Carotid revascularization and aortic dissection studies add real-world outcomes data from VA cohorts
Vascular disease surgery at the Boston VAMC. Referrals for vascular surgery through the VA Community Care program nearly tripled over five years, driven overwhelmingly by endovascular interventions for peripheral artery disease, according to a comprehensive cost analysis presented at the Vascular Annual Meeting (VAM26) in Boston last month. VA photo
BOSTON — Referrals for vascular surgery through the VA Community Care program nearly tripled over five years, driven overwhelmingly by endovascular interventions for peripheral artery disease, according to a comprehensive cost analysis presented at the Vascular Annual Meeting (VAM26) in Boston, June 10–13. Three additional studies drawn from VA data presented at the meeting addressed long-term carotid revascularization outcomes and a novel endovascular strategy for one of the most lethal emergencies in vascular surgery.
PAD Referrals and Costs Surge Under MISSION Act
More than 180,000 veterans receive care for peripheral artery disease (PAD) within the VA healthcare system and more of them are turning to community care than ever. Demand for vascular surgical services related to PAD has grown substantially since the 2019 implementation of the MISSION Act, which expanded veterans’ access to care outside VA facilities. A new analysis quantifying the scope and cost of that shift found that community care referrals for vascular surgery nearly tripled, rising from 21,407 in fiscal year 2020 to 62,487 in fiscal year 2025, a 192% increase over five years.
Researchers analyzed data from the VA Community Care Referral Dashboard and Integrated Informatics and Analytics across all VA centers nationwide, examining referral volume, justification for community care, and total payment claims for vascular surgery procedure codes. Distance from a VA facility was by far the most common reason for referral, accounting for seven out of eight cases, a finding consistent with the geographic distribution of the veteran population and the specialized nature of vascular surgical care.
Endovascular interventions dominated the cost picture throughout the study period. Femoral-popliteal atherectomy, a minimally invasive procedure to remove plaque from leg arteries. The highest-paid procedure code in nearly every year analyzed, femoral-popliteal atherectomy payments rose from approximately $4.5 million to $9.9 million from 2020 to 2025. Payments for iliac endovascular interventions grew from $1.65 million to $5.6 million, while total payments for all infrainguinal endovascular interventions more than quadrupled, rising from $8.8 million to $40.2 million over the study period.
Despite national concerns about the clinical value and cost of atherectomy procedures driven by limited comparative effectiveness data, the proportion of infrainguinal endovascular charges attributable to atherectomy remained relatively stable, ranging from 60.1% to 67% of total charges across years.
The concentration of spending in endovascular procedurals was stunning, with the highest-paid non-endovascular procedure ranking no higher than seventh among paid codes in any given year. No open bypass or groin-level reconstruction procedures appeared among the top 30 paid codes.
“As access to care outside the VA Community Care continues to expand, it is crucial to know which vascular procedures veterans are receiving and how resources are being utilized,” said senior author and presenter Gale Tang, MD, section chief of vascular surgery at the VA Puget Sound Health Care System and associate professor of vascular surgery at the University of Washington in Seattle. “These findings underscore the importance of comparative effectiveness research to help physicians make evidence-based treatment decisions.”
Gale Tang, MD, Section Chief of Vascular Surgery, Puget Sound VA Health Care System and Associate Professor of Vascular Surgery, University of Washington, Seattle
PAD affects more than 10 million Americans and can progress to chronic limb-threatening ischemia, a severe condition that carries a high risk of amputation and death. Veterans face elevated PAD risk due to higher rates of smoking, diabetes, and hypertension compared with the general population. The investigators noted plans to examine regional variation in atherectomy rates both within and outside VA Community Care, and to evaluate procedure volumes per patient as a measure of care quality and resource stewardship.1
Long-Term Carotid Outcomes: TFCAS Carries Higher Risk Than CEA or TCAR
A separate study using VA-wide electronic health record data offered what investigators described as the most robust real-world comparison to date of long-term outcomes after the three main approaches to carotid revascularization for asymptomatic high-grade carotid stenosis: carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TFCAS).
The analysis drew on the VA Informatics and Computing Infrastructure, which consolidates electronic health record data from all 144 VA acute-care facilities nationwide. Mary S. Lin, MD, MS, a general surgery resident at the University of Maryland School of Medicine and colleagues identified 11,922 patients who underwent revascularization for asymptomatic disease between 2015 and 2024. The total included 9,546 CEA procedures, 1,057 TCAR procedures, and 1,319 TFCAS procedures. A deep-learning natural language processing algorithm developed by the research team classified procedure type from operative notes with 97% accuracy, enabling consistent identification across the full national dataset.
The primary outcome was time to a composite of stroke, death, or myocardial infarction following revascularization. In Cox proportional hazards models adjusted for age, sex, race, and comorbidities, TFCAS carried a meaningfully higher risk of the composite outcome compared with both CEA (HR 1.58) and TCAR (HR 1.65). By contrast, outcomes after TCAR and CEA were statistically equivalent (HR 0.96), with no significant difference between the two approaches over a mean follow-up of approximately four years.
The findings carry practical weight given the ongoing evolution of carotid intervention practice. TCAR, a hybrid approach that achieves flow reversal to reduce embolic risk during stenting, has grown in use since its introduction but has been largely absent from major randomized trials, including CREST-2, which compared TFCAS with CEA. Long-term outcome data for TCAR have been limited and potentially subject to selection bias in registry-based analyses. The VA’s comprehensive EMR infrastructure, which captures all patients rather than selectively enrolled or reported cases, addresses some of those limitations.2
CAS Versus CEA in a High-Risk VA Population: Long-Term Benefits of Stenting
A third study examined outcomes of carotid artery stenting versus endarterectomy across a nationwide VA cohort spanning 25 years, focusing on a population characterized by extraordinarily high cardiovascular risk.
