Vascular surgeons are endovascularly-trained and have better safety records

Oct 28 2009

Vascular surgeons have the highest market share and the lowest overall mortality and morbidity rates for peripheral arterial interventions (PAI), when compared to interventional cardiologists and interventional radiologists who also perform this procedure. Mohammad H. Eslami, MD, FACS, associate professor of vascular surgery at the University of Massachusetts Medical School in Worcester and his colleagues findings reported in the Nov. 2009 issue of the Journal of Vascular Surgery®, published by the Society for Vascular Surgery®.

"With all three specialties involved in PAI procedures, there has been a significant increase of PAI which in certain locations has led to significant 'turf wars' as to who should perform them and who should not," said Dr. Eslami.

"Using the Nationwide Inpatient Sample our research team reviewed 23,825 PAI cases (about 75 percent of the providers' specialties) from 1998 to 2005," add Dr. Eslami. "We found the market share for vascular surgeons increased from 27 percent to 43 percent, while the cardiologists' share rose from 10 to 29 percent. The radiologists, who previously almost exclusively used endovascular methods to treat patients with peripheral arterial disease (PAD), had their share decrease from 36 percent to 6 percent. A yearly percentage of unidentified providers remained relatively stable with a median value of 22 percent, and did not affect the market share trends."

The majority of all PAI procedures (52.3 percent) were performed at teaching hospitals, where trends were even more pronounced, showing that market shares for vascular surgeons and interventional cardiologist were higher, compared to the radiologists' share which again reflected a decline. In these settings the vascular surgeons' market share even had a more robust rise during the study period (18 percent to 48 percent).

Researchers noted that in-hospital mortality rates were highest for radiologists 2.1 percent vs. 1.2 percent for vascular surgeons and 0.6 percent for interventional cardiologists. When combing the overall post-procedure iatrogenic arterial injuries (IAI) and mortality, the vascular surgeon group was the lowest at 1.7 percent. The radiologists had 3.00 percent; cardiologists were at 3.04 percent. Compared with vascular surgeons, the mortality rate odds ratio was 1.62 times higher for the radiologist group's patients.

The vascular surgeons also had the lowest post-procedure IAI at 0.5 percent compared to the radiologists at 0.9 percent and cardiologists at 1.3 percent. Study authors indicated that a higher percentage of IAI for the cardiology group may be due that it having the highest rates of elective admissions for PAI, which suggests a prior diagnostic evaluation during cardiac catheterization.

"In previous research 25 percent of PAI performed by cardiologists are performed soon after catheterization, while only 5 percent are performed the same day," said Dr. Eslami. "Re-entry of the access artery within a short time after the initial cardiac catheterization may predispose these arteries to injury and may lead to a higher rate of IAI among the patients."

Researchers noted that PAI has increased seven-fold from 1976 to 1996 for patients with peripheral artery disease (PAD) because endovascular methods are replacing traditional therapies. The rapid growth of PAI may stem from higher rate of diagnosis of PAD by primary care providers, an increasing U.S. population age with correspondingly higher arterial occlusive disease rates and the improvement of PAI techniques. Researchers added that perhaps the most significant contributing factor to the increasing number of interventions is when PAD is revealed in patients through diographic (radiographic) diagnosis during coronary evaluations.

"We concluded vascular surgeons are endovascularly-trained, and have better access to fluoroscopy units and better safety records; therefore they will continue to increase their market share," said Dr. Esalmi.