent wound care visits.

Based on data from a randomized trial, he expects guidelines, including those in the United States, to be revised to list early endovascular ablation as a 1b or 1A recommendation, thereby establishing this intervention as a standard.

If follow-up after 3 years confirms a lower rate of recurrence, an advantage previously shown for open surgery relative to compression healing, the case for early endovascular intervention will be even stronger, according to Dr. Davies.

NEW YORK – Guidelines for the management of leg ulcerations will be changed to accommodate the results of the Early Venous Reflux Ablation trial, according to this video interview with the senior author, Alun H Davies, DSc, professor of vascular surgery, Imperial College, London.

In this video interview, conducted at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation, Dr. Davies recaps the major results of the study, which associated immediate endovascular ablation (early intervention) with significantly faster healing than did compression therapy with ablation, considered only after 6 months (delayed intervention).

These data have been published (N Engl J Med 2018 May 31;378:2105-14), but Dr. Davies focused in this interview on the cost efficacy of early intervention with endovascular ablation. In the United Kingdom, where the study was conducted, the data support the cost efficacy, but Dr. Davies predicted even greater savings in the United States because of the expense of frequent wound care visits.

Based on data from a randomized trial, he expects guidelines, including those in the United States, to be revised to list early endovascular ablation as a 1b or 1A recommendation, thereby establishing this intervention as a standard.

If follow-up after 3 years confirms a lower rate of recurrence, an advantage previously shown for open surgery relative to compression healing, the case for early endovascular intervention will be even stronger, according to Dr. Davies.

NEW YORK – Embolic protection devices to prevent debris from causing complications in percutaneous cardiac procedures also have a role when treating occlusions in the lower extremities, according to an expert who reviewed data and spoke about his experience at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

In this video interview, Peter Schneider, MD, chief of the division of vascular therapy at the Hawaii Kaiser Permanente Medical Group, Honolulu, provided an expert’s opinion about when filters can be helpful to reduce risk of complications.

According to Dr. Schneider, filters do have relative disadvantages so he does not advocate their use when risk is low. Among these disadvantages, the wire used to place the filter can make the endovascular procedure more difficult.

However, he said that there are well-documented cases in which debris in the runoff of a lower limb endovascular procedure resulted in adverse clinical consequences. Importantly, these may not be acute clinical events. Rather, occlusions in the tibial or pedal collaterals may remain asymptomatic for months or years.

Outlining those clinical situations that pose the greatest risk, Dr. Schneider identified several specific patient groups for whom he would advocate filters, particularly those with a large thrombotic burden. Based on his own experience, he provided some tips about situations in which he now employs embolic protection devices routinely.

NEW YORK – Embolic protection devices to prevent debris from causing complications in percutaneous cardiac procedures also have a role when treating occlusions in the lower extremities, according to an expert who reviewed data and spoke about his experience at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

In this video interview, Peter Schneider, MD, chief of the division of vascular therapy at the Hawaii Kaiser Permanente Medical Group, Honolulu, provided an expert’s opinion about when filters can be helpful to reduce risk of complications.

According to Dr. Schneider, filters do have relative disadvantages so he does not advocate their use when risk is low. Among these disadvantages, the wire used to place the filter can make the endovascular procedure more difficult.

However, he said that there are well-documented cases in which debris in the runoff of a lower limb endovascular procedure resulted in adverse clinical consequences. Importantly, these may not be acute clinical events. Rather, occlusions in the tibial or pedal collaterals may remain asymptomatic for months or years.

Outlining those clinical situations that pose the greatest risk, Dr. Schneider identified several specific patient groups for whom he would advocate filters, particularly those with a large thrombotic burden. Based on his own experience, he provided some tips about situations in which he now employs embolic protection devices routinely.

NEW YORK – Embolic protection devices to prevent debris from causing complications in percutaneous cardiac procedures also have a role when treating occlusions in the lower extremities, according to an expert who reviewed data and spoke about his experience at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

In this video interview, Peter Schneider, MD, chief of the division of vascular therapy at the Hawaii Kaiser Permanente Medical Group, Honolulu, provided an expert’s opinion about when filters can be helpful to reduce risk of complications.

According to Dr. Schneider, filters do have relative disadvantages so he does not advocate their use when risk is low. Among these disadvantages, the wire used to place the filter can make the endovascular procedure more difficult.

However, he said that there are well-documented cases in which debris in the runoff of a lower limb endovascular procedure resulted in adverse clinical consequences. Importantly, these may not be acute clinical events. Rather, occlusions in the tibial or pedal collaterals may remain asymptomatic for months or years.

