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Knowledge 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.Retrospective 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.Of 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 with15 years of experience obtained their training primarily during residency or fellowship (96.7%).Between 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.

Background Patients at risk of mortality after amputation have not been well identified. We sought to devise a clinical index predicting 30-day mortality after amputation that would allow stratification of intensity of postoperative care. Methods The National Surgical Quality Improvement Program (NSQIP) database (2005–2009) was analyzed for patients who had above- or below-knee amputations. An additive risk index was created based on logistic regression that examined patient demographics, comorbidities, and operative characteristics. A threshold score for clinical action was identified as the score at which the gain in certainty was maximized. The primary outcome measure was 30-day mortality. Results Among 9244 patients analyzed, there were 744 deaths (8.1%) at 30 days, with 280 occurring after hospital discharge (37.9%). The final index includes 11 components with a total score range of 0–13: age (60–79 or ≥80 years), history of congestive heart failure, chronic obstructive pulmonary disease, or major cardiac surgery, using steroid medications, having dependent functional status, dyspnea, being on dialysis, having impaired sensorium, or preoperative sepsis. This index has a c-statistic of 0.7391, and the score at which clinical action should be taken is ≥5. The observed probability of 30-day mortality increased from 1.06% at a score of 1 to 10% at 5 and 38.5% at a score of 10. Conclusions More than one-third of deaths within 30 days of major amputation occur after discharge from acute care. A novel index to predict 30-day mortality after major amputation is described. Patients receiving a score ≥5 face a substantial risk of mortality and should be held in the hospital longer or, if discharged, receive closer postoperative follow-up.