Adoption of Endovascular Repair of Abdominal Aortic Aneurysm in California: Lessons for Future Dissemination of Surgical Technology

BackgroundKnowledge of the pattern of adoption of endovascular approach (endovascular aortic repair [EVAR]) to abdominal aortic aneurysm (AAA) could direct future dissemination of complex surgical technology.MethodsRetrospective longitudinal analysis of the California Office of Statewide Health Planning and Development inpatient database from 2001 to 2008, accompanied by a cross-sectional survey of surgeons. The setting was all inpatient hospitals in California. Patients were those who underwent repair of AAA. The main outcome measure was the endovascular repair of AAA and the training experience of the surgeons.ResultsOf the 33,277 patients with AAA, 11,755 (35%) underwent endovascular repair; 76% were men, mean age was 73 (median, 75) years, 13% of aneurysms were ruptured, and 20% were treated at teaching hospitals. The rate of EVAR increased from 19% in 2001 to 55% in 2008. On multivariate analysis, calendar year, older age, male gender, nonruptured status, teaching hospitals, and high-volume hospitals, but not race or insurance status, were identified as independent predictors of EVAR. The survey revealed that surgeons with ≥15 years of experience obtained their training primarily from the manufacturer (58.8%), whereas those with <15 years of experience obtained their training primarily during residency or fellowship (96.7%).ConclusionBetween 2001 and 2008, there was a 290% increase in the rate of EVAR for AAA in California. The early adopters obtained their training directly or indirectly from the manufacturers. Training programs did not begin to offer formal training in this technology until the rapid growth was already taking place. This suggests that academic medical centers and/or professional organizations should develop plans to play a stronger and earlier role in educating physicians about a new technology.