European Study Assesses Impact of Centralization and EVAR on Treatment of Ruptured AAA


August 8, 2018—An assessment of the variations and their impact on outcomes in the current management of ruptured abdominal aortic aneurysms (RAAAs) among centers and countries was published by Jacob Budtz-Lilly, MD, et al in European Journal of Vascular and Endovascular Surgery (EJVES; 2018;65;181–188). Using international registries, the investigators evaluated the degree of implementation of endovascular aneurysm repair (EVAR) and levels of vascular surgery centralization.

The study analyzed RAAA repairs from vascular surgical registries in 11 countries from 2010 to 2013. Data were analyzed overall, per country, per treatment modality (EVAR or open aortic repair [OAR]), center volume (quintiles I–V), and whether centers were predominantly EVAR (defined as ≥ 50% of RAAAs repaired with EVAR) or OAR. Perioperative mortality was the primary outcome.

Centers with a primarily EVAR approach or with high case volume were found to have a lower perioperative mortality rate. However, most repairs are still performed in low-volume centers and in centers with a primarily OAR strategy. "Reorganization of acute vascular surgical services may improve outcomes of RAAA repair," concluded the investigators in EJVES.

As summarized in EJVES, the study included 9,273 patients (mean age, 74.7 years; 82.7% were men). The mean AAA diameter at rupture was 7.6 cm; of these, 10.7% were < 5.5 cm. EVAR was performed in 23.1% of cases. There were 6,817 procedures performed in primarily OAR centers and 1,217 performed in primarily EVAR centers.

The investigators reported in EJVES:

  • Perioperative mortality was 28.8% overall, 32.1% for OAR, and 17.9% for EVAR (P < .001). The adjusted odds ratio (OR) was 0.38 (P < .001).
  • Perioperative mortality was 23% in predominantly EVAR centers and 29.7% in predominantly OAR centers (P < .001). The adjusted OR was 0.6 (P < .001).
  • Perioperative mortality was lower in the highest-volume centers (QI > 22 repairs per year; 23.3%) than in QII–V (30%; P < .001).
  • Perioperative mortality after OAR was lower in high-volume centers compared with the other centers (25.3% vs 34%; P < .001).
  • There was no significant difference in perioperative mortality after EVAR between centers based on volume.

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