Outlining those clinical situations that pose the greatest risk, Dr. Schneider identified several specific patient groups for whom he would advocate filters, particularly those with a large thrombotic burden. Based on his own experience, he provided some tips about situations in which he now employs embolic protection devices routinely.

NEW YORK – Vascular surgeons are the only specialty qualified to treat all vascular disorders with open surgery and/or endovascular treatment, including the thoracic aorta, according to the updated “Guidelines for hospital privileges in vascular surgery and endovascular interventions: Recommendations of the Society for Vascular Surgery.”

The guidelines, published in May’s Journal of Vascular Surgery, were last updated in 2008, said Keith D. Calligaro, MD, who spoke on their importance and potential benefits to vascular surgeons during his presentation at the VEITHsymposium.

The thoracic aorta component of the guidelines addresses scope of practice concerns between vascular and thoracic surgeons, said Dr. Calligaro, who is a clinical professor of surgery, University of Pennsylvania, and chief of vascular surgery and endovascular therapy at Pennsylvania Hospital, both in Philadelphia.

The guidelines relied on training requirements to provide some of the data to define vascular surgeons and privileges. The open vascular surgery training requirements still are defined by the Residency Review Committee for surgery, and those requirements include 250 major open vascular cases during training, including 30 open abdominal operations, 25 carotid, 45 peripheral open surgery cases, and 10 complex vascular surgeries, said Dr. Calligaro. “In terms of endovascular treatment, the training requirements are over 100 diagnostic caths and over 80 therapeutic interventions, and during training you would have had to have done more than 20 EVARs [endovascular aneurysm repairs].” That number jumped up from five EVARs in the previous guidelines.

Ultimately, “the SVS is basically saying ‘you need to be a vascular surgeon to perform vascular surgery,’ and you need have to have completed an Accreditation Council for Graduate Medical Education–accredited vascular residency.

“So if you are a general surgeon or a heart surgeon and you go to a new hospital and say ‘I want to do vascular,’ the vascular surgeon at that institution can refer to this document and say ‘no, the SVS is saying [the surgeon doesn’t] have the training.’ And I think that’s a pretty gutsy and important call,” said Dr. Calligaro.

It is a different case for endovascular surgery, he said. In this case, the requirement is to have completed an ACGME-accredited program in either vascular surgery, interventional radiology, or interventional cardiology to indicate the appropriate level of training. But SVS agreed with the recommendation by the American College of Cardiology that cardiologists not only had to complete 1 year of coronary interventions but also 1 year of peripheral intervention training, as well.

“So if you are at your hospital and have a cardiologist who is starting to do peripheral vascular stuff, now at least you can wave part of this document and say ‘Hey, look, the most important vascular society in the country is saying that, unless this individual had a year of peripheral training, this cardiologist should not be allowed to do endovascular peripheral interventions,’ ” Dr. Calligaro said.

mlesney@mdedge.com

SOURCE: Calligaro KD et al. J Vasc Surg. 2018 May;67(5):1337-44.

NEW YORK – Vascular surgeons are the only specialty qualified to treat all vascular disorders with open surgery and/or endovascular treatment, including the thoracic aorta, according to the updated “Guidelines for hospital privileges in vascular surgery and endovascular interventions: Recommendations of the Society for Vascular Surgery.”

The guidelines, published in May’s Journal of Vascular Surgery, were last updated in 2008, said Keith D. Calligaro, MD, who spoke on their importance and potential benefits to vascular surgeons during his presentation at the VEITHsymposium.

The thoracic aorta component of the guidelines addresses scope of practice concerns between vascular and thoracic surgeons, said Dr. Calligaro, who is a clinical professor of surgery, University of Pennsylvania, and chief of vascular surgery and endovascular therapy at Pennsylvania Hospital, both in Philadelphia.

The guidelines relied on training requirements to provide some of the data to define vascular surgeons and privileges. The open vascular surgery training requirements still are defined by the Residency Review Committee for surgery, and those requirements include 250 major open vascular cases during training, including 30 open abdominal operations, 25 carotid, 45 peripheral open surgery cases, and 10 complex vascular surgeries, said Dr. Calligaro. “In terms of endovascular treatment, the training requirements are over 100 diagnostic caths and over 80 therapeutic interventions, and during training you would have had to have done more than 20 EVARs [endovascular aneurysm repairs].” That number jumped up from five EVARs in the previous guidelines.

Ultimately, “the SVS is basically saying ‘you need to be a vascular surgeon to perform vascular surgery,’ and you need have to have completed an Accreditation Council for Graduate Medical Education–accredited vascular residency.

