Evolution and Contemporary National Benchmarks in Endovascular Abdominal Aortic Aneurysm Repair from the Society for Vascular Surgery Vascular Quality Initiative.

Abstract

The Society for Vascular Surgery Vascular Quality Initiative (SVS-VQI) Endovascular Abdominal Aortic Aneurysm Repair (EVAR) Registry represents the largest and most comprehensive prospectively maintained non-claims-based dataset of endoluminal repairs in North America. As part of the SVS-VQI benchmarking initiative, we sought to define national reference standards for patient selection, perioperative outcomes, and process-of-care metrics. All EVAR procedures from 2011 to 2024 were included and stratified by indication as elective, symptomatic (intact, non-ruptured), or ruptured. The primary endpoint was in-hospital mortality; secondary endpoints included in-hospital complications, adherence to SVS guideline-endorsed elective diameter treatment thresholds (men ≥5.5 cm; women ≥5.0 cm), discharge prescription of guideline-directed medical therapy, and one-year follow-up compliance. Risk-adjusted observed-to-expected (O:E) mortality ratios were derived from mixed-effects logistic regression models incorporating patient- and procedure-level covariates. Temporal trends were analyzed using linear and logistic regression across four periods: 2011-13, 2014-17, 2018-21, and 2022-24. Among 90,370 EVARs performed across >400 centers, 76,350 (85%) were elective, 8,349 (9%) symptomatic-intact, and 5,671 (6%) ruptured. Mean patient age was 73.5±8.8 years, and 17,531 (19%) were women. Adoption of percutaneous femoral access increased markedly after 2014, exceeding 80% of all cases across the study period (overall rate 81.1% [95%CI, 80.8-81.4]) and reaching a contemporary benchmark of 89.4% (95%CI, 89.1-89.8) in 2022-24. In-hospital mortality was 0.5% (95%CI, 0.42-0.52) for elective, 2.2% (1.91-2.56) for symptomatic-intact, and 21.5% (20.4-22.6) for ruptured repairs. Over time, mortality declined from 0.6% in 2011-13 to 0.4% in 2022-24 (p=.02) for elective cases, from 2.3% to 1.8% (p=.14) for symptomatic-intact, and from 24.0% to 20.6% (p=.09) for ruptures. Composite in-hospital complication rates decreased significantly across all indications (p<.001). Among elective repairs, adherence to diameter-based guidelines improved modestly, with male non-compliance decreasing from 46% to 40% and female non-compliance declining from 23% to 21%. In 2024, 87% of patients were discharged on an antiplatelet agent, 83% on a statin, and 74% on both. By 2022, one-year clinical follow-up reached 79%, while imaging surveillance was reported in 51%. EVAR outcomes within the SVS-VQI demonstrate persistently low in-hospital mortality and improving perioperative morbidity over time. Despite these gains, opportunities remain to improve adherence to societally endorsed diameter treatment thresholds, optimal medical therapy, and post-EVAR imaging surveillance. These findings establish contemporary national benchmarks for EVAR performance and provide reference standards for center-level comparison and quality improvement within the SVS-VQI.