The decline of open abdominal aortic aneurysm surgery among individual training programs and vascular surgery trainees.

OBJECTIVE: In the past decade, treatment of abdominal aortic aneurysm (AAA) has dramatically shifted from open repair to an endovascular approach. The decreasing number of open AAA repairs (OAR) has raised concerns regarding future vascular surgeons' competence to perform this complex and high-risk procedure. Prior work has documented decreasing open aortic volume among surgical residents. However, these studies report average national case volume with a limited understanding of the variation in OAR exposure among training programs and trainees. We sought to evaluate the current open AAA repair trends among individual accredited vascular surgery training programs and vascular surgery residents to better evaluate trainees' exposure to OAR.

METHODS: We identified elderly Medicare beneficiaries undergoing OAR and endovascular aneurysm repair (EVAR) between 2010 and 2014. Accredited vascular surgery training program hospitals were identified. OAR and EVAR volume was aggregated at the program level and the number of senior vascular surgery trainees per year at each program was captured. The training program all-payer total AAA repair volume was calculated based on the national proportion of patients undergoing AAA covered by Medicare in the Vascular Quality Initiative. Temporal trends in program and vascular surgery trainee OAR and EVAR volume were calculated.

RESULTS: A total of 119,408 (77%) EVAR and 35,042 (23%) were identified in the Medicare database between 2010 and 2014. Of these, 21% were performed among the 111 training programs, including 22,227 (73%) EVAR and 8416 (27%) OAR. The total OAR volume among training programs decreased by 38% during the study period, from a median of 29.1 to 18.2 OAR. In 2014, 25% of programs performed fewer than 10 OARs annually. Among senior vascular surgery trainees, the median number of OAR decreased from 10.0 in 2010 to 6.4 in 2014 and approximately one-half of senior trainees had exposure to fewer than five OAR in 2014.

CONCLUSIONS: Exposure to OAR among vascular surgery training programs has dramatically decreased, with nearly one-half of senior trainees performing fewer than five OAR in 2014. The variable and diminishing OAR exposure among vascular surgery training program highlights growing concerns surrounding competence in complex open repairs and suggest that only a small proportion of current trainees have ample opportunity to develop confidence and proficiency in this high-risk operation.