Editor's Choice - The Impact of Centralisation and Endovascular Aneurysm Repair on
Treatment of Ruptured Abdominal Aortic Aneurysms Based on International Registries.
OBJECTIVES: Current management of ruptured abdominal aortic aneurysms (RAAA) varies
among centres and countries, particularly in the degree of implementation of endovascular
aneurysm repair (EVAR) and levels of vascular surgery centralisation. This study assesses
these variations and the impact they have on outcomes. MATERIALS AND METHODS: RAAA
repairs from vascular surgical registries in 11 countries, 2010-2013, were investigated.
Data were analysed overall, per country, per treatment modality (EVAR or open aortic
repair [OAR]), centre volume (quintiles IV), and whether centres were predominantly
EVAR (>/=50% of RAAA performed with EVAR [EVAR(p)]) or predominantly OAR [OAR(p)].
Primary outcome was peri-operative mortality. Data are presented as either mean values
or percentages with 95% CI within parentheses, and compared with chi-square tests,
as well as with adjusted OR. RESULTS: There were 9273 patients included. Mean age
was 74.7 (74.5-74.9) years, and 82.7% of patients were men (81.9-83.6). Mean AAA diameter
at rupture was 7.6 cm (7.5-7.6). Of these aneurysms, 10.7% (10.0-11.4) were less than
5.5 cm. EVAR was performed in 23.1% (22.3-24.0). There were 6817 procedures performed
in OAR(p) centres and 1217 performed in EVAR(p) centres. Overall peri-operative mortality
was 28.8% (27.9-29.8). Peri-operative mortality for OAR was 32.1% (31.0-33.2) and
for EVAR 17.9% (16.3-19.6), p < .001, and the adjusted OR was 0.38 (0.31-0.47), p
< .001. The peri-operative mortality was 23.0% in EVAR(p) centres (20.6-25.4), 29.7%
in OAR(p) centres (28.6-30.8), p < .001; adjusted OR = 0.60 (0.46-0.78), p < .001.
Peri-operative mortality was lower in the highest volume centres (QI > 22 repairs
per year), 23.3% (21.2-25.4) than in QII-V, 30.0% (28.9-31.1), p < .001. Peri-operative
mortality after OAR was lower in high volume centres compared with the other centres,
25.3% (23.0-27.6) and 34.0% (32.7-35.4), respectively, p < .001. There was no significant
difference in peri-operative mortality after EVAR between centres based on volume.
CONCLUSIONS: Peri-operative mortality is lower in centres with a primary EVAR approach
or with high case volume. Most repairs, however, are still performed in low volume
centres and in centres with a primary OAR strategy. Reorganisation of acute vascular
surgical services may improve outcomes of RAAA repair.