“So if you are a general surgeon or a heart surgeon and you go to a new hospital and say ‘I want to do vascular,’ the vascular surgeon at that institution can refer to this document and say ‘no, the SVS is saying [the surgeon doesn’t] have the training.’ And I think that’s a pretty gutsy and important call,” said Dr. Calligaro.

It is a different case for endovascular surgery, he said. In this case, the requirement is to have completed an ACGME-accredited program in either vascular surgery, interventional radiology, or interventional cardiology to indicate the appropriate level of training. But SVS agreed with the recommendation by the American College of Cardiology that cardiologists not only had to complete 1 year of coronary interventions but also 1 year of peripheral intervention training, as well.

“So if you are at your hospital and have a cardiologist who is starting to do peripheral vascular stuff, now at least you can wave part of this document and say ‘Hey, look, the most important vascular society in the country is saying that, unless this individual had a year of peripheral training, this cardiologist should not be allowed to do endovascular peripheral interventions,’ ” Dr. Calligaro said.

mlesney@mdedge.com

SOURCE: Calligaro KD et al. J Vasc Surg. 2018 May;67(5):1337-44.

NEW YORK – Vascular surgeons are the only specialty qualified to treat all vascular disorders with open surgery and/or endovascular treatment, including the thoracic aorta, according to the updated “Guidelines for hospital privileges in vascular surgery and endovascular interventions: Recommendations of the Society for Vascular Surgery.”

The guidelines, published in May’s Journal of Vascular Surgery, were last updated in 2008, said Keith D. Calligaro, MD, who spoke on their importance and potential benefits to vascular surgeons during his presentation at the VEITHsymposium.

The thoracic aorta component of the guidelines addresses scope of practice concerns between vascular and thoracic surgeons, said Dr. Calligaro, who is a clinical professor of surgery, University of Pennsylvania, and chief of vascular surgery and endovascular therapy at Pennsylvania Hospital, both in Philadelphia.

The guidelines relied on training requirements to provide some of the data to define vascular surgeons and privileges. The open vascular surgery training requirements still are defined by the Residency Review Committee for surgery, and those requirements include 250 major open vascular cases during training, including 30 open abdominal operations, 25 carotid, 45 peripheral open surgery cases, and 10 complex vascular surgeries, said Dr. Calligaro. “In terms of endovascular treatment, the training requirements are over 100 diagnostic caths and over 80 therapeutic interventions, and during training you would have had to have done more than 20 EVARs [endovascular aneurysm repairs].” That number jumped up from five EVARs in the previous guidelines.

Ultimately, “the SVS is basically saying ‘you need to be a vascular surgeon to perform vascular surgery,’ and you need have to have completed an Accreditation Council for Graduate Medical Education–accredited vascular residency.

“So if you are a general surgeon or a heart surgeon and you go to a new hospital and say ‘I want to do vascular,’ the vascular surgeon at that institution can refer to this document and say ‘no, the SVS is saying [the surgeon doesn’t] have the training.’ And I think that’s a pretty gutsy and important call,” said Dr. Calligaro.

It is a different case for endovascular surgery, he said. In this case, the requirement is to have completed an ACGME-accredited program in either vascular surgery, interventional radiology, or interventional cardiology to indicate the appropriate level of training. But SVS agreed with the recommendation by the American College of Cardiology that cardiologists not only had to complete 1 year of coronary interventions but also 1 year of peripheral intervention training, as well.

“So if you are at your hospital and have a cardiologist who is starting to do peripheral vascular stuff, now at least you can wave part of this document and say ‘Hey, look, the most important vascular society in the country is saying that, unless this individual had a year of peripheral training, this cardiologist should not be allowed to do endovascular peripheral interventions,’ ” Dr. Calligaro said.

mlesney@mdedge.com

SOURCE: Calligaro KD et al. J Vasc Surg. 2018 May;67(5):1337-44.

NEW YORK – A clever strategy to evaluate long term outcomes in patients undergoing endovascular abdominal aortic aneurysm repair identified a 20% rate of reintervention, according to data presented at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation by Philip P. Goodney, MD.

In this video interview with Dr. Goodney, an associate professor of vascular surgery at Geisel School of Medicine at Dartmouth, Hanover, N.H., he explains how Medicare data were employed to track patients long term, even when they had moved to other hospital systems.

The main message from the long-term follow-up is that there is a persistent risk of recurrence and need for reintervention, according to Dr. Goodney. The hypothesis was that there would be an early risk of failure, followed by a diminishing need for reintervention over time, but this was not what was observed.Rather, the findings suggest that the rate of reinterventions was relatively steady over the course of follow-up, suggesting that patients should be informed of a persistent risk. However, Dr. Goodney reports that age was not a predictor of reintervention, so that older patients were at no greater risk.

