title: The impact of endovascular repair on specialties performing abdominal aortic aneurysm repair.
abstract: BACKGROUND
  Abdominal aortic aneurysm (AAA) repair has been performed by various surgical specialties for many years. Endovascular aneurysm repair (EVAR) may be a disruptive technology, having an impact on which specialties care for patients with AAA. Therefore, we examined the proportion of AAA repairs performed by various specialties over time in the United States and evaluated the impact of the introduction of EVAR.
  
  
  METHODS
  The Nationwide Inpatient Sample (2001-2009) was queried for intact and ruptured AAA and for open repair and EVAR. Specific procedures were used to identify vascular surgeons (VSs), cardiac surgeons (CSs), and general surgeons (GSs) as well as interventional cardiologists and interventional radiologists for states that reported unique treating physician identifiers. Annual procedure volumes were subsequently calculated for each specialty.
  
  
  RESULTS
  We identified 108,587 EVARs and 85,080 open AAA repairs (3011 EVARs and 12,811 open repairs for ruptured AAA). VSs performed an increasing proportion of AAA repairs during the study period (52% in 2001 to 66% in 2009; P < .001). GSs and CSs performed fewer repairs during the same period (25% to 17% [P < .001] and 19% to 13% [P < .001], respectively). EVAR was increasingly used for intact (33% to 78% of annual cases; P < .001) as well as ruptured AAA repair (5% to 28%; P < .001). The proportion of intact open repairs performed by VSs increased from 52% to 65% (P < .001), whereas for EVAR, the proportion went from 60% to 67% (P < .001). The proportion performed by VSs increased for ruptured open repairs from 37% to 53% (P < .001) and for ruptured EVARs from 28% to 73% (P < .001). Compared with treatment by VSs, treatment by a CS (0.55 [0.53-0.56]) and GS (0.66 [0.64-0.68]) was associated with a decreased likelihood of undergoing endovascular rather than open AAA repair.
  
  
  CONCLUSIONS
  VSs are performing an increasing majority of AAA repairs, in large part driven by the increased utilization of EVAR for both intact and ruptured AAA repair. However, GSs and CSs still perform AAA repair. Further studies should examine the implications of these national trends on the outcome of AAA repair.
authors.affiliation: Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
authors.forename: Rob
authors.initials: R
authors.lastname: Hurks
authors.affiliation: Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.|Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands.
authors.forename: Klaas H J
authors.initials: KHJ
authors.lastname: Ultee
authors.affiliation: Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.|Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Dominique B
authors.initials: DB
authors.lastname: Buck
authors.affiliation: Critical Care Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
authors.forename: George S
authors.initials: GS
authors.lastname: DaSilva
authors.affiliation: Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
authors.forename: Peter A
authors.initials: PA
authors.lastname: Soden
authors.affiliation: Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Joost A
authors.initials: JA
authors.lastname: van Herwaarden
authors.affiliation: Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands.
authors.forename: Hence J M
authors.initials: HJM
authors.lastname: Verhagen
authors.affiliation: Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
authors.forename: Marc L
authors.initials: ML
authors.lastname: Schermerhorn
mesh_terms: D000368:Aged; D017544:Aortic Aneurysm, Abdominal / Q000175:diagnosis / Q000601:surgery*; D001019:Aortic Rupture / Q000175:diagnosis / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000639:trends*; D016208:Databases, Factual; D057510:Endovascular Procedures / Q000639:trends*; D005260:Female; D006801:Humans; D008297:Male; D010818:Practice Patterns, Physicians' / Q000639:trends*; D013038:Specialization / Q000639:trends*; D066231:Surgeons / Q000639:trends*; D013997:Time Factors; D014481:United States