Aidin Baghbani, MD, a vascular surgery resident at the University of Texas Health Science Center at Houston and co-investigators from the Michael E. DeBakey VA Medical Center and Baylor College of Medicine, identified 52,616 patients who underwent carotid intervention between 2000 and 2025. Of those, 44,888 received CEA and 7,728 received carotid artery stenting. The cohort was 98% male with a mean age of 70 years and mean follow-up of 12.5 years. More than 99% had at least one cardiac risk factor and 93% met criteria for metabolic disease, making it among the highest-risk real-world populations studied in this context.
Patients selected for stenting carried a heavier comorbidity burden than those who underwent CEA, with higher rates of prior myocardial infarction, congestive heart failure, peripheral arterial disease, and renal failure, and a higher mean Charlson Comorbidity Index. Despite that baseline disadvantage, stenting was associated with lower long-term all-cause mortality (56.9% versus 64.0%; adjusted odds ratio 0.72) and fewer major adverse cardiovascular events (25.8% versus 28.3%; adjusted odds ratio 0.88) in multivariable analyses. Adjusted analyses also showed lower odds of cerebrovascular accident, myocardial infarction, and carotid restenosis after stenting. Thirty-day unadjusted rates of mortality and adverse events were slightly higher in the stenting group, consistent with the known periprocedural risk profile of the procedure, but adjusted long-term outcomes favored stenting across multiple endpoints.
The investigators concluded that the findings support the safety and long-term effectiveness of carotid artery stenting in carefully selected high-risk patients. “These findings support the safety and effectiveness of CAS in carefully selected high-risk patients and suggest that its long-term benefits may outweigh modest periprocedural risk,” in populations with the comorbidity profile typical of the veteran population, the researchers said. 3
Upfront Endovascular Fenestration for Aortic Dissection With Visceral Malperfusion
A case series from Vanderbilt University Medical Center and the Nashville, TN, VAMC described a selective endovascular-first strategy for one of the most lethal and technically demanding emergencies in vascular surgery: acute Type A aortic dissection complicated by visceral malperfusion.
Acute Type A aortic dissection carries high perioperative mortality and typically demands emergent open proximal aortic repair on cardiopulmonary bypass to prevent rupture, cardiac tamponade, or death. When dissection extends to compress visceral vessels, however, the standard aorto-centric approach may leave abdominal organs ischemic for the duration of a prolonged central repair, a delay that can prove fatal in its own right. The optimal sequencing of repair in patients presenting with concurrent visceral malperfusion syndrome remains actively debated.
Clare Lipscombe, MD, a general surgery resident at Vanderbilt University Medical Center and co-investigators including John Curci, MD, associate professor of vascular surgery and chief of vascular surgery at the Nashville VA Medical Center, presented outcomes in three patients who arrived with acute Type A dissections, abdominal pain, and lactic acidosis indicating active visceral ischemia from severe true lumen compression. In each case, the surgical team determined in consultation with cardiac surgery that proceeding directly to central repair would impose an unacceptable delay in visceral reperfusion.
All three patients were taken emergently to the hybrid operating room for upfront aortic fenestration and thoracic stent graft placement. Bilateral common femoral arteries were accessed, with intravascular ultrasound used to confirm true and false lumen position. A crossing catheter was advanced from the compressed true lumen into the false lumen, a wire introduced and snared to establish through-and-through access, and a five-centimeter fenestration created in the descending thoracic aorta under continuous intravascular ultrasound guidance. A thoracic stent graft was then deployed to expand the true lumen and restore visceral flow.
Completion aortograms confirmed true lumen expansion and reconstitution of visceral perfusion in all three cases, with resolution of abdominal pain and normalization of lactic acidosis. Two patients subsequently underwent open proximal aortic repair. The third patient, despite successful visceral reperfusion, died in hospital from decompensation of underlying cirrhosis, a comorbidity that had factored into the initial decision to pursue endovascular stabilization rather than immediate open repair.
The authors acknowledged the limitations inherent in a three-patient series but argued that the cases illustrate a clinically important principle: in selected patients with time-sensitive end-organ ischemia, early endovascular intervention to restore visceral flow, with delayed definitive proximal repair, may offer meaningful advantage over the traditional sequence. The approach aligns with emerging literature supporting individualized rather than uniform management of malperfusion in acute Type A dissection.4
- Tang G, et al. VA community care vascular surgery costs are dominated by endovascular interventions for peripheral artery disease. Vascular Annual Meeting; June 13, 2026; Boston, MA.
- Lin MS, Mayorga-Carlin M, Sorkin JD, Lal BK. Long-term outcomes of carotid revascularization for asymptomatic carotid stenosis among veterans nationwide. Vascular Annual Meeting; June 13, 2026; Boston, MA. Abstract RS29.
- Baghbani A, Razjouyan J, Sharafkhaneh A, Saqib NU, Oderich G, Barshes NR. Nationwide outcomes of carotid endarterectomy versus carotid artery stenting in a predominantly male, very high cardiovascular risk Veterans Affairs population. Vascular Annual Meeting; June 12, 2026; Boston, MA. Abstract PC134.
- Lipscombe C, Woodruff G, Alslaim H, Naslund T, Curci J, Al Adas Z. Management of acute Type A dissections complicated by visceral malperfusion with aortic fenestration and thoracic stent graft: a multi-case series. Vascular Annual Meeting; June 11, 2026; Boston, MA. Abstract IP069.