NEW YORK – A clever strategy to evaluate long term outcomes in patients undergoing endovascular abdominal aortic aneurysm repair identified a 20% rate of reintervention, according to data presented at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation by Philip P. Goodney, MD.

In this video interview with Dr. Goodney, an associate professor of vascular surgery at Geisel School of Medicine at Dartmouth, Hanover, N.H., he explains how Medicare data were employed to track patients long term, even when they had moved to other hospital systems.

The main message from the long-term follow-up is that there is a persistent risk of recurrence and need for reintervention, according to Dr. Goodney. The hypothesis was that there would be an early risk of failure, followed by a diminishing need for reintervention over time, but this was not what was observed.Rather, the findings suggest that the rate of reinterventions was relatively steady over the course of follow-up, suggesting that patients should be informed of a persistent risk. However, Dr. Goodney reports that age was not a predictor of reintervention, so that older patients were at no greater risk.

NEW YORK – A clever strategy to evaluate long term outcomes in patients undergoing endovascular abdominal aortic aneurysm repair identified a 20% rate of reintervention, according to data presented at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation by Philip P. Goodney, MD.

In this video interview with Dr. Goodney, an associate professor of vascular surgery at Geisel School of Medicine at Dartmouth, Hanover, N.H., he explains how Medicare data were employed to track patients long term, even when they had moved to other hospital systems.

The main message from the long-term follow-up is that there is a persistent risk of recurrence and need for reintervention, according to Dr. Goodney. The hypothesis was that there would be an early risk of failure, followed by a diminishing need for reintervention over time, but this was not what was observed.Rather, the findings suggest that the rate of reinterventions was relatively steady over the course of follow-up, suggesting that patients should be informed of a persistent risk. However, Dr. Goodney reports that age was not a predictor of reintervention, so that older patients were at no greater risk.

NEW YORK – With a median follow-up of almost 4 years in more than 200 patients, the snorkel/chimney technique of endovascular repair of complex abdominal aortic aneurysms continues to generate very good results, according data presented at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

In a video interview with Jason T. Lee, MD, professor of vascular surgery, Stanford (Calif.) University, who presented the long-term results, he explains why these findings are important.

After several single-center studies associated the snorkel/chimney technique with good rates of patency and durability, the PERICLES Registry was created almost 10 years ago to test whether these data could be reproduced in the real world.The data presented by Dr. Lee involved outcomes in 244 patients who were followed for at least 2.5 years. The median follow-up is 47 months.

The results overall confirm that this is a viable technique, according to Dr. Lee who noted very little diminution of patency rates in this long-term cohort relative to the previously published follow-up of 17.1 months.

He acknowledged that the snorkel/chimney repair is not free of potential complications, particularly gutter endovascular leaks, but he recounted that at least some resolve over time. Moreover, he suggests that several strategies are being pursued that appear promising for avoiding this risk.

Most importantly, the registry, which captured the experience at 13 centers in the United States and Europe, shows outcomes that are similar to those reported at centers where the techniques were developed and championed.

NEW YORK – With a median follow-up of almost 4 years in more than 200 patients, the snorkel/chimney technique of endovascular repair of complex abdominal aortic aneurysms continues to generate very good results, according data presented at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

In a video interview with Jason T. Lee, MD, professor of vascular surgery, Stanford (Calif.) University, who presented the long-term results, he explains why these findings are important.

After several single-center studies associated the snorkel/chimney technique with good rates of patency and durability, the PERICLES Registry was created almost 10 years ago to test whether these data could be reproduced in the real world.The data presented by Dr. Lee involved outcomes in 244 patients who were followed for at least 2.5 years. The median follow-up is 47 months.

The results overall confirm that this is a viable technique, according to Dr. Lee who noted very little diminution of patency rates in this long-term cohort relative to the previously published follow-up of 17.1 months.

He acknowledged that the snorkel/chimney repair is not free of potential complications, particularly gutter endovascular leaks, but he recounted that at least some resolve over time. Moreover, he suggests that several strategies are being pursued that appear promising for avoiding this risk.

Most importantly, the registry, which captured the experience at 13 centers in the United States and Europe, shows outcomes that are similar to those reported at centers where the techniques were developed and championed.

