Society for Vascular Surgery Vascular Quality Initiative Contemporary Benchmarks: Endovascular Abdominal Aortic Aneurysms.

OBJECTIVE: 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 nonclaim-based dataset of endoluminal repairs in the 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.

METHODS: All EVAR procedures from 2011 to 2024 were included and stratified by indication as elective, symptomatic (intact and nonruptured), or ruptured. The primary end point was in-hospital mortality; secondary end points 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 1-year follow-up compliance. Risk-adjusted observed-to-expected 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 to 2013, 2014 to 2017, 2018 to 2021, and 2022 to 2024.

RESULTS: Among 90,370 EVARs performed across >400 centers, 76,350 (85%) were elective, 8349 (9%) symptomatic-intact, and 5671 (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% confidence interval (CI), 80.8-81.4] and reaching a contemporary benchmark of 89.4% (95% CI, 89.1-89.8) in 2022 to 2024. In-hospital mortality was 0.5% (95% CI, 0.42-0.52) for elective, 2.2% (95% CI, 1.91-2.56) for symptomatic-intact, and 21.5% (95% CI, 20.4-22.6) for ruptured repairs. Over time, mortality declined from 0.6% in 2011 to 2013 to 0.4% in 2022 to 2024 (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 noncompliance decreasing from 46% to 40% and female noncompliance 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%, whereas imaging surveillance was reported in 51%.

CONCLUSIONS: 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.