The COVID-19 pandemic has had an unprecedented impact on the healthcare system in the United States. The redistribution of resources and suspension of elective procedures and other services has placed a financial stress across all service lines. The financial impact on the practice of vascular surgery has not yet been quantified. This study hypothesized that vascular surgery divisions have experienced losses affecting the hospital and professional side that will not be recoupable without significant productivity increases. Administrative claims data for clinical services performed by the vascular surgery division at a tertiary medical center from March-April 2019 and March-April 2020 were analyzed. These claims were separated into two categories: Hospital claims (Inpatient and Outpatient) and Professional claims (professional reimbursement for all services provided). Medicare reimbursement methodologies were utilized to assign financial value: Diagnosis-Related Group (DRG) for inpatient services, Ambulatory Payment Classification (APC) for outpatient services, and Medicare Physician Fee Schedule (MPFS) for professional reimbursement and work relative value units (wRVU). Reimbursements and productivity (wRVU) were compared between the two time periods. A financial model was created to determine the increase in future productivity over baseline required to mitigate losses incurred during the pandemic. A total of 11,317 vascular surgery claims were reviewed. Hospital reimbursement during the pandemic decreased from $4,982,114 to $2,649,521, -47% (inpatient: $3,505,775 to $2,128,133, -39%; outpatient $1,476,339 to $521,388, -65%) while professional reimbursement decreased from $933,897 to $430,967, -54% when compared to the same time period in 2019. Professional productivity as measured by wRVUs sustained a similar decline from 10478 wRVU to 5386 wRVU, -51%. Modeling sensitivity analyses demonstrated that if a vascular division were able to increase Inpatient and Outpatient revenue, above pre-pandemic levels, by 10%, 5%, or 3%, it would take 9 months, 19 months, or 31 months, respectively, for the hospital to recover pandemic-associated losses. Similarly, professional reimbursement recovery would require 11 months, 20 months, or 36 months for a similar increase in productivity. The COVID-19 pandemic has had a profound and lasting impact on the world in terms of lives lost and financial hardships. The financial impact on a vascular surgery division has resulted in losses ranging from 39% to 65% when compared to pre-pandemic period the previous year. Because complete mitigation of losses is not feasible in the short-term, alternative and novel strategies are needed to financially sustain the vascular division and hospital during a prolonged recovery period.

BACKGROUND: Fenestrated endografts are customized, patient-specific, endovascular devices with potential to significantly reduce morbidity and mortality of short-neck infrarenal and juxtarenal abdominal aortic aneurysm repair. The Zenith fenestrated endovascular graft (ZFEN) for abdominal aortic aneurysms (Cook Medical, Bloomington, Ind), Food and Drug Administration-approved in 2012, remains the only fenestrated device available in the United States. This technology is among the most technically complex catheter-based procedures and, therefore, inherently associated with serious risk for device-related complications. We sought to define patterns of physician and hospital adoption of ZFEN. METHODS: Deidentified datasets containing numbers of physicians trained, orders by physicians and hospitals, and designs (fenestration/scallop configuration) was provided for U.S. ZFEN devices ordered (April 2012-August 2015). We evaluated the number of physicians trained, the number of devices ordered, hospital characteristics, and fenestration/scallop design configurations. Cook Medical assembled the datasets but played no role in study design, analysis, or interpretation of data. RESULTS: Between April 2012 and August 2015, 553 physicians attended formal ZFEN training sessions, 388 (70%) of whom ordered a total of 2669 devices. An increase in orders per month (nine in June 2012 and 91 in August 2015, 911% growth; P < .001) and in number of physicians ordering per month (eight in June 