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Invited Commentary
August 2017

Optimal vs Feasible Volume Thresholds in Vascular Surgery

Author Affiliations
  • 1Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
JAMA Surg. 2017;152(8):766-767. doi:10.1001/jamasurg.2017.1081

The volume-outcome relationship in vascular surgery has been an especially controversial topic recently, given the declining trainee exposure to complex open vascular cases, additional series reporting improved outcomes with higher volume, and medical organizations, such as Leapfrog, recommending volume thresholds for certain procedures.1-3 However, the definition of volume and the delineation of a specific threshold number of cases below which surgeons should not be credentialed remain unclear. In this issue of JAMA Surgery, Mao et al4 took a unique approach to looking at outcomes among the very lowest-volume surgeons—those performing no more than 1 procedure on average per year. Not surprisingly, these surgeons, who make up nearly 50% of surgeons performing open abdominal aortic aneurysm repair (OAR) and carotid endarterectomy in New York, have markedly worse outcomes, including higher perioperative mortality following OAR and higher perioperative stroke and myocardial infarction following carotid endarterectomy. Additionally, these outcome disparities disproportionately affect minority patients, who are more often treated at low-volume centers by low-volume surgeons, as described by Mao et al4 and others.5,6