NEW YORK – With a median follow-up of almost 4 years in more than 200 patients, the snorkel/chimney technique of endovascular repair of complex abdominal aortic aneurysms continues to generate very good results, according data presented at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

In a video interview with Jason T. Lee, MD, professor of vascular surgery, Stanford (Calif.) University, who presented the long-term results, he explains why these findings are important.

After several single-center studies associated the snorkel/chimney technique with good rates of patency and durability, the PERICLES Registry was created almost 10 years ago to test whether these data could be reproduced in the real world.The data presented by Dr. Lee involved outcomes in 244 patients who were followed for at least 2.5 years. The median follow-up is 47 months.

The results overall confirm that this is a viable technique, according to Dr. Lee who noted very little diminution of patency rates in this long-term cohort relative to the previously published follow-up of 17.1 months.

He acknowledged that the snorkel/chimney repair is not free of potential complications, particularly gutter endovascular leaks, but he recounted that at least some resolve over time. Moreover, he suggests that several strategies are being pursued that appear promising for avoiding this risk.

Most importantly, the registry, which captured the experience at 13 centers in the United States and Europe, shows outcomes that are similar to those reported at centers where the techniques were developed and championed.

NEW YORK – Artificial intelligence is currently linked to specific problem solving and is not some form of Terminator model capable of handling multiple tasks with autonomy. In other words, each time you hear the term “AI,” it is a computer solving a specific problem or task using algorithms “and not ‘thinking’ like you and me,” said Ido Weinberg, MD, assistant professor, Harvard Medical School, Boston.

AI is present in daily life – everything from cellphones to the Alexa voice interface on a smart speaker. That AI system, however, is amassing data, learning about you, and using that data intelligently, Dr. Weinberg said at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

AI in health care make sense, he said, because the health sector is a vast consumer market with potential for financial gain. Repetition, which is common in the health sector, is one of the foundations required for using AI and robotics. If a task can be repeated, then it means a machine can do it, said Dr. Weinberg.

The spread of AI and robotics one day may improve health care accessibility in remote areas where physicians with the appropriate training may not be available.

AI is already at work in the health care industry. “Pulmonary nodule detection can be done better with machines than by people, pathological identification and scanning of various slides can be done better by a machine than by a humans,” he said.

Artificial intelligence also can be designed to detect emotion by assessing various cues in phrasing, key words, and tone. These AI functions already are being used by sales reps on the phone to defuse and control interactions with customers and complainants. AI also can be implemented in interactions with people, which is an important part of dealing with patients, Dr. Weinberg said. Drug discovery is a key area where AI is flourishing, as well.

Luckily, in terms of physicians keeping their jobs, there are barriers to the use of AI to replace clinicians, Dr. Weinberg pointed out. Health care is not a monolith, and every specialty is different, meaning AI would have to be tailored to each task and specialty for each unique field. Quick proliferation of AI across the board is unlikely, especially when the varying roles of nurses and physician assistants are included.

Although robots in science fiction stories and films often are capable of multitasking a variety of needs, robots at present are much more limited in real life. In surgical situations, for example, they can perform specifically tailored tasks but cannot extend beyond those defined parameters as a real surgeon can, according to Dr. Weinberg, and this lack of flexibility is a severe limitation on the expansion of AI into health care.

Despite these limitations, Dr. Weinberg urged attendees to consider how AI can be used to facilitate their work.

“Believe in the roadblocks, but be a fast adopter – an early adopter – and understand where AI can currently augment you and make you better and more productive,” he said. “And keep doing procedures; AI and robotics currently have a problem with most of those,” Dr. Weinberg concluded.

Dr. Weinberg reported no conflicts relevant to his talk.

mlesney@mdedge.com

NEW YORK – Artificial intelligence is currently linked to specific problem solving and is not some form of Terminator model capable of handling multiple tasks with autonomy. In other words, each time you hear the term “AI,” it is a computer solving a specific problem or task using algorithms “and not ‘thinking’ like you and me,” said Ido Weinberg, MD, assistant professor, Harvard Medical School, Boston.

AI is present in daily life – everything from cellphones to the Alexa voice interface on a smart speaker. That AI system, however, is amassing data, learning about you, and using that data intelligently, Dr. Weinberg said at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

AI in health care make sense, he said, because the health sector is a vast consumer market with potential for financial gain. Repetition, which is common in the health sector, is one of the foundations required for using AI and robotics. If a task can be repeated, then it means a machine can do it, said Dr. Weinberg.

The spread of AI and robotics one day may improve health care accessibility in remote areas where physicians with the appropriate training may not be available.

AI is already at work in the health care industry. “Pulmonary nodule detection can be done better with machines than by people, pathological identification and scanning of various slides can be done better by a machine than by a humans,” he said.