2012 and 62 in August 2015, 675% growth; P < .001) was observed. Teaching hospitals, representing all U.S. regions (Midwest 927, 35%; South 799, 30%; Northeast 547, 20%; West 396, 15%), accounted for 1703 (64%) ZFEN orders. Of 553 trained physicians, 165 (30%) ordered no devices, 116 (21%) ordered 1 device, 144 (26%) ordered 2-5 devices, 61 (11%) ordered 6-10 devices, 39 (7%) ordered 11-20, and 28 (5%) ordered > 20 devices. For physicians contributing > 6 months of data (n = 336), the average number of devices ordered per year was three (standard deviation, 4); 272 (81%) ordered < /= 5 devices/year, 15 (4.5%) ordered 11-20 devices/year, and 3 (0.9%) ordered > 20 devices/year. Of devices with design details available (2618 of 2669; 98%), most common designs were 2 small fenestrations/1 scallop (1443; 55%), 2 small fenestrations/1 large fenestration (568; 22%), 1 small fenestration/1 scallop (173, 6.6%), and 2 small fenestrations (169; 6.5%). The average number of target vessels incorporated in each design was 2.7/device; 2071 (79%) incorporated three, 398 (15%) incorporated two. CONCLUSIONS: Since 2012, ZFEN has demonstrated a ninefold increase in monthly orders, with 553 physicians trained. Unlike the experience of rapid dissemination seen with infrarenal endografts, only 28 (5%) physicians have ordered > 20, whereas 165 (30%) have ordered none, and 272 (81%) ordered < /= 5 devices/year. Assuming that volume, in general, correlates with outcomes, this adoption pattern raises questions whether fenestrated technology should be regionalized to high-volume centers.

BACKGROUND: More than 80% of infrarenal aortic aneurysms are treated by endovascular repair. However, adoption of fenestrated and branched endovascular repair for complex aortic aneurysms has been limited, despite high morbidity and mortality associated with open repair. There are few published reports of consecutive outcomes, inclusive of all fenestrated and branched endovascular repairs, starting from the inception of a complex aortic aneurysm program. Therefore, we examined a single center's consecutive experience of fenestrated and branched endovascular repair of complex aortic aneurysms. METHODS: This is a single-center, prospective, observational cohort study evaluating 30-day and 1-year outcomes in all consecutive patients who underwent fenestrated and branched endovascular repair of complex aortic aneurysms (definition: requiring one or more fenestrations or branches). Data were collected prospectively through an Institutional Review Board-approved registry and a physician-sponsored investigational device exemption clinical trial (G130210). RESULTS: We performed 100 consecutive complex endovascular aortic aneurysm repairs (November 2010 to March 2016) using 58 (58%) commercially manufactured custom-made devices and 42 (42%) physician-modified devices to treat 4 (4%) common iliac, 42 (42%) juxtarenal, 18 (18%) pararenal, and 36 (36%) thoracoabdominal aneurysms (type I, n = 1; type II, n = 4; type III, n = 12; type IV, n = 18; arch, n = 1). The repairs included 309 fenestrations, branches, and scallops (average of 3.1 branch arteries/case). All patients had 30-day follow-up for 30-day event rates: three (3%) deaths; six (6%) target artery occlusions; five (5%) progressions to dialysis; eight (8%) access complications; one (1%) paraparesis; one (1%) bowel ischemia; and no instances of myocardial infarction, paralysis, or stroke. Of 10 type I or type III endoleaks, 8 resolved (7 with secondary intervention, 1 without intervention). Mean follow-up time was 563 days (interquartile range, 156-862), with three (3%) patients lost to follow-up. On 1-year Kaplan-Meier analysis, survival was 87%, freedom from type I or type III endoleak was 97%, target vessel patency was 92%, and freedom from aortic rupture was 100%. Average lengths of intensive care unit stay and inpatient stay were 1.4 days (standard deviation, 3.3) and 3.6 days (standard deviation, 3.6), respectively. CONCLUSIONS: These results show that complex aortic aneurysms can now be treated with minimally invasive fenestrated and branched endovascular repair. Endovascular technologies will likely continue to play an increasingly important role in the management of patients with complex aortic aneurysm disease.

