Variations in Abdominal Aortic Aneurysm Care: A Report from the International Consortium of Vascular Registries
Background—This project by the International Consortium of Vascular Registries, a collaboration of 11 vascular surgical quality registries, was designed to evaluate international variation in the contemporary management of abdominal aortic aneurysm (AAA) with relation to recommended treatment guidelines from the Society for Vascular Surgery and the European Society for Vascular Surgery.
Methods—Registry data for open and endovascular AAA repair during 2010-2013 were collected from 11 countries. Variations in patient selection and treatment were compared across countries and across centers within countries.
Results—Among 51,153 patients, 86% were treated for intact AAA (iAAA) and 14% for ruptured AAA (rAAA). Women constituted 18% of the entire cohort (range: 12% Switzerland, 21% USA, p<0.01). Intact AAA were repaired at smaller than guideline-recommended diameters in 31% of men (<5.5cm, range: 6% Iceland, 41% Germany, p<0.01) and 12% of women with iAAA (<5cm, range 0% Iceland, 16% USA, p<0.01). Overall, utilization of EVAR for iAAA varied from 28% in Hungary to 79% in the USA, p<0.01, and for rAAA from 5% in Denmark to 52% in the USA, p<0.01. In addition to the between country variations, significant variations were present between centers in each country in terms of EVAR use and rate of small AAA repair. Countries that more frequently treated small AAAs tended to use EVAR more frequently (trend: correlation coefficient 0.51, p=0.14). Octogenarians made up 23% of all patients with a range of 12% in Hungary to 29% in Australia, p<0.01. In countries with a fee-for-service reimbursement system (Australia, Germany, Switzerland, USA), the proportion of small AAA (33%) and octogenarians undergoing iAAA repair (25%) was higher compared to countries with a population-based reimbursement model (small AAA repair 16%, octogenarians 18%), p<0.01. In general, center-level variation within countries in management of AAA was as important as variation between countries.
Conclusions—Despite homogeneous guidelines from professional societies, significant variation exists in the management of AAA, most notably for iAAA diameter at repair, utilization of EVAR and the treatment of elderly patients. ICVR provides an opportunity to study treatment variation across countries and to encourage optimal practice by sharing these results.
- Clinical practice
- aortic surgery
- endovascular repair
- international comparison
- Received August 5, 2016.
- Revision received September 18, 2016.
- Accepted September 29, 2016.
Circulation is published on behalf of the American Heart Association, Inc., by Wolters Kluwer. This is an open access article under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0/), which permits use, distribution, and reproduction in any medium, provided that the original work is properly cited.