Artificial intelligence also can be designed to detect emotion by assessing various cues in phrasing, key words, and tone. These AI functions already are being used by sales reps on the phone to defuse and control interactions with customers and complainants. AI also can be implemented in interactions with people, which is an important part of dealing with patients, Dr. Weinberg said. Drug discovery is a key area where AI is flourishing, as well.

Luckily, in terms of physicians keeping their jobs, there are barriers to the use of AI to replace clinicians, Dr. Weinberg pointed out. Health care is not a monolith, and every specialty is different, meaning AI would have to be tailored to each task and specialty for each unique field. Quick proliferation of AI across the board is unlikely, especially when the varying roles of nurses and physician assistants are included.

Although robots in science fiction stories and films often are capable of multitasking a variety of needs, robots at present are much more limited in real life. In surgical situations, for example, they can perform specifically tailored tasks but cannot extend beyond those defined parameters as a real surgeon can, according to Dr. Weinberg, and this lack of flexibility is a severe limitation on the expansion of AI into health care.

Despite these limitations, Dr. Weinberg urged attendees to consider how AI can be used to facilitate their work.

“Believe in the roadblocks, but be a fast adopter – an early adopter – and understand where AI can currently augment you and make you better and more productive,” he said. “And keep doing procedures; AI and robotics currently have a problem with most of those,” Dr. Weinberg concluded.

Dr. Weinberg reported no conflicts relevant to his talk.

mlesney@mdedge.com

NEW YORK – Artificial intelligence is currently linked to specific problem solving and is not some form of Terminator model capable of handling multiple tasks with autonomy. In other words, each time you hear the term “AI,” it is a computer solving a specific problem or task using algorithms “and not ‘thinking’ like you and me,” said Ido Weinberg, MD, assistant professor, Harvard Medical School, Boston.

AI is present in daily life – everything from cellphones to the Alexa voice interface on a smart speaker. That AI system, however, is amassing data, learning about you, and using that data intelligently, Dr. Weinberg said at a symposium on vascular and endovascular issues sponsored by the Cleveland Clinic Foundation.

AI in health care make sense, he said, because the health sector is a vast consumer market with potential for financial gain. Repetition, which is common in the health sector, is one of the foundations required for using AI and robotics. If a task can be repeated, then it means a machine can do it, said Dr. Weinberg.

The spread of AI and robotics one day may improve health care accessibility in remote areas where physicians with the appropriate training may not be available.

AI is already at work in the health care industry. “Pulmonary nodule detection can be done better with machines than by people, pathological identification and scanning of various slides can be done better by a machine than by a humans,” he said.

Artificial intelligence also can be designed to detect emotion by assessing various cues in phrasing, key words, and tone. These AI functions already are being used by sales reps on the phone to defuse and control interactions with customers and complainants. AI also can be implemented in interactions with people, which is an important part of dealing with patients, Dr. Weinberg said. Drug discovery is a key area where AI is flourishing, as well.

Luckily, in terms of physicians keeping their jobs, there are barriers to the use of AI to replace clinicians, Dr. Weinberg pointed out. Health care is not a monolith, and every specialty is different, meaning AI would have to be tailored to each task and specialty for each unique field. Quick proliferation of AI across the board is unlikely, especially when the varying roles of nurses and physician assistants are included.

Although robots in science fiction stories and films often are capable of multitasking a variety of needs, robots at present are much more limited in real life. In surgical situations, for example, they can perform specifically tailored tasks but cannot extend beyond those defined parameters as a real surgeon can, according to Dr. Weinberg, and this lack of flexibility is a severe limitation on the expansion of AI into health care.

Despite these limitations, Dr. Weinberg urged attendees to consider how AI can be used to facilitate their work.

“Believe in the roadblocks, but be a fast adopter – an early adopter – and understand where AI can currently augment you and make you better and more productive,” he said. “And keep doing procedures; AI and robotics currently have a problem with most of those,” Dr. Weinberg concluded.

Dr. Weinberg reported no conflicts relevant to his talk.

mlesney@mdedge.com

NEW YORK – Registry data can be used to craft guidance for determining the appropriateness of procedures at vein centers, based on data presented by Thomas W. Wakefield, MD at the 2018 Veith Symposium.

The Vascular Quality Initiative Varicose Vein Registry (VQI-VVR), initiated in 2014 by the Society for Vascular Surgery in conjunction with the American Venous Forum, captures procedures that are performed in vein centers, office-based practices, and ambulatory or inpatient settings. The VVR looks at ablation and phlebectomy techniques and captures data including patient demographics, history, procedure data, plus early and late office-based and patient-reported follow-up in order to benchmark and improve outcomes and develop best practices and to help meet vein center certification requirements. The VVR includes 39 centers and more than 23,000 procedures.

