Salvatore T Scali1, Adam Beck2, Art Sedrakyan3, Jialin Mao3, Christian-Alexander Behrendt4, Jonathan R Boyle5, Maarit Venermo6, Rumi Faizer7, Marc Schermerhorn8, Barry Beiles9, Zoltan Szeberin10, Nikolaj Eldrup11, Ian Thomson12, Kevin Cassar13, Martin Altreuther14, Sebastian Debus4, Amundeep Johal15, Martin Bjorck16, Jack L Cronenwett17, Kevin Mani16. 1. University of Florida College of Medicine, Division of Vascular Surgery & Endovascular Therapy, Gainesville, FL, USA. Electronic address: salvatore.scali@surgery.ufl.edu. 2. Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL, USA. 3. Population Health Sciences, Weill Cornell Medical College, New York, NY, USA. 4. Department of Vascular Medicine, Working Group GermanVasc, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany. 5. Cambridge Vascular Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK. 6. Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland. 7. Division of Vascular Surgery, University of Minnesota, Minneapolis, MN, USA. 8. Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Boston, MA, USA. 9. Australasian Vascular Audit, Australasian Society for Vascular Surgery, Melbourne, Australia. 10. Department of Vascular Surgery, Semmelweis University, Budapest, Hungary. 11. Department of Vascular Surgery, Rigshospitalet, Copenhagen University, Copenhagen, Denmark. 12. Department of Surgery, University of Otago, Dunedin, New Zealand. 13. Department of Surgery, Faculty of Medicine and Surgery, University of Malta, Malta. 14. Department of Vascular Surgery, St. Olavs Hospital, Trondheim, Norway. 15. The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK. 16. Department of Surgical Sciences, Uppsala University, Uppsala, Sweden. 17. Section of Vascular Surgery, Dartmouth-Hitchcock Medical Centre, Lebanon, NH, USA.
Abstract
OBJECTIVE: As open abdominal aortic aneurysm (AAA) repair (OAR) rates decline in the endovascular era, the endorsement of minimum volume thresholds for OAR is increasingly controversial, as this may affect credentialing and training. The purpose of this analysis was to identify an optimal centre volume threshold that is associated with the most significant mortality reduction after OAR, and to determine how this reflects contemporary practice. METHODS: This was an observational study of OARs performed in 11 countries (2010 - 2016) within the International Consortium of Vascular Registry database (n = 178 302). The primary endpoint was post-operative in hospital mortality. Two different methodologies (area under the receiving operating curve optimisation and Markov chain Monte Carlo procedure) were used to determine the optimal centre volume threshold associated with the most significant mortality improvement. RESULTS: In total, 154 912 (86.9%) intact and 23 390 (13.1%) ruptured AAAs were analysed. The majority (63.1%; n = 112 557) underwent endovascular repair (EVAR) (OAR 36.9%; n = 65 745). A significant inverse relationship between increasing centre volume and lower peri-operative mortality after intact and ruptured OAR was evident (p < .001) but not with EVAR. An annual centre volume of between 13 and 16 procedures per year was associated with the most significant mortality reduction after intact OAR (adjusted predicted mortality < 13 procedures/year 4.6% [95% confidence interval 4.0% - 5.2%] vs. ≥ 13 procedures/year 3.1% [95% CI 2.8% - 3.5%]). With the increasing adoption of EVAR, the mean number of OARs per centre (intact + ruptured) decreased significantly (2010 - 2013 = 35.7; 2014 - 2016 = 29.8; p < .001). Only 23% of centres (n = 240/1 065) met the ≥ 13 procedures/year volume threshold, with significant variation between nations (Germany 11%; Denmark 100%). CONCLUSION: An annual centre volume of 13 - 16 OARs per year is the optimal threshold associated with the greatest mortality risk reduction after treatment of intact AAA. However, in the current endovascular era, achieving this threshold requires significant re-organisation of OAR practice delivery in many countries, and would affect provision of non-elective aortic services. Low volume centres continuing to offer OAR should aim to achieve mortality results equivalent to the high volume institution benchmark, using validated data from quality registries to track outcomes.
OBJECTIVE: As open abdominal aortic aneurysm (AAA) repair (OAR) rates decline in the endovascular era, the endorsement of minimum volume thresholds for OAR is increasingly controversial, as this may affect credentialing and training. The purpose of this analysis was to identify an optimal centre volume threshold that is associated with the most significant mortality reduction after OAR, and to determine how this reflects contemporary practice. METHODS: This was an observational study of OARs performed in 11 countries (2010 - 2016) within the International Consortium of Vascular Registry database (n = 178 302). The primary endpoint was post-operative in hospital mortality. Two different methodologies (area under the receiving operating curve optimisation and Markov chain Monte Carlo procedure) were used to determine the optimal centre volume threshold associated with the most significant mortality improvement. RESULTS: In total, 154 912 (86.9%) intact and 23 390 (13.1%) ruptured AAAs were analysed. The majority (63.1%; n = 112 557) underwent endovascular repair (EVAR) (OAR 36.9%; n = 65 745). A significant inverse relationship between increasing centre volume and lower peri-operative mortality after intact and ruptured OAR was evident (p < .001) but not with EVAR. An annual centre volume of between 13 and 16 procedures per year was associated with the most significant mortality reduction after intact OAR (adjusted predicted mortality < 13 procedures/year 4.6% [95% confidence interval 4.0% - 5.2%] vs. ≥ 13 procedures/year 3.1% [95% CI 2.8% - 3.5%]). With the increasing adoption of EVAR, the mean number of OARs per centre (intact + ruptured) decreased significantly (2010 - 2013 = 35.7; 2014 - 2016 = 29.8; p < .001). Only 23% of centres (n = 240/1 065) met the ≥ 13 procedures/year volume threshold, with significant variation between nations (Germany 11%; Denmark 100%). CONCLUSION: An annual centre volume of 13 - 16 OARs per year is the optimal threshold associated with the greatest mortality risk reduction after treatment of intact AAA. However, in the current endovascular era, achieving this threshold requires significant re-organisation of OAR practice delivery in many countries, and would affect provision of non-elective aortic services. Low volume centres continuing to offer OAR should aim to achieve mortality results equivalent to the high volume institution benchmark, using validated data from quality registries to track outcomes.