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Noninvasive, Catheter-Based Procedures Increased by a Whopping 979% in the Late 1990s

The number of vascular procedures everything from repair of aneurysms to angioplasty for clogged neck arteries has doubled in the United States in the past 20 years, according to a new study by researchers from NewYork-Presbyterian Hospital. The jump was most pronounced for people over 75, who experienced a 67% increase in vascular procedures per capita between 1980 and 2000.

The study also found that noninvasive (endovascular) procedures that use catheters tiny tubes that are threaded through blood vessels are booming in popularity. Catheters allow surgeons to fix potentially life-threatening aneurysms and clear clogged arteries without opening up the body. Compared with traditional open surgery, patients who undergo catheter-based procedures generally have a rapid recovery and end up with only tiny scars as reminders of their treatment.

As the population continues to age, both innovative and traditional vascular procedures will only become more common, according to the report in the Journal of Vascular Surgery.

Our study found that 800,000 vascular procedures were conducted in 2000, and we predict based on the aging of the population that there will be as many as 2.2 million vascular cases by 2030, said senior investigator Dr. K. Craig Kent, Chief of the Division of Vascular Surgery at NewYork-Presbyterian Hospital and Professor of Surgery at Weill Cornell Medical College and Columbia University College of Physicians Surgeons. Certainly a lot of things could change over 30 years, but it does make you think. We need to be sure we have enough vascular interventionalists to take care of the increased demand.

Dr. Kent and colleagues looked at data from the National Hospital Discharge Survey collected between 1980 and 2000. They specifically looked at patients discharged from the hospital for one of eight different types of vascular procedures, including aneurysm repair, carotid endarterectomy (a type of stroke-preventing surgery in which fatty plaque is removed from neck arteries), artery-clearing angioplasty, and amputations. The study did not include angioplasty to clear clogged heart arteries, which is considered in a separate category, or varicose vein removal, which is usually done on an outpatient basis.

The researchers found that the number of procedures increased from 412,557 in 1980 to 801,537 in 2000, which represented a per capita increase of more than 50%. Hospital stays of seven or more days dropped by 41% in that time, and short hospital stays less than 24 hours jumped by 15%. For example, 80% of patients in 1980 stayed in the hospital for at least a week, while this was true for only 38% in 2000.

We wanted to understand and look at the trends in treating patients over a relatively long time period, said Dr. Kent. Much has changed recently. We've had such significant improvements in technology that many more procedures are being performed with minimally invasive techniques.

Our study was provocative in that it included hospitals across the country, said Dr. Kent. Sometimes if you look only at a single institution, there is selection bias, he said. The researchers found that the frequency of repair for abdominal aortic aneurysm (AAA) a potentially life-threatening, balloon-like weak spot in the largest artery in the body stayed relatively stable between 1980 to 2000. However, the use of catheter-based techniques to treat AAAs seems to have increased dramatically in the last few years, while rates of open surgical repair have fallen, Dr. Kent said. In general, the study found that the use of all catheter-based procedures jumped by 979% between 1995 and 2000.

What surprised all of us was that lower extremity revascularizations were the most common type of procedures conducted by vascular surgeons in 1980. By 2000, catheter-based interventions were the most common, said lead study author Dr. Patrice Anderson, Clinical Outcomes Research Fellow with Weill Cornell Medical College's Division of Vascular Surgery and Columbia University's InCHOIR (International Center for Health Outcomes and Innovation Research). We anticipated that endovascular interventions would increase over time, but the extent of the change was surprising. It certainly has implications for how vascular surgeons are trained.

Lower extremity revascularizations are procedures that are performed to restore blood flow to the legs, a problem that can lead to amputation if not corrected. There was a decrease in surgery to restore blood flow, but there was an increase in catheter-based procedures to achieve the same result, said Dr. Anderson.

The frequency of carotid endarterectomy increased dramatically 69% but it's not clear how many of those procedures were done with traditional surgery or with a catheter-based angioplasty.

We couldn't directly look at that because there isn't a separate code for the two procedures, but my guess is that many of those interventions are being done with catheters rather than with traditional open surgery, Dr. Anderson said.

The increase in catheter-based procedures may be based partly on patient preference, she said.

Rather than have an incision in the neck from carotid surgery, or a long incision on their abdomen for aortic aneurysm repair, patients would prefer to have only a minimal or no incision from a catheter intervention, she said. A patient sees a smaller scar, and it's not nearly as scary. However, these techniques are relatively new so the long-term outcome is not nearly as well known as open surgery.

I think for patients it's very individualized as to whether traditional surgery or a catheter-based procedure is most appropriate. It depends on your preoperative physical state some patients have multiple health problems and may not be candidates for surgery, but may be able to undergo an endovascular procedure, Dr. Kent said. However, it's not clear if the durability of the procedures are the same as open surgery. Patients may require re-treatment sooner with endovascular repair, though more study is needed.

I think that certainly if vascular surgeons want to be in the forefront in treating peripheral vascular disease, they are going to have to combine catheter-based approaches with open techniques. I don't think the open techniques will ever go away, but in order to stay at the forefront of treating vascular disease, surgeons are going to have to expand their capabilities, Dr. Kent said.

In addition to Drs. Kent and Anderson, the study authors include Dr. Annetine Gelijns (associate professor of surgery at Columbia University College of Physicians Surgeons), Dr. Alan Moskowitz (associate professor of clinical medicine at Columbia University College of Physicians Surgeons), Dr. Raymond Arons (assistant professor of nursing at Columbia University School of Nursing), Lopa Gupta, Alan Weinberg, Dr. Peter Faries (assistant professor of surgery at Weill Cornell Medical College), and Dr. Roman Nowygrod (professor of surgery at Columbia University College of Physicians Surgeons).