Dr. Wakefield, who heads the VVR, used this registry as a means to illustrate how VQIs could be used to establish whether “the expected health benefit exceeds the expected negative consequences by a sufficiently wide margin that the procedure is worth doing.” This can be considered to be “appropriateness, which is part of ethical treatment.” Dr. Wakefield is the Stanley Professor of Vascular Surgery at the University of Michigan and section head, vascular surgery, University of Michigan Cardiovascular Center, Ann Arbor.

Data from the VQI registry (of which the VVR is a component) are now being used to generate appropriateness reports, said Dr. Wakefield.

The VQI represents a large comprehensive database of long-term data to define appropriate care. In addition, the VQI infrastructure is already geared to producing these reports both at a center and at a surgeon level. One disadvantage of the VVR registry, however, is low participation – only the 39 centers – and that it doesn’t capture cosmetic procedures and lesser (C1) disease. Further, it’s “likely the VQI participants are the ‘good actors,’ ” he added.

Targets for appropriateness include the proportion of patients undergoing ablation C2 or C4 disease or greater, the mean number of ablations per patient, the mean number of ablations per limb, and the proportion of perforated ablations for greater than C4 disease. Plotting out the data for these procedures at the center level can be assessed against current thinking on best practices in the various areas. For example, “the mean number of ablations per patient has been suggested at 1.8 to be about the right number,” and he used the graph of the center performance in this area to show that most of the centers were below this objective.

In an even more appropriate example of how this kind of data could be used to determine appropriateness, Dr. Wakefield described how perforated ablations should be performed for greater than C4 disease, but not for C2 disease. He described how, according to the actual data in the registry, there have been 870 total perforated treatments recorded, 38% for C2 disease, and of these 332 procedures, almost half of these were performed at one center only, with two other centers reporting 30 such procedures. “So clearly there are three centers that are doing perforated ablations for patients that are outside the guidelines,” Dr. Wakefield pointed out.

In future, payer demand is likely to demand that each treating physician provide evidence of the appropriateness of procedures performed, as well as appropriate patient selection and adherence to best practices, and good outcomes, which is part of what a society-based registry such as the VVR can provide.

“I believe the VQI-VVR is well-positioned to meet these needs. And if we ask the question ‘can VQI be used as a benchmark for setting ethical standards,’ I think it can certainly be used to help set appropriate standards, and since appropriateness is one part of ethical standards, I believe it has a role,” he concluded.

Dr. Wakefield reported that he had no disclosures.

mlesney@mdedge.com

NEW YORK – Registry data can be used to craft guidance for determining the appropriateness of procedures at vein centers, based on data presented by Thomas W. Wakefield, MD at the 2018 Veith Symposium.

The Vascular Quality Initiative Varicose Vein Registry (VQI-VVR), initiated in 2014 by the Society for Vascular Surgery in conjunction with the American Venous Forum, captures procedures that are performed in vein centers, office-based practices, and ambulatory or inpatient settings. The VVR looks at ablation and phlebectomy techniques and captures data including patient demographics, history, procedure data, plus early and late office-based and patient-reported follow-up in order to benchmark and improve outcomes and develop best practices and to help meet vein center certification requirements. The VVR includes 39 centers and more than 23,000 procedures.

Dr. Wakefield, who heads the VVR, used this registry as a means to illustrate how VQIs could be used to establish whether “the expected health benefit exceeds the expected negative consequences by a sufficiently wide margin that the procedure is worth doing.” This can be considered to be “appropriateness, which is part of ethical treatment.” Dr. Wakefield is the Stanley Professor of Vascular Surgery at the University of Michigan and section head, vascular surgery, University of Michigan Cardiovascular Center, Ann Arbor.

Data from the VQI registry (of which the VVR is a component) are now being used to generate appropriateness reports, said Dr. Wakefield.

The VQI represents a large comprehensive database of long-term data to define appropriate care. In addition, the VQI infrastructure is already geared to producing these reports both at a center and at a surgeon level. One disadvantage of the VVR registry, however, is low participation – only the 39 centers – and that it doesn’t capture cosmetic procedures and lesser (C1) disease. Further, it’s “likely the VQI participants are the ‘good actors,’ ” he added.