OBJECTIVE: Carotid artery stenting (CAS) has emerged as an alternative to carotid endarterectomy (CEA) for the treatment of carotid artery stenosis. Unlike CEA, CAS is performed by a wide variety of specialists including vascular surgeons (VS), interventional cardiologists (IC), and interventional radiologists (IR). This study compares the indications, in-patient mortality rate, and in-patient stroke rate for patients undergoing CAS, according to operator specialty. METHODS: The State In-patient Databases from New York and Florida, made available by the Healthcare Cost and Utilization Project, were reviewed by International Classification of Disease (ICD)-9-CM codes to identify all patients treated with CAS for the years 2005 and 2006. This cohort was then stratified according to operator specialty defined by procedures performed by each operator over the years surveyed. Primary endpoints were in-patient death and stroke. Propensity score matching adjusting for indication, demographics, and comorbidities was employed to evaluate the influence of operator type on outcomes. RESULTS: During the study period, 4001 CAS procedures were performed. All primary analyses compared VS (n = 1350) to non-VS (n = 2651). Patient characteristics were similar, except VS treated fewer patients with CAD (44.2% vs 50.9%, P < .001) and valvular disease (6.3% vs 8.6%, P = .01) and more patients with chronic lung disease (19.4% vs 15.9%, P = .01). Each group performed an equal proportion of CAS for symptomatic disease (8.1% vs 9.0%, P = .32). Univariate analysis revealed no difference in mortality (0.9% vs 0.5%, P = .13) or stroke (1.3% vs 1.5%, P = .73). Propensity score matched analysis also demonstrated no difference in mortality (0.7% vs 0.4%, P = .48) or stroke (1.1% vs 1.7%, P = .27). Subgroup analysis comparing VS, IC, and IR showed no significant difference in mortality or stroke, but demonstrated that of the three specialties, IC treated the smallest proportion of symptomatic patients. The proportion of CAS performed by VS differed significantly by state (New York 46%, Florida 19%, P < .01). CONCLUSION: Despite a paucity of level 1 evidence for CAS in asymptomatic patients and current Centers for Medicare and Medicaid Services (CMS) policy limiting reimbursement for CAS to only high-risk symptomatic patients, VS and non-VS are treating primarily asymptomatic patients. Perioperative rates of stroke and death are equivalent between VS, IC, and IR. Regional variation of operator type is substantial, and despite similar outcomes, <50% of CAS is performed by VS.

BACKGROUND: Endovascular procedure volume has increased rapidly, and endovascular procedures have become the initial treatment option for many vascular diseases. Consequently, training in endovascular procedures has become an essential component of vascular surgery training. We hypothesized that, due to this paradigm shift, open surgical case volume may have declined, thereby jeopardizing training and technical skill acquisition in open procedures. METHODS: Vascular surgery trainees are required to log both open and endovascular procedures with the Accreditation Council for Graduate Medical Education (ACGME). We analyzed the ACGME database (2001-2007), which records all cases (by Current Procedural Terminology [CPT] code) performed by graduating vascular trainees. Case volume was evaluated according to the mean number of cases performed per graduating trainee. RESULTS: The mean number of total major vascular procedures performed per trainee increased by 174% between 2001 and 2007 (from 298.3 to 519.2). Endovascular diagnostic and therapeutic procedures increased by 422% (from 63.7 to 269.1) and accounted for 93.0% of the increase in total procedures. The number of open aortic procedures (aneurysm, occlusive, mesenteric, renal) decreased by 17.1% (from 49.7 to 41.2), while the number of endovascular aortic aneurysm repair procedures increased by 298.8% (from 16.9 to 50.5). Specifically, open aortic aneurysm procedures decreased by 21.8%, aortobifemoral bypass increased by 3.2%, and open mesenteric or renal procedures decreased by 13%. Infrainguinal bypass procedures remained relatively constant (from 37.6 to 36.5, 2.9% decrease), and the number of carotid endarterectomy procedures performed did not change significantly (from 43.6 to 42.2, 3.2% decrease). CONCLUSION: Vascular surgery trainees are performing a vastly increased total number of procedures. This increase in total procedure volume is almost entirely attributable to the recent increase in endovascular procedures. Aside from a small decline in open aortic procedures, the volume of open surgical procedures has largely remained stable. It is essential that vascular surgery training programs continue to focus on both endovascular and open surgical skills in order for vascular surgeons to remain the premier specialists to care for patients with vascular disease.