Since FDA approval of endovascular aneurysm repair in 1999, the management of abdominal aortic aneurysms has transformed. Only 5.2% of AAAs were repaired by EVAR in 2000 compared to 74% in 2010. While the volume of AAA cases has remained constant at about 45,000 cases annually, the increase in EVAR has led to a 34% drop in open AAA cases. This national decline in open AAA cases is paralleled by a 33% decline in open AAA cases completed by vascular trainees since 2001, as reported in national Accreditation Council for Graduate Medical Education case logs.
In conjunction with this decrease in open AAA repair volume, trainees are reporting low confidence in independently performing open aneurysm cases, with nearly 40% of 2014 graduating vascular trainees having expressed low confidence in their ability on a 3-point Likert scale (1 – not confident, 2 – somewhat confident, 3 – very confident).
Over the past decade, we have also seen a threefold increase in adjudicated cases against vascular surgeons due to complications arising from open AAA cases, along with an increase in litigation against vascular surgeons who have been in practice for fewer than 3 years.
Open AAA surgery volume will continue to decrease as branched and fenestrated technology improves, and as expanded utilization in patients with complex anatomy occurs with the next generation of endografts.
By 2020, based on prediction models, vascular trainees will complete only five open aneurysm cases during their training, This raises serious questions about how we will educate the next generation of vascular surgeons to safely and effectively manage patients who can be treated only by open repair.