Targets for appropriateness include the proportion of patients undergoing ablation C2 or C4 disease or greater, the mean number of ablations per patient, the mean number of ablations per limb, and the proportion of perforated ablations for greater than C4 disease. Plotting out the data for these procedures at the center level can be assessed against current thinking on best practices in the various areas. For example, “the mean number of ablations per patient has been suggested at 1.8 to be about the right number,” and he used the graph of the center performance in this area to show that most of the centers were below this objective.

In an even more appropriate example of how this kind of data could be used to determine appropriateness, Dr. Wakefield described how perforated ablations should be performed for greater than C4 disease, but not for C2 disease. He described how, according to the actual data in the registry, there have been 870 total perforated treatments recorded, 38% for C2 disease, and of these 332 procedures, almost half of these were performed at one center only, with two other centers reporting 30 such procedures. “So clearly there are three centers that are doing perforated ablations for patients that are outside the guidelines,” Dr. Wakefield pointed out.

In future, payer demand is likely to demand that each treating physician provide evidence of the appropriateness of procedures performed, as well as appropriate patient selection and adherence to best practices, and good outcomes, which is part of what a society-based registry such as the VVR can provide.

“I believe the VQI-VVR is well-positioned to meet these needs. And if we ask the question ‘can VQI be used as a benchmark for setting ethical standards,’ I think it can certainly be used to help set appropriate standards, and since appropriateness is one part of ethical standards, I believe it has a role,” he concluded.

Dr. Wakefield reported that he had no disclosures.

mlesney@mdedge.com

NEW YORK – Registry data can be used to craft guidance for determining the appropriateness of procedures at vein centers, based on data presented by Thomas W. Wakefield, MD at the 2018 Veith Symposium.

The Vascular Quality Initiative Varicose Vein Registry (VQI-VVR), initiated in 2014 by the Society for Vascular Surgery in conjunction with the American Venous Forum, captures procedures that are performed in vein centers, office-based practices, and ambulatory or inpatient settings. The VVR looks at ablation and phlebectomy techniques and captures data including patient demographics, history, procedure data, plus early and late office-based and patient-reported follow-up in order to benchmark and improve outcomes and develop best practices and to help meet vein center certification requirements. The VVR includes 39 centers and more than 23,000 procedures.

Dr. Wakefield, who heads the VVR, used this registry as a means to illustrate how VQIs could be used to establish whether “the expected health benefit exceeds the expected negative consequences by a sufficiently wide margin that the procedure is worth doing.” This can be considered to be “appropriateness, which is part of ethical treatment.” Dr. Wakefield is the Stanley Professor of Vascular Surgery at the University of Michigan and section head, vascular surgery, University of Michigan Cardiovascular Center, Ann Arbor.

Data from the VQI registry (of which the VVR is a component) are now being used to generate appropriateness reports, said Dr. Wakefield.

The VQI represents a large comprehensive database of long-term data to define appropriate care. In addition, the VQI infrastructure is already geared to producing these reports both at a center and at a surgeon level. One disadvantage of the VVR registry, however, is low participation – only the 39 centers – and that it doesn’t capture cosmetic procedures and lesser (C1) disease. Further, it’s “likely the VQI participants are the ‘good actors,’ ” he added.

Targets for appropriateness include the proportion of patients undergoing ablation C2 or C4 disease or greater, the mean number of ablations per patient, the mean number of ablations per limb, and the proportion of perforated ablations for greater than C4 disease. Plotting out the data for these procedures at the center level can be assessed against current thinking on best practices in the various areas. For example, “the mean number of ablations per patient has been suggested at 1.8 to be about the right number,” and he used the graph of the center performance in this area to show that most of the centers were below this objective.

In an even more appropriate example of how this kind of data could be used to determine appropriateness, Dr. Wakefield described how perforated ablations should be performed for greater than C4 disease, but not for C2 disease. He described how, according to the actual data in the registry, there have been 870 total perforated treatments recorded, 38% for C2 disease, and of these 332 procedures, almost half of these were performed at one center only, with two other centers reporting 30 such procedures. “So clearly there are three centers that are doing perforated ablations for patients that are outside the guidelines,” Dr. Wakefield pointed out.

In future, payer demand is likely to demand that each treating physician provide evidence of the appropriateness of procedures performed, as well as appropriate patient selection and adherence to best practices, and good outcomes, which is part of what a society-based registry such as the VVR can provide.

“I believe the VQI-VVR is well-positioned to meet these needs. And if we ask the question ‘can VQI be used as a benchmark for setting ethical standards,’ I think it can certainly be used to help set appropriate standards, and since appropriateness is one part of ethical standards, I believe it has a role,” he concluded.

Dr. Wakefield reported that he had no disclosures.

mlesney@